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Developing a Comprehensive Model of Intensive Care Unit Processes

Concept of Operations

Romig, Mark, MD*†; Tropello, Steven P., MD, MS*; Dwyer, Cindy, RN, BSN*‡; Wyskiel, Rhonda M., RN, BSN*‡; Ravitz, Alan, MS; Benson, John, MS; Gropper, Michael A., MD, PhD§; Pronovost, Peter J., MD, PhD*†; Sapirstein, Adam, MD*†

doi: 10.1097/PTS.0000000000000189
Original Articles

Objectives This study aimed to use a systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce several different patient harms.

Methods We developed a conceptual framework or concept of operations (ConOps) to analyze different types of harm that included 4 steps as follows: risk assessment, appropriate therapies, monitoring and feedback, as well as patient and family communications. This framework used a transdisciplinary approach to inventory the tasks and work flows required to eliminate 7 common types of harm experienced by patients in the intensive care unit. The inventory gathered both implicit and explicit information about how the system works or should work and converted the information into a detailed specification that clinicians could understand and use.

Prototype ConOps to Eliminate Harm Using the ConOps document, we created highly detailed work flow models to reduce harm and offer an example of its application to deep venous thrombosis. In the deep venous thrombosis model, we identified tasks that were synergistic across different types of harm. We will use a system of systems approach to integrate the variety of subsystems and coordinate processes across multiple types of harm to reduce the duplication of tasks. Through this process, we expect to improve efficiency and demonstrate synergistic interactions that ultimately can be applied across the spectrum of potential patient harms and patient locations.

Conclusions Engineering health care to be highly reliable will first require an understanding of the processes and work flows that comprise patient care. The ConOps strategy provided a framework for building complex systems to reduce patient harm.

From the *Johns Hopkins Medicine Armstrong Institute for Quality and Patient Safety,

Applied Physics Laboratory, and

Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland;

§Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.

Correspondence: Mark Romig, MD, 600 N Wolfe St, Meyer 299C, Baltimore, MD 21287 (e-mail:

This study was supported by the Gordon and Betty Moore Foundation.

Mr Benson reports grant support from the Gordon and Betty Moore Foundation. Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association, Inc (improve blood pressure control); honoraria from various health care organizations for speaking on patient safety and quality (the Leigh Bureau manages these engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; fees to be a strategic advisor to the Gordon and Betty Moore Foundation (December 2013 to March 2014); and stock and fees to serve as a director for Cantel Medical. Dr Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. The following authors report no conflicts: Dr Romig, Mr Tropello, Ms Dwyer, Ms Wyskiel, Dr Gropper, and Dr Sapirstein.

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