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ARMSTRONG INSTITUTE
F O R PAT I E N T S A F E T Y A N D Q U A L I T Y
2013 Annual Report
Putting Values into Action
I act humbly.
I appreciate and respect others.
I am accountable to myself to continuously improve myself, my team and Johns Hopkins Medicine.
OUR MISSION
We partner with patients, their loved ones and
others to eliminate preventable harm, optimize
patient outcomes and experience, and reduce
waste in health care delivery.
OUR VISION
Saving lives by leading the world in
patient safety and quality care
These are more than mantras. These statements are the “core behaviors” that the Armstrong Institute adopted to guide us
on the journey to eliminate preventable harm to patients, improve outcomes and reduce waste in health care. As you read in
this annual report about our busy, productive second year, you will hopefully see these behaviors shining through. We hold
ourselves to high standards, but we also recognize that no one has the all the answers. We seek help from all quarters to fix
health care’s flaws.
Consider Project EMERGE, an initiative to radically transform ICU care, made possible by visionary financial support from
the Gordon and Betty Moore Foundation. The institute is partnering with engineers from The Johns Hopkins University’s
Applied Physics Laboratory, bioethics experts, human factors engineers, biostatisticians, software engineers, educators and
many, many doctors and nurses. In all, 18 disciplines are working together, with remarkable results so far.
Look at the effort to improve patient safety and quality across Johns Hopkins Medicine. For the first time, several Hopkinsaffiliated medical centers received national recognition for their achievements in consistently following a broad set of publicly
reported, evidence-based practices known as core measures. This achievement would not have been possible without the productive, enriching partnerships formed among the institute’s experts, quality improvement specialists across the organization,
and staff at these hospitals. We are grateful for the commitment of clinicians, staff and hospital leaders to this meaningful
work; it is this commitment that will help us achieve the goal of zero preventable harm across Johns Hopkins Medicine.
Learn about the training opportunities we’ve developed. For example, a new yearlong program prepared 16 Johns Hopkins
residents to integrate safety and quality into their clinical careers. An innovative Online Patient Safety Certificate Program
debuted, with the promise to help build a fleet of patient safety champions, at Johns Hopkins and beyond.
This report is an opportunity to look back and celebrate the institute’s
work over our second year—through June 2013—and see how far
we have come. Just as much, it’s a chance to thank those who have
collaborated with us on so many levels to achieve progress.
C. Michael Armstrong
Chairman, Armstrong Institute for Patient Safety and Quality
Chairman, Board of Trustees
Johns Hopkins Medicine
Peter J. Pronovost, M.D., Ph.D.
Director, Armstrong Institute for Patient Safety and Quality
Senior Vice President, Patient Safety and Quality
Johns Hopkins Medicine
Armstrong Institute Annual Report 2013
Armstrong Institute Annual Report 2013 • 1
TABLE OF
CONTENTS
Designing Safer Systems
Accelerating Improvement
Advancing Performance Measures
Quick Takes
We are drawing on the expertise of
multiple disciplines and other high-risk
fields to design care-delivery systems
that reduce the risk of errors.
We are advancing the science of how
to spread successful patient safety and
quality improvement strategies on a
broad scale, at Johns Hopkins Medicine
and beyond.
We seek to create and refine meaningful performance measures while
using them to motivate improvement
across health care organizations.
Learn more about the institute’s
second year, in statistics and charts.
The Picture of Patient Care.................................4
The Core of Quality Care....................................12
Gauging Our Progress............................................22
Organizational Chart...............................................26
Beyond Words.............................................................6
Harnessing Expertise...............................................14
Grading Care...............................................................24
By the Numbers.........................................................27
New Thinking for the ICU.....................................7
Charting the Course................................................15
Safety Reviews Without the Pressure............8
Focused on Distractions........................................16
Untangling the Web of Risk.................................10
Fictional Hospital, Realistic
Problems.........................................................................17
At a Glance....................................................................28
Distance Learning.......................................................19
Deepening Roots.......................................................20
Peering at Scopes.......................................................21
2 • Armstrong Institute Annual Report 2013
Armstrong Institute Annual Report 2013 • 3
DESIGNING
SAFER SYSTEMS
Asking health care workers to “try harder” isn’t the
answer for preventing patient harm, improving outcomes
and reducing waste. Clinicians must be surrounded by
care delivery systems that support their passion for
delivering high-quality care, rather than get in their way.
The Armstrong Institute is borrowing strategies from
other high-reliability fields, such as nuclear power and
systems engineering, to realize this vision.
THE PICTURE OF PATIENT CARE
Project EMERGE integrates ICU technology,
clinicians and patients like never before.
In the modern ICU, a battery of
sophisticated machines pump, whir,
calculate, beep and scan the patient,
spewing out reams of medical data.
But because these technological
wonders don’t collate or assess all of
the diverse readings of a patient’s wellbeing, it’s no simple task for clinicians
to integrate all of this information and
answer the most important questions:
How is my patient doing? Is he or
she receiving all the recommended
treatments? Is care in line with the
patient’s needs?
A visionary project led by the institute
aims to change that, by creating a
“system of systems” that combines and
makes sense of this flood of information. Rather than piece together the
patient story from multiple monitors
and clinical information systems, clinicians will be able to refer to a tablet
computer to get the big picture.
Improving situational awareness is
just one goal of Project EMERGE,
4 • Armstrong Institute Annual Report 2013
an effort that has brought together
physicians, engineers, bioethicists and
scientists from 18 different disciplines
to reimagine the ICU. Funded by $9.4
million from the Gordon and Betty
Moore Foundation, the project also
aims to ensure that patients are treated
with respect and dignity while creating
more ideal ICU work processes, fostering a culture of safety, and enhancing
accountability and learning.
At the heart of this project is the computer tablet. On one screen, clinicians
can review a dashboard tracking the
patient’s risk for experiencing prevent-
able harms such as delirium, harmful
blood clots and ventilator-associated
pneumonia. The most urgent situations are highlighted on the tablet
screen in red, while developing problems are highlighted in yellow, and
trouble-free areas are listed in green.
With a tap of the screen, clinicians
can see what must be done to reduce
a patient’s risk of a particular harm.
A screen on ventilator-associated
harms, for instance, displays recommended treatments—such as draining
of secretions or maintaining the head
of the bed at a 30-degree angle—and
whether they have been followed over
the previous 24 hours.
“It’s innovative,” says Armstrong
Institute Operations Manager
Nancy Edwards, who is also project
manager for EMERGE. The displays
on the tablet “remind staff when
to do tasks as well as alert them to
urgent situations. It coordinates and
integrates all the data from the monitoring equipment, even if it is made by
different manufacturers using different
software coding.”
Patients and their loved ones will
have their own tablet, providing new
options for how to be involved, and
even participate, in care activities.
The tablet gives patients and
families another means to interact with the care team and ensure
everyone is on the same page about
the patient’s goals of care.
The EMERGE system also will integrate sensor devices, such as hand-grip
strength meters and pedometers, to
track a patient’s progress on important
physical indicators.
The surgical ICU (SICU) at The
Johns Hopkins Hospital is piloting
the tablet-based system. A refined
version launches in early 2014 at
Johns Hopkins Bayview Medical
Center’s medical intensive care unit.
After further tweaks, the system
debuts on the West Coast at the
University of California, San Francisco
Medical Center.
John Benson, an APL project manager, says the EMERGE platform will
be adapted elsewhere. “We are building a modular, open-source system
that can run on any hospital infrastructure,” he says. Medical device
manufacturers can use EMERGE’s
software code to develop equipment
that is fully compatible with the
system. Other hospitals can use the
EMERGE programming too.
Future plans call for the new ICU
system to monitor additional preventable harms and patient activities
as well as offering physicians more
detailed feedback. “This project is both
revolutionary and evolutionary,” says
Howard Carolan, an Armstrong
Institute assistant project manager.
“As we gain more knowledge from
initial lessons learned, we’ll have a
platform on which to incorporate
adjustments, as well as enhance
caregiver accountability.”
Integrating and analyzing the mounds
of data flowing from today’s ICU
equipment “will be a huge addition,”
notes Cindy Dwyer, a SICU nurse
clinician who is coordinating the pilot
project there. “Right now we have
multiple machines that don’t talk to
one another, and as a result, we have
multiple documentations to do by
hand. Once all the systems are tied
together, much of that work will be
eliminated, there will be decreased risk
of errors and the ICU will be safer.”
Cyndy Dwyer, Nancy Edwards,
Howard Carolan
The Johns Hopkins University
Applied Physics Laboratory (APL) is
building this integrated platform, a
complex feat that draws on the same
systems engineering principles that it
has used in such areas as space exploration and ballistic missile systems.
In the field of health care, EMERGE
is unique, says Alan Ravitz, who is
leading APL’s team. “We want to use
technology as a tool to make the ICU
as efficient as possible and to improve
outcomes,” he says. The challenge
for APL has been “to understand
the human elements so we can give
clinicians the system they want.”
Funded by $9.4 million from
the Gordon and Betty Moore
Foundation, the project also
aims to ensure that patients are
treated with respect and dignity.
Armstrong Institute Annual Report 2013 • 5
BEYOND WORDS
EMERGE explores what it means to treat patients with
dignity and respect.
Today’s ICU clinicians strive to treat
complex medical conditions within a
disjointed system that often works against
them, producing irritating false alarms from
physiological monitors, burdensome documentation requirements and other distractions. It’s no surprise that patients and their
loved ones may be inadequately engaged in
the care process and sometimes not treated
with respect and dignity.
So when the Armstrong Institute launched
Project EMERGE to redesign ICU care, the
goal went beyond integrating various technologies. It also had to integrate patients and
their loved ones as members of the care team.
Two of the seven preventable harms targeted
by EMERGE deal with such issues—loss of
respect and dignity, and staff failure to align
care with the patient’s goals.
The project team has created a special tablet
computer for patients and their loved ones
to ask questions of staff or voice concerns.
Family members can also volunteer through
the patient-family tablet to assist with
personal care and therapy that should speed
recovery—such as helping patients to walk—
then watch instructional videos for carrying
out those tasks. They can enter background
information, the patient’s favorite or least
favorite foods and complaints, for staff
to see. They can post photos—perhaps a
humanizing reminder of how they looked
when healthy.
Meanwhile, patients and families can learn
about care team staff, treatment and testing
schedules, patient progress and other details.
Jeremy Sugarman, a professor of
bioethics and medicine, and a team of
faculty at Johns Hopkins’ Berman Institute
for Bioethics are advising Project EMERGE
on developing the patient-family tablet. They
are also helping the team define and measure
dignity and respect so that the team can then
design and test interventions for improvement.
6 • Armstrong Institute Annual Report 2013
“What constitutes respect and dignity in an
ICU setting? What does it look like?” he asks.
The team is developing a conceptual model,
Sugarman says, to get a clearer sense of what
these terms mean. He notes that this is a
complex issue. “Devising accurate measuring
tools is difficult but a necessary first step if we
are going to improve treatment.”
Rebecca Aslakson, a critical care physician who is also board-certified in palliative care, is working on measures that will
indicate if there is a disconnect between the
patients’ goals and clinicians’ objectives. Does
the patient simply want to be comfortable,
while the ICU team is still recommending
“cure”-related, invasive interventions?
Care providers need to know if there is a
difference, Aslakson says, so they meet
patients’ goals.
On the tablet, the family’s well-being is also
measured through questions that gauge
depression and anxiety. If the answers
indicate serious family upsets in coping with
the stress, counseling could be provided.
Jeremy Sugarman
“This is a new way of thinking about delivering ICU care,” Aslakson notes. “We’re trying
out things that traditionally haven’t been
done, like incorporating elements of holistic
care for the patient and family that focus on
their psychological and emotional health.”
7
PROJECT EMERGE
7 PREVENTABLE HARMS:
»» Delirium
»» ICU-Acquired Weakness
»» Ventilator-Associated Harms
»» DVT/PE
»» CLABSI
»» Loss of Respect & Dignity
»» Care Unaligned with Patient
NEW THINKING FOR THE ICU
Innovation Days spark wild ideas for the future of critical care.
In the ICU of the future, a voiceprompted computer assistant could give
clinicians bedside medical guidance and
rapid-fire calculations of medications.
Providers might wear headgear with an
optical computer providing instant access
to the patient record and current status.
Implantable sensors would monitor and
even treat patients, and then stream that
information to the care team.
These suggestions flowed from two
Innovation Days convened by the
institute to help conceive revolutionary
models for a safer ICU. They have also
helped to inform Project EMERGE, the
ICU redesign effort.
“Some ideas were huge eye-openers,” says
Jo Leslie, an Armstrong Institute senior
quality coach who helped plan and facili-
tate these sessions. “What they suggested
could dramatically help health care.”
Joining the first Innovation Day, in
December, were clinicians, researchers
and engineers, as well as representatives
from medical technology companies,
patient advocacy groups, medical societies and a business school. The second, in
March, brought together a digitally savvy
crowd—such as engineering students and
young physicians and nurses—who provided feedback on EMERGE prototypes
and devised their own proposals.
The agendas followed the principles of
human-centered design: Participants spent
their mornings directly talking with ICU
patients and staff and observing workflow,
then returned to the institute to generate
ideas and rapidly prototype them.
No ideas are considered too outlandish,
says visiting Armstrong Institute faculty
and co-facilitator Doug Solomon.
Solomon is a fellow at IDEO, an international firm that popularized humancentered design.
Overall, participants recommended far
greater integration of computer systems
and devices to reduce workload and
eliminate errors. They wanted patients
and families to interact more easily with
the caregivers. Younger participants urged
that more work be done by voice, rather
than typing at a keyboard.
Their ideas show what can happen, Leslie
says, when people from vastly different
perspectives get together.
Armstrong Institute Annual Report 2013 • 7
SAFETY REVIEWS WITHOUT THE PRESSURE
The institute adapts a page from the nuclear energy field
to assess organizational safety.
An unannounced visit by a hospital
accreditation survey team prompts a
familiar drill: It’s all hands on deck
as the organization puts its best foot
forward, hoping no one slips up and
clinicians provide the right answers
to surveyors’ questions.
While such an exercise is necessary,
the Armstrong Institute is pursuing another approach for surfacing a hospital’s
safety weaknesses without the threat of
punitive action: It is conducting peer-topeer assessments—voluntary, collegial
reviews where an environment of openness leads to sharing of best practices,
frank discussions of safety hazards and
concrete action plans for improving
safety and performance.
The idea for these reviews comes from
the nuclear power industry, which
began peer-to-peer safety assessments of
plants after the 1979 near-meltdown of a
nuclear reactor at the Three Mile Island
plant in Pennsylvania.
A nuclear industry institute sends a multidisciplinary team of outside experts to
evaluate a plant’s safety program, discuss
their findings with plant managers and
identify ways to improve.
The institute has adapted this process
to evaluate specific outcomes, such as
health care-associated infections; specific areas, like the operating room; and
whole quality and safety programs.
“It’s based on respect for local wisdom”
and internally driven improvements,
says Lori Paine, director of patient
safety for the institute and The Johns
Hopkins Hospital.
The institute first adapted the peer-topeer process for CLABSI Conversations,
in which reviewers meet with senior
leadership, intensive care unit staff
Jacky Schultz
The assessment revealed
a disconnect between
what the front-line staff
thought the organization’s
safety priorities were and
what senior leadership
believed they were.
There was a
communications gap.
Lori Paine
8 • Armstrong Institute Annual Report 2013
It was good to get someone from the
outside to lead you in a constructive
organization conversation.
and infection preventionists to discuss
best practices, identify safety defects
and develop solutions for eliminating
central line-associated bloodstream
infections.
Armstrong experts devised a similar
model for hospital-level assessments.
Last winter, Suburban Hospital volunteered as the first participant in these
reviews, dubbed Quality and Patient
Safety Conversations.
Paine led a multidisciplinary group of
a dozen reviewers from across Johns
Hopkins Medicine. They met with
Suburban’s quality improvement teams,
front-line staff and hospital executives
to gauge each group’s perceptions of
Suburban’s safety goals and progress.
Suburban officials appreciated the open,
transparent approach. “It was good to
get someone from the outside to lead
you in a constructive organization
conversation,” notes Jacky Schultz,
Suburban’s executive vice president and
chief operating officer.
“The assessment revealed a disconnect
between what the front-line staff thought
the organization’s safety priorities were
and what senior leadership believed
they were,” says Paine. “There was a
communications gap.”
This outside assessment prompted
Schultz to use a series of employee
forums at Suburban “to clearly communicate our safety scores and send a
message to all 1,500 employees about our
patient safety values, the metrics we use
to see if we are living up to our values
and how we define accountability.”
The review team also found that frontline staff felt “underutilized” as experts
in patient safety. To reverse this, the
hospital made sure that staff representatives from its nursing councils had the
opportunity to participate in initiatives
led by the Maryland Patient Safety
Center and attend safety events within
Johns Hopkins Medicine. Using these
experiences, these staff have already
started contributing to improvements—
for instance, reducing patient falls.
The institute has also taken its Safety
and Quality Conversations overseas, conducting assessments at a large hospital in
Sao Paolo, Brazil, in early 2013.
Now Paine’s team at the Armstrong
Institute is “refining our instruments
and processes” as a result of these initial
collaborative assessment reviews.
Armstrong Institute Annual Report 2013 • 9
UNTANGLING THE WEB OF RISK
A transdisciplinary approach sheds light on the complex
nature of patient safety hazards in cardiac surgery.
Too often, responses to patient safety
hazards take a narrow—and ineffective—
approach. Write new policies. Post signs outside of patient rooms. Re-educate staff after
a mistake.
It’s more complicated than that, of course.
Modern medicine stands at the intersection of
people, technology, the physical environment,
work processes and organizations. Before
devising solutions, we need a comprehensive
understanding of these elements and how they
can interact to jeopardize patients.
“One person—whether it be an expert in
teamwork and communication or a specialist in patient safety culture—could
never have all the answers,” says David
Thompson, an outcomes researcher and
clinician with the institute. “We can get a
more complete picture of risk if we take a
holistic approach.”
Following that premise, the Armstrong Institute brought together a team of experts from
multiple backgrounds to survey the myriad
hazards in cardiac surgery. This group—including clinicians, human factors engineers,
outcomes researchers, psychologists and
sociologists—reviewed 22 surgeries at five
well-respected hospitals.
We can get a more
complete picture
of risk if we take a
holistic approach.
10 • Armstrong Institute Annual Report 2013
They uncovered a whopping 58 different types
of hazards. Among other risks, they found
that disorganized medication carts might lead
a clinician to select the wrong drug. A case
was scheduled at the last minute, preventing
the surgical team from reviewing the patient’s
full medical history. A surgeon was introduced to a new brand of cautery gun in the
middle of a procedure, and it didn’t work.
Lack of standardization was another issue.
“Even in well-known, major cardiac surgery
centers, they had problems complying with
guidelines that prevent surgical-site infections,” says Ayse Gurses, a human factors
engineer on the study. “They each have their
own way of doing things.”
The research team’s approach revealed how
systemic issues—from nonintuitive device
interfaces to purchasing decisions—can predispose clinical care to fall short in such areas.
For example, at four of the five hospitals in
the study, the IV pumps used in the cardiac
ORs were different from those in ICUs or
post-anesthesia care units. As a result, medications had to be changed over from one pump
to another during transitions of care, increasing the risk of patients receiving an inadvertent bolus or interrupting a crucial drug.
Digging deeper, the team discovered that
top management at these sites had decided
to save money by purchasing a less expensive brand of pump for the ICUs, or buying
ICU pumps without safety features such as
medication libraries.
The researchers made a bevy of recommendations, such as coordinating the purchase of
technologies across different hospital units,
standardizing care and creating checklists or
Ayse Gurses
other cognitive aids to follow best practices
and improve communication.
Some of the lessons and recommendations
from that study are being applied in an
Armstrong Institute-led improvement project
in 12 cardiac surgery centers. With funding
from the Agency for Healthcare Research and
Quality, Armstrong Institute researchers led
by co-principal investigators Thompson and
Peter Pronovost, are working with front-line
staff to reduce infections while improving
coordination and collaboration among different teams of providers as patients transition
from the OR to the ICU and then to the
inpatient floor.
The project team found, through audits, that
infection control practices frequently fell
short of best practices, in areas such as sterile
technique or skin antisepsis.
“Staff thinks that they are doing the right
thing, but our audits are identifying where
they are exposing patients to infections,”
Thompson says.
Now, these cardiac surgery centers have
adopted some of the institute’s recommendations and are beginning to see improvements, including reductions in infection
rates and improved handoffs and teamwork
across units.
ACCELERATING
IMPROVEMENT
Despite more than a decade of work, the effort to
reduce preventable harm has achieved only modest
results, with improvements typically occurring in isolated
areas. The Armstrong Institute has led some of the few
projects that have achieved results at scale. Through our
programs at Johns Hopkins Medicine and abroad, we
continue to advance knowledge about the ingredients for
speeding the pace and scope of improvement.
THE CORE OF QUALITY CARE
Bob Hody, Tiffany Callender, Renee Demski
An organization-wide campaign improves delivery of evidence-based practice.
In early 2012, hospital executives
and trustees across Johns Hopkins
Medicine set an ambitious goal: to be
a national leader in quality and safety
by consistently scoring at 96 percent
or better on 40-plus evidence-based
practices known as core measures,
such as delivering recommended
vaccinations and providing accurate
discharge instructions.
Meeting these targets would prove
anything but simple for the health
system’s five Maryland and District of
Columbia hospitals, each with its distinct culture, quality-improvement infrastructure and strengths. Yet thanks
to an organization-wide effort that
may serve as a model for other quality
and safety endeavors here, the health
system hit 97 percent compliance in all
seven targeted areas this year.
12 • Armstrong Institute Annual Report 2013
For meeting those goals, Howard
County General Hospital, Suburban
Hospital, Sibley Memorial Hospital
and The Johns Hopkins Hospital
received the Delmarva Foundation’s
2013 Excellence Award for Quality
Improvement in Hospitals. The Johns
Hopkins Hospital, Sibley Memorial
Hospital and All Children’s Hospital
are also expected to receive the Joint
Commission Top Performer on Key
Quality Measures Award for their
achievements in 2012.
Attaining high compliance with these
core measures required a well-orchestrated effort across disciplines and
departments. Nearly 40 work groups
were formed to focus on the measures
needing improvement. Armstrong
Institute staff provided faculty
expertise on implementation science,
a project manager, and a Lean Sigma
Master Black Belt to each group to
identify barriers to improvement and
devise locally tailored solutions using
robust process improvement tools.
The institute encourages and guides
teams as they come up with interventions. “Local solutions work best,
in addition to collaborating across
entities and sharing lessons learned
and best practices to advance performance,” says Renee Demski, senior
director of quality improvement for
the health system and a senior director
of the institute.
“The Armstrong Institute gave us tools
and a structured process for documentation so we could see bright spots
and the areas where we needed more
work,” notes Leslie Hack, clinical
quality review manager at Howard
County General Hospital.
Hack says that adding phone calls
to remind nurses to remove urinary
catheters from patients within two days
of surgery improved compliance with
a core measure designed to prevent
urinary tract infections. But a review
revealed a higher incidence of misses
over the weekend, when extra staff
weren’t available to make such calls.
To close the gap, the team enlisted
nursing shift directors to follow up on
catheters that need to be removed over
the weekend.
In a pilot project, a clinical team at
Sibley Memorial Hospital took steps to
improve care for heart failure patients,
such as placing them in one unit with
an assigned pharmacist, instituting
multidisciplinary rounds, and
developing detailed assessments of
post-discharge needs and follow-ups.
The readmissions rate for this group
dropped by 7 percent, and compliance
with the core measure requirement to
provide complete discharge instructions
to all heart failure patients surpassed the
organizational goal.
The institute also implemented an
accountability model—a plan that calls
for review at progressively higher levels
of the organization if performance stays
below target. “The accountability plan
was huge,” notes Tiffany Callender,
the institute’s core measures project
manager. She says it assisted teams in
achieving higher levels of performance
by establishing clear expectations and
supporting continuous improvement
and learning. Monthly engagement
by hospital leaders “makes a big
difference,” Callender adds.
Johns Hopkins
Medicine Safety and
Quality Goals, 2013
Hospital executives and trustees
across Johns Hopkins Medicine have
committed to demonstrating the
organization’s national leadership in
patient safety and quality, by consistently
meeting the following goals.
Core Measures
At least 96% compliance on each core
measure
Hand Hygiene:
At least 85% compliance in inpatient areas
Catheter-Associated
Bloodstream Infections
Below the National Healthcare Safety
Network (NHSN) 25th percentile
Surgical-Site Infections:
Below the NHSN pooled mean for
select procedures
Armstrong Institute Annual Report 2013 • 13
John Probasco,
Paul Nagy
HARNESSING EXPERTISE
The Lean Sigma team forms partnerships across Johns
Hopkins Medicine to boost core measures performance.
The Armstrong Institute’s Lean Sigma
team has touched hundreds of care
delivery processes across Johns Hopkins Medicine. Reducing readmissions. Streamlining the triage process.
Designing safer medication preparation processes.
While many of those projects have
brought significant improvements in
isolated areas, the team’s work last
year on core measures shows that it
can help to raise organization-wide
performance, too.
After system leaders and trustees set
a target of 96 percent compliance on
designated core measures, the institute
assigned Lean Sigma coaches to guide
40 multidisciplinary teams tasked
with achieving that goal. They met
with quality improvement leaders at
five Johns Hopkins-affiliated hospitals
to help them find the causes of low
scores, identify the reasons for errors
and put changes in place.
“We’re excited about the opportunity
the core measures project gives us to
collaborate across the system,” says
Laura Winner, head of the Lean
Sigma team. The coaches “are influencers. They bring skill sets that help
a group identify barriers to good
health care.”
While Lean Sigma was created to
reduce waste and defects in manufacturing, Winner’s team was among
the first to adapt the methodology to
health care.
At Howard County General Hospital,
a multidisciplinary team helped boost
scores in performing balloon angioplasty (PCI) on heart attack patients
within 90 minutes of arrival in the
Emergency Department. “It looked
impossible” to reach the 96 percent
goal, recalls Bridget Carver, a
nurse who runs the hospital’s catheter
laboratory. “We went into this project
with a very jaded perspective because
we didn’t see how we could do it.”
This attitude was due, in part, to the
fact that meeting the goal seemed
impossible for certain complex and
serious cases—for instance, when it is
not clear whether a patient is having a
heart attack or aortic dissection.
Winner started meeting with the team
and “helped us break down every step
of the process,” Carver says. They
conducted an A3 analysis, in which
difficulties and solutions are detailed
on a sheet of A3-sized (11-inch by
17-inch) paper.
Among other changes made, Emergency Department Director Robin
Wessels assigned a nurse to meet
patients as soon as they enter the waiting room; those with chest pains are
taken to the EKG area immediately.
To further speed the process, the
Emergency Department’s one EKG
was placed between two stretchers so
that a second exam can begin as soon
as one test is completed.
Meanwhile, Jeanette Nazarian,
the hospital’s ICU director, worked
on reducing preparation time so that
when the interventional cardiologist
arrives, the staff is ready to proceed
immediately with the angioplasty.
The team also learned that it could
exclude some of the complex cases for
valid reasons, provided that these reasons were appropriately documented.
The turnaround was startling.
Howard County General’s PCI
compliance rate, which was typically
between 75 and 80 percent most
months, hit 90 percent last April and
then rose to a sustained 100 percent.
“Lean Sigma got us really focused
in a systematic way,” says Carver.
“It helped us look at every aspect of
this process to see what needed to
be fixed.”
We’re excited about the
opportunity the core
measures project gives
us to collaborate across
the system.
CHARTING THE COURSE
The AIRS program helps residents integrate quality and safety into their career paths.
For years, young physicians seeking to
make safety and quality improvement a
career focus have had to blaze their own
trails—seeking out mentors, developing
leadership skills and pursuing education
outside the standard medical training.
Many undoubtedly have been dissuaded
by the absence of a clear path.
That’s why the institute created a firstof-its-kind Armstrong Institute Resident
Scholars (AIRS) program—a yearlong
career-altering curriculum in which Johns
Hopkins residents learn patient safety
concepts and apply them to clinical safety
projects.
“Residents receive very little guidance on
how to be successful change agents in a
medical environment,” notes AIRS director Paul Nagy, an Armstrong Institute
core faculty member. “We are training
senior-level residents and fellows who want
to make quality improvement a big part of
their careers.”
Sixteen residents and fellows from 12
departments across Johns Hopkins
Medicine participated in the inaugural
14 • Armstrong Institute Annual Report 2013
AIRS program, which began in July 2012.
Eighteen are in the 2013 class. Academic
work includes 160 hours of education in
such areas as identifying and mitigating hazards, reducing waste and defects
through Lean Sigma, and promoting a
culture of safety.
Nagy also introduces participants to role
models—experts at the institute who
found ways to focus their careers on
quality and safety improvement.
That interaction sets the stage for each
scholar’s safety improvement project,
conducted under the guidance of an
Armstrong Institute faculty mentor.
Neurologist John Probasco, an
AIRS scholar, focused on improving
care and discharge for multiple sclerosis
patients admitted to his unit at The Johns
Hopkins Hospital.
“I wanted to see in what ways we could
plan for the patient’s discharge from Day
After reviewing each step, from admissions
to departure, Probasco and a multidisciplinary team developed three innovations: a user-friendly electronic checklist
that prompts nurses and residents on
what needs to be done for each patient;
a separate checklist for daily rounds on
a patient’s anticipated discharge date,
medications, therapy and paperwork requirements; and a checklist for the patient
about steroid treatment, what to expect
and what to do at home.
Primary data are encouraging. After
implementing the interventions, the time
between final treatment and discharge
for these patients fell from 7.5 hours to 4
hours; length of hospital stay dropped by a
full day.
“The AIRS program gave me excellent exposure to the science of patient safety and
quality, both at Hopkins and nationally,”
he says. “It has come to form the foundation for my own future career.”
One and identify barriers preventing
earlier discharge,” he explains.
Armstrong Institute Annual Report 2013 • 15
Susan Peterson
FICTIONAL HOSPITAL,
REALISTIC PROBLEMS
The online Patient Safety Certificate
Program immerses participants in
problem-solving.
Mercy Grace Hospital is in trouble.
Newspaper stories report that the
500-bed hospital has one of the nation’s worst patient safety records,
including a disturbing upsurge
in bloodstream infections. These
problems are costing Mercy Grace
business and damaging its reputation. The CEO orders department
chiefs “to get to the bottom of this
and come up with a plan of attack,”
and you are appointed to a team that
will lead safety improvements.
Solving the problems of this fictitious
hospital system is an adult learning
strategy used by the Armstrong Institute in its new, Online Patient Safety
Certificate Program. First introduced
to 40 participants in a patient safety
improvement project led by the institute in the emirate of Abu Dhabi, it
has since been made widely available.
An Armstrong Institute Resident Scholar takes on handoff-related errors in the ED.
Such situations prompted Susan
Peterson, an AIRS scholar and emergency medicine physician, to conduct an
observational study of 30 resident handoffs
in the ED last winter. Her findings: 90 percent of the time, residents failed to record
all relevant information—medications to
be administered, food restrictions, reasons
for choosing a particular antibiotic—in
patient charts before leaving for the day.
One reason is that residents had their
work interrupted every 8.5 minutes to
answer staff questions, even during the
16 • Armstrong Institute Annual Report 2013
critical time span when handoffs between
shifts occur.
Using a tool for observing patient safety
activity developed by her Armstrong
Institute faculty adviser, human factors
engineer Ayse Gurses, Peterson assessed
how the Emergency Department residents
went about their tasks during handoffs,
how they interacted with technology and
equipment, how they were affected by the
work environment and how the department
was organized during handoff periods. She
then devised a bundle of interventions.
Working with departmental information
technology staff, Peterson modified the
department’s electronic medical chart so
it is easier for residents to document—
and physicians to supervise—five critical
elements of patient care at shift changes.
These elements are history and complications; what’s been done so far; medications;
pending issues; and patient disposition or
other matters.
Like most improvement projects, the
changes weren’t solely technical. Knowing
that she needed to alter attitudes, Peterson
met with Emergency Department residents
to explain how disrupted communication at shift changes can harm patients—
for example, by pointing to studies that
show 12 percent of all errors happen
during handoffs.
The new process “ensures residents are
discussing in the medical chart all essential
The e-learning versions are based on
the institute’s five-day certificate program, but with about half the course
modules of the in-person course. The
five-day program, led by subject matter experts at the Armstrong Institute, also uses the fictitious hospital
setting as a narrative framework,
but provides additional opportunities for peer-to-peer learning and a
safe environment to explore how to
implement solutions.
Recognizing the broad demand for
such a course in the United States,
the institute launched the online
certificate in September 2013 via
MedConcert, a cloud-based Web
platform. (Johns Hopkins employees
will be able to access this course for
free via the internal My Learning
We were determined to go beyond
the traditional e-learning experience.
FOCUSED ON DISTRACTIONS
In busy Emergency Departments during
shift change, residents juggle tasks amid a
stream of interruptions. It is a hectic period
prone to errors.
responses, additional reading and a
full list of resources.
handoff details,” Peterson notes. “Before,
it was disjointed. ER residents are so busy.
But when they were confronted by data,
they were eager to make changes.”
After these steps were initiated, the
percentage of fully documented handoffs
in the medical charts during resident
handoffs jumped from 10 percent to 66
percent. Peterson sees a similar approach
improving communication during patient
transfers to in-patient rooms and shift
handoffs in other hospital units.
Peterson praises the AIRS training
program for teaching her “how to look
at a process like this and garner buy-in.
It has provided me with a structured
and pragmatic approach to quality
improvement and safety,” she says.
It is not a typical online course. “We
were determined to go beyond the
traditional e-learning experience that
is mainly rote,” says Dianne Rees,
an instructional designer at the institute. “Our program gives students
structure and a narrative framework
that links together the course’s 13
modules.” As they are introduced to
concepts in patient safety, they apply
them in case studies and scenarios at
Mercy Grace.
Both the Abu Dhabi and U.S. Web
versions provide lots of help through
on-screen prompts, suggested
platform.) Participants can take the
course on their own and at their own
pace, or they can team up with colleagues and work in teams.
Overall, participants in the SEHA
program and those who beta-tested
the U.S. course have found the
program modules highly engaging
and relevant to their work, although
online learning is new for many,
Rees says.
“This is still in its infancy,” Rees says.
“We understand that people solve
problems in very different ways.”
Armstrong Institute Annual Report 2013 • 17
Sponsored Projects
Vanquishing VAP
DISTANCE LEARNING
The institute fosters overseas culture change.
Fostering a culture of patient safety
is challenging enough on your own
clinical unit or department. Try
doing the same in a country that is
7,000 miles away, and you need a
new set of tools.
In early 2012, the Armstrong
Institute began a two-year project in
17 ICUs across the emirate of Abu
Dhabi that aims to transform safety
culture while reducing preventable harms. Working mostly from
a distance, the Armstrong team
trained staff on scientific approaches
to patient safety, while helping to
build a cadre of safety advocates who
could bolster their organizations’
ability to lead improvement efforts.
Meanwhile, the incidence of central
line-related bloodstream infections
in Abu Dhabi’s 17 ICUs has dropped
by nearly a third.
“We are creating a community where
the staff has new lenses for patient
safety and is incorporating safe practices into their daily routines,” says
anesthesiologist Sean Berenholtz,
co-investigator on the project.
We are creating a community where
the staff has new lenses for patient
safety and is incorporating safe practices
into their daily routines.
18 • Armstrong Institute Annual Report 2013
To encourage this change, the institute has led monthly coaching calls
introducing participants to concepts
such as the science of safety, the
Comprehensive Unit-based Safety
Program, and best practices for the
prevention of central line-related
bloodstream infections. The team
built a new social networking site to
allow the community to talk across
hospitals and work together as a team
on assignments and projects. A new,
online Patient Safety Certificate Program prepared 40 participants to be
change agents in their organizations.
Sean Berenholtz,
Hanan Edrees
Participating ICUs are also measuring teamwork and safety culture, for
the first time, and feeding results
back to the staff and senior leaders.
The emirate’s health organization,
SEHA, has been “tremendously
supportive of efforts to change the
attitude of providers toward a culture
of safety,” says Berenholtz. Still,
creating an atmosphere where health
care workers feel free to speak openly
about safety hazards without fear of
retribution will take time. Traditionally in the Middle East, he notes,
clinicians are often hesitant to speak
up with safety concerns. Some fear
losing their jobs if they admit that
they themselves have committed
an error.
Continents away, the project is
helping to create a greater sense
of community. During a visit to
the emirate in May, an Armstrong
Institute team recognized that the
hospitals’ patient safety teams had
never met or discussed common
concerns. “That was an eye-opener,”
recalls Hanan Edrees, the institute’s international project manager.
Over the course of the project, she
says, the teams have begun to gel,
encouraged by some of the results
they see. Bloodstream infection rates
have dropped to zero on some units.
“Everyone is very excited,” Edrees
says. “Teams are engaged in the
project and are communicating more
often. As a result, their infection
rates are decreasing.”
Fifty-eight ICUs in 43 Maryland and
Pennsylvania hospitals are participating in a five-year project to eliminate
ventilator-associated pneumonia
(VAP). Funded by the Agency for
Healthcare Research and Quality
(AHRQ) and the National Heart,
Lung, and Blood Institute of the
National Institutes of Health.
Reducing Surgical
Complications
The institute is partnering with the
American College of Surgeons in a
four-year undertaking to reduce preventable infections and complications
during inpatient surgery. So far, more
than 150 hospitals across the country
are participating. Funded by AHRQ.
Cardiac Surgery Care
Twelve hospitals across the United
States are participating in a threeyear study to improve the safety of
patients undergoing cardiac surgery.
Teams in each hospital’s cardiac OR,
ICU and surgical floor seek to eliminate hospital-acquired infections while
enhancing teamwork and communication at transitions of care. Funded
by AHRQ.
Improving ED Discharge
The institute is collaborating with the
Department of Emergency Medicine
and the Johns Hopkins Bloomberg
School of Public Health to develop a
tool that addresses the complex issues that lead to discharge-related
problems in the Emergency Department. Funded by AHRQ.
Understanding Patient- and
Family-Centered Care
Our research identified U.S. hospitals that excel—or have seen great
improvements—in delivering patientcentered care. Selected hospitals
presented their strategies at a bestpractices conference in Sept. 2013.
Funded by AHRQ and the Gordon and
Betty Moore Foundation.
Controlling Blood Pressure
The institute is working with the
American Medical Association to
bring the high blood pressure of 10
million Americans under control
by 2017.
Armstrong Institute Annual Report 2013 • 19
DEEPENING ROOTS
Clinical
Communities at
Johns Hopkins
Medicine
Existing Communities
»» Intensive Care Units
»» Hospitalists
»» Medication Safety
»» Post-Anesthesia Care Units
»» Neonatal Intensive Care Units
»» Patient-Centered Care Across
Maternity Services
»» Cleaning, Disinfection and
Sterilization
»» Congestive Heart Failure
»» Surgery
Future Communities
(launch expected by
late 2013)
»» Behavioral Health
»» Diabetes
»» Joints
Clinical Communities gain traction as an approach
to improvement.
The key steps for preventing ventilatorassociated pneumonia (VAP) are wellestablished. Keep the patient’s bed at
a 30-degree angle. Perform twice-daily
mouthwashes. Drain secretions. Much
more complicated is translating those and
other evidence-based protocols into consistent, everyday practice on a large scale.
This difficult task is a focus of the ICU
Clinical Community, which convenes
providers from critical care units across
Johns Hopkins Medicine’s five Maryland
and District of Columbia hospitals. In
addition to implementing a bundle of
VAP prevention measures in each ICU,
clinical community participants have
rolled up their sleeves to identify and
remove barriers to safer ICU care.
One such barrier turned out to be a lack
of uniformity in medical equipment
purchases. “We had to be sure everyone
was using the same products,” says Brad
Winters, a Johns Hopkins intensivist
and co-chair of the ICU Clinical Community. Not all ICUs were using a new
suction device attached to breathing tubes
that is highly effective in draining secretions and reducing bacteria. “We had to
work closely with our purchasing departments to make this happen,” he notes. “It
took a lot of time and coordination.”
This is one of nine system-wide clinical
communities at Johns Hopkins working
on quality improvement projects. By the
end of 2013, three more communities will
be started.
As opposed to top-down improvement
efforts, the clinical community is built on
faith in the wisdom of front-line clinicians
and staff. The community establishes
quality and safety initiatives, sets project
goals, and develops metrics to monitor
progress towards achieving those goals.
The institute facilitates these groups,
providing not only administrative support
20 • Armstrong Institute Annual Report 2013
We’re learning
from each other.
It’s been incredibly
valuable.
but also access to core resources, such
as expertise in measurement and
improvement tools.
The ICU Clinical Community is working on multiple other projects, such as
installing a system-wide ICU dashboard
and getting ventilated patients moving
as soon as possible, to avoid what studies
have shown can be the damage from long
durations of mechanical ventilation.
But perhaps what is most important is
how these groups “are continuing to
gel,” says the Armstrong Institute’s Lois
Gould, who directs the Clinical Community effort. “It’s truly a team effort
where you can be open, direct and say
what’s on your mind,” while zeroing in
on improvements that can be shared
throughout the Johns Hopkins system.
Another benefit is already evident in the
ICU Clinical Community: closer working partnerships among intensivists at the
five hospitals. Previously, “we didn’t have
much of a relationship with the academic
hospital ICUs,” admits Leo Rotello,
medical director of Suburban Hospital’s
ICU and director of critical care for
Johns Hopkins Community Physicians.
Through the work of the clinical community that Rotello co-chairs, “there’s been
increased sharing of ideas and enhanced
coordination in transferring ICU patients
to more specialized units.”
“We’re learning from each other,” Rotello
says. “It’s been incredibly valuable.”
Mike Zenilman
PEERING AT SCOPES
One new clinical community sets its sights on an infection hazard.
Fifteen million times a year in the
United States, the flexible gastrointestinal endoscope screens various parts of a
patient’s GI tract. If not properly sterilized, these and other scopes are prime
breeding grounds for bacteria. That’s
why one newly formed clinical community is initially focusing on this essential
medical device.
“While most of the time endoscopy
is a safe procedure, if one scope is not
sterilized correctly, hundreds of patients
are placed at risk for infection,” says
Michael Zenilman, a general surgeon at Suburban Hospital, regional
director of surgery for Johns Hopkins’
community hospitals and co-chair of the
Cleaning, Disinfection and Sterilization
Clinical Community.
While many clinical communities at
Johns Hopkins Medicine have been
created around a setting of care—such
as ICUs and hospital medicine—this
quality improvement model is also being
harnessed to help with specific processes
of care, bringing together experts from
multiple care settings and disciplines.
This Cleaning, Disinfection and
Sterilization community, for instance,
includes infection control specialists,
surgeons, nurses, environmental service
leaders, executives, risk managers and
quality improvement specialists who
recognize the risks posed by improper
care of reusable devices and instruments.
Following an initial survey and analysis,
the group decided to target the cleaning
of endoscopes.
“Unclean scopes can have pretty
devastating results, such as transmitting hepatitis and HIV,” says Renee
Blanding, vice president for medical
affairs at Bayview and co-chair of the
clinical community.
The first order of business for this
clinical community was taking inventory of all the endoscopes across Johns
Hopkins Medicine. “You’d think
we would know, but we don’t,” says
Zenilman. Blanding recalls walking
around Bayview one day and discovering
that there are hundreds of scopes within
the facility, often with very specific instructions for cleaning and sterilization.
Once it has catalogued all of these flexible scopes, the community will analyze the problem and seek to establish
standards throughout Johns Hopkins
Medicine for maintaining germ-free
equipment. “The risk if we don’t do this
is huge,” Zenilman says.
Armstrong Institute Annual Report 2013 • 21
ADVANCING
PERFORMANCE
MEASURES
For health care performance measures to motivate
improvement, they must be valid and meaningful,
with broad buy-in from clinicians, patients, insurers,
policy-makers and others. Then, they need to become
highly visible within health care organizations so that
staff become engaged in raising their marks. The
Armstrong Institute is working on both fronts in this
rapidly evolving field.
GAUGING OUR PROGRESS
New dashboard will provide customized quality
and safety measures to staff across Johns Hopkins.
Across health care, clinicians often
operate blind to measures of how well
they are performing in critical areas.
While hospital-acquired infection
rates, patient survey results and the
like are discussed in the boardroom
and departmental meetings, those on
the front lines get little feedback about
aspects of care they might improve.
The Armstrong Institute plans to drastically change that when it introduces
the Johns Hopkins Medicine Quality
and Safety Dashboard. This Web22 • Armstrong Institute Annual Report 2013
based display will allow staff across the
organization to see customized data
on how well their unit, service and
hospital is performing in key measures.
It debuts in late 2013 or early 2014.
With the dashboard, “you can really
see trends and evaluate performance
over time so you know where to
improve,” says Nana Khunlertkit,
a human factors engineer with the
institute. She feels it will be especially
valuable to clinical staff because for
the first time, they will have a more
Nana Khunlertkit
detailed understanding of how their
unit is performing.
Initially, four performance areas will
appear on the dashboard: patient
experience of care survey results; rates
of ICU central-line infections; handhygiene compliance; and selected core
measure scores (acute myocardial infarction, childhood asthma, heart failure, immunization of patients, surgical
care improvement and pneumonia).
Performance data will be accessible to
everyone from patient transport staff
to clinicians to hospital executives. Each
will be able to see an individualized view
of their unit’s, service’s or hospital’s safety
and quality data. They also can compare
their unit’s performance to other units
within the system’s five acute care general
hospitals, or to organizational targets.
Bringing these measures together into
one online repository has been a complex and massive undertaking for the
institute’s faculty and staff, including its
Clinical Informatics team. The project
has required pulling together data held in
different electronic systems from multiple
hospitals, while ensuring uniformity of
measurement and reporting methods.
Such an all-in-one view is not available
yet. “To date, quality and safety reports
have not been joined together,” says Matt
Austin, an institute instructor guiding on
the dashboard project. “They’ve not been
customized to the user. It has been a
disparate system.”
A prototype dashboard was evaluated this
summer by 150 individuals at five Johns
Hopkins-affiliated hospitals. The common
response from front-line staff “was pretty
awesome,” says Khunlertkit, who handled
the usability testing. Focus group responses were uniformly positive and many commented on how valuable the dashboard
would be for them, she notes.
As the dashboard project matures, the list
of measures will continue to expand, with
an ultimate goal of the dashboard becoming part of the electronic health record, so
staff can tap this resource quickly.
Armstrong Institute Annual Report 2013 • 23
GRADING CARE
Institute provides guidance on The Leapfrog Group’s safety and quality ratings.
Try assigning a single letter grade
to a hospital’s patient safety performance and you can be sure that
your scoring methodology will be
scrutinized—particularly by those
not at the top of the class.
That was the predictable result after
the nonprofit The Leapfrog Group
released its first Hospital Safety
Score on thousands of hospitals
across the country. While “A”
hospitals hailed their grades as
further evidence of high-quality
care, those receiving D’s and F’s
often took issue with their results
and how the highly publicized score
was compiled.
To ensure the continued validity of
its score and to stay on top of the
quickly evolving world of health
care performance measurement,
The Leapfrog Group tapped the
Armstrong Institute to provide
scientific guidance for both the
Hospital Safety Score and its longrunning Leapfrog Hospital Survey.
A team of researchers led by Matt
Austin, an Armstrong Institute
instructor and former director of
Leapfrog’s survey efforts, is spearheading this work.
“We are taking responsibility for
the science of these ratings and
providing research guidance to
Leapfrog on the performance measurements,” Austin says.
This assignment not only involves
analyzing the integrity of the current safety measures that make up
the composite score but researching
potential additions, recommending changes in Leapfrog’s scoring
algorithm, and working closely
with the group’s Blue Ribbon Expert Panel of eight national patient
safety experts on the Hospital
Safety Score. This panel includes
Armstrong Institute Director
Peter Pronovost.
Additionally, Austin’s team
is serving a support role for
Leapfrog’s staff in making these
measurements understandable to
the general public.
The institute’s demonstrated expertise in applying research to practice
led to this collaboration, according to Leah Binder, president
and CEO of The Leapfrog Group,
which works on behalf of employers and purchasers everywhere to
inform Americans about the quality
and safety of care. Partnering with
the Armstrong Institute “assures
that the information we give people
to make life-and-death decisions
about their hospital care is supported by the best evidence.”
The institute has already helped to
make adjustments in the methods
behind the Hospital Safety Score,
which is based on publicly available
data. For instance, some medical
centers complained that they were
marked down for not reporting
data through Leapfrog’s voluntary
annual survey. In those cases, Leapfrog turned to data from the American Hospital Association to assign
a letter grade for safety. After an
empirical analysis, Austin revised
the method for using this data to
make sure scoring was fair.
This joint initiative with Leapfrog
builds on previous collaborations
between the two patient safety
groups. Pronovost serves as the
longtime chair of Leapfrog’s ICU
Physician Staffing expert panel—
which put forth a key measure in
assessing if hospitals are using specially trained physicians in caring
for the sickest patients.
The arrangement holds potential
long-term benefits for the institute.
Assisting the Blue Ribbon panel,
notes Austin, should lead to valuable insights and new collaborations. “Together we will be creating
standardized methods for measuring patient safety performance,”
he says.
We are taking responsibility for the science of
these ratings and providing research guidance to
Leapfrog on the performance measurements.
Matt Austin
24 • Armstrong Institute Annual Report 2013
Armstrong Institute Annual Report 2013 • 25
ORGANIZATIONAL
CHART
BY THE NUMBERS
LEARNING AND DEVELOPMENT
JHM PATIENT SAFETY
& QUALITY BOARD
JHM QUALITY SAFETY
& SERVICE EXECUTIVE
COMMITTEE
ARMSTRONG INSTITUTE
FOR PATIENT SAFETY
& QUALITY
ARMSTRONG INSTITUTE
ADVISORY BOARD
TEAM
COMMUNICATIONS
BUILDING/
COUNCIL
INTERNAL
IMPROVEMENT
COUNCIL
INTERPROFESSIONAL
QUALITY AND SAFETY
COUNCIL
HEALTH POLICY
& OPPORTUNITY
COUNCIL
RESEARCH
FACILITATION
COUNCIL
26 • Armstrong Institute Annual Report 2013
PRODUCT
DEVELOPMENT/
MARKETING
COUNCIL
PATIENT- &
QUALITY
EXTERNAL
QUALITY & SAFETY
PERFORMANCE INFORMATICS FAMILY-CENTERED
COUNCIL
CARE COUNCIL
COUNCIL
COUNCIL
$10.5 million Contract and grant funding for sponsored projects in fiscal year 2013 ($5.25 million private, $5.22 million government)
150
U.S. hospitals participating in the Surgical Unit-Based Safety Program, an Armstrong Institute- led effort to reduce preventable complications and infections in inpatient surgery
58 ICUs across 43 hospitals in Maryland and Pennsylvania participating in a five-year project to reduce ventilator-associated pneumonia
12
Cardiac surgery centers participating in the Cardiac Surgical Translational Study, a three-year
study to reduce health care-associated infections and improve teamwork and coordination of care
18
Disciplines working on the EMERGE project to create the next-generation ICU
IMPROVEMENT WORK AT JOHNS HOPKINS MEDICINE
89
40 4
EDUCATIONAL
DEVELOPMENT
COUNCIL
CLINICAL
COMMUNITIES
COUNCIL
LEAN SIGMA
COUNCIL
IMPROVEMENT PROJECTS AROUND THE UNITED STATES AND WORLD
ARMSTRONG INSTITUTE
EXECUTIVE COMMITTEE
PHYSICIAN QUALITY
AND SAFETY COUNCIL
14,500 Registrations for “The Science of Safety in Healthcare,” a massive online open course led by Armstrong Institute faculty, Cheryl Dennison-Himmelfarb of the school of nursing and Peter Pronovost. (1228 participants received a Statement of Accomplishment)
1700
Members of the JHM community completing the Science of Safety online training module
460
Participants at 4th Annual Johns Hopkins Medicine Patient Safety Summit. This conference
featured 50 podium presentations and 75 posters.
352
Trained in Lean and Lean Sigma (including 222 internal)
164
Participants in CUSP Implementation Workshop (including 97 internal)
160
Johns Hopkins medical and nursing students completing the TIME safety course
78
Participants in five-day Patient Safety Certificate Program (including 71 internal)
16
Armstrong Institute Resident Scholars in the program’s first year
COMMON
PREVENTABLE
CAUSES OF HARM
COUNCIL
SERVICE LINE
PROTOCOLS
COUNCIL
Active CUSP teams in existence, a 117 percent increase from two years ago
Workgroups created with Armstrong Institute support to improve performance on core measures
Hospitals across Johns Hopkins Medicine receiving the Delmarva Foundation Quality Award for their performance on core measures
FACULTY
105
5
Faculty affiliated with the Armstrong Institute (70 core, 29 associate, 6 visiting)
Johns Hopkins University divisions represented (schools of medicine, nursing, business, engineering and public health)
Armstrong Institute Annual Report 2013 • 27
AT A GLANCE
July 2012
With 16 participants, the first cohort
of Armstrong Institute Resident
Scholars begins a yearlong program
that prepares these early-career
physicians for career paths in
patient safety and quality.
November 2012
August 2012
Gordon and Betty Moore Foundation announce
$8.9 million grant to the Armstrong Institute,
to eliminate harms in the ICU and better
engage patients and their families as
members of the care team. The grant
brings the foundation’s total support of
the institute to $9.4 million.
December 2012
Institute hosts National Workshop
on Quality for Medical Education,
exposing residents and medical
students to the potential for
integrating quality and safety
into their clinical careers.
Marty Makary, an Armstrong Institute
core faculty member, and Peter
Pronovost report that surgical “never
events,” such as retained sponges,
occur an estimated 4,000 times
per year in the United States.
Institute hosts ICU Innovation Day,
bringing together clinicians, engineers,
industry, consumer groups and others
in a workshop to envision the ICU of
the future.
Diagnostic Error in Medicine
Conference, which the institute
co-hosts with Society to Improve
Diagnosis in Medicine, is held at
the Johns Hopkins medical
campus.
Institute announces that it will provide scientific
guidance to national nonprofit The Leapfrog
Group for its Hospital Safety Score and
Leapfrog Hospital Survey.
Institute staff moves to
Constellation Energy Building
in downtown Baltimore.
May 2013
April 2013
March 2013
The institute hosts its second Innovation
Day, bringing together early-career
students, residents and others to
share their ideas on what the
next-generation ICU should look
like.
A bedside electronic device that measures
eye movements can determine whether
severe dizziness is stroke or something
benign, reports neurologist David
Newman-Toker, a core faculty
member with the institute.
Online patient safety certificate course
makes its debut in Abu Dhabi as part of
an improvement project with SEHA,
the emirate’s health authority.
Forty-seven participants meet at Armstrong
Institute for a full–day workshop on using
electronic health records to improve patient
safety, sponsored by the National Institute
of Standards and Technology. The meeting
leads to a series of recommendations
issued in August.
Peter Pronovost named #5 most
influential physician executive by
Modern Healthcare.
28 • Armstrong Institute Annual Report 2013
June 2013
Researchers, including Armstrong Institute
faculty, report that hospitals may be reaping
enormous income for ICU patients whose
hospital stays are complicated by preventable
bloodstream infections. Private insurers paid
the most for these stays—about
$400,000—while hospitals lost money
when the government paid.
More than 460 people attend the 4th Annual Johns
Hopkins Medicine Patient Safety Summit, which is
supported and organized by the Armstrong
Institute as well as patient safety officers
across the organization.
Hospitals should randomly test physicians for drug
and alcohol use to protect patient safety, in much the
same way as other industries to protect their
customers, write Armstrong Institute faculty
members Julius Cuong Pham and Peter
Pronovost in the Journal of the American
Medical Association.
Armstrong Institute Annual Report 2013 • 29
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