I. Organization Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality

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1 I. Organization Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality II. III. Solution Title Pursuing High Reliability and National Leadership in Quality and Safety Program/Project Description, Including Goals The need to improve health care quality and reduce medical costs is well documented. Despite decades of efforts, patients continue to suffer preventable harm, much of this harm from failing to deliver recommended therapies. To remedy these problems and in response to changes in payment policy, hospitals are increasingly merging with other hospitals, physician practices, managed care organizations, home health agencies, and skilled nursing facilities to create large, integrated health systems. While such alliances offer promise, they create complex management structures that often pose challenges when coordinating improvement efforts and creating accountability across such convoluted health systems. Johns Hopkins Medicine (JHM), the academic health system that incorporates the Johns Hopkins University School of Medicine and the Johns Hopkins Health System (JHHS), is committed to improving value and advancing improvement science. JHM leaders formed the Armstrong Institute for Patient Safety and Quality (Armstrong Institute) to lead quality improvement and patient safety efforts throughout JHM, and created a management structure for the oversight of these efforts. Parallel to those efforts, the JHM Board of Trustees committed to becoming national leaders in patient safety and quality. The board s first empirical quality goal was to ensure that patients served by JHM received recommended care at least 96% of the time. Specifically, the board wanted JHM to meet or exceed 96% performance on core measures that enabled their hospitals to achieve the Delmarva Foundation for Medical Care Excellence Award for Quality Improvement in Hospitals and The Joint Commission Top Performer award, awards that had remained elusive for JHHS hospitals. This project focused on efforts across the JHHS to meet or exceed the 96% goal, evaluate the ability of JHHS to realize this goal, and determine the effectiveness of our board governance structure. IV. Process Armstrong Institute for Patient Safety and Quality The Armstrong Institute, housed within the Johns Hopkins University School of Medicine, coordinated the JHM initiative to achieve 96% performance on the core 1

2 measures. The Armstrong Institute coordinates the research, training, and improvement for patient safety and quality across JHM, partnering with the JHHS, the Johns Hopkins University schools of public health, engineering, business, and nursing and with the university s Applied Physics Laboratory and Berman Ethics Institute. The institute functions throughout JHM to build capacity for improvement science among staff, to advance the science of improvement, and to help design, implement, and evaluate improvement programs and support systems, and to create robust accountability systems. The goal of the Armstrong Institute is to partner with patients, their loved ones, and others to eliminate preventable harm, optimizing patient outcomes and experiences, and reducing wasted health care resources. The Institute comprises faculty and staff from over 8 schools and institutes representing 18 different disciplines. Setting The strategy was executed across five inpatient hospitals within Johns Hopkins Medicine. Four hospitals are located in Maryland; one in the District of Columbia. Two hospitals are academic medical centers (The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center); three hospitals are community hospitals (Howard County General Hospital, Sibley Memorial Hospital and Suburban Hospital). V. Solution Four-part Conceptual Model Clarifying and communicating goals A memorandum was sent from the chairman of the JHM Patient Safety and Quality Board Committee and the director of the Armstrong Institute to all staff clarifying the need for the 96% goal, identifying the Armstrong Institute as the coordinating body for the initiative, and asking everyone to work together to achieve the goal. Building Capacity Armstrong Institute staff conducted a gap analysis to identify core measures to target for improvement. AI leaders reviewed each hospital s compliance scores in 2011 and targeted a measure for improvement if the aggregate measure for the five hospitals was below 96%, or if any hospital performed below 96% for 2 of 12 months. Nine target measures were identified. In June 2012, AI leaders formed a clinical work group for each targeted core measure. Each group had an improvement team (physicians, nurses, information 2

3 technology staff, and quality improvement staff) from each hospital and an Armstrong Institute team (project manager, improvement science faculty member, and Lean Sigma Master Black Belt). The Armstrong Institute team coordinated the work and provided clinical and process improvement expertise. Groups met weekly for the first three months, then transitioned to meeting monthly. Work groups used a variety of Lean Sigma tools, such as process maps, fishbone diagrams, and the Define-Measure-Analyze-Improve-Control (DMAIC) framework to systematically identify failures and find ways to improve and control performance. Hospital teams used the A3 Lean Sigma tool to manage and communicate their DMAIC work. The A3 tool was used to aggregate performance at the individual measure, the hospital level, and the JHHS level and to produce reports for key stakeholders at each level. For example, Armstrong Institute staff generated a system-level A3 report for JHHS leaders and the JHM board, and hospital presidents presented their hospital-level A3 during performance reviews as part of the accountability plan described below. Transparency and Accountability The JHM Board of Trustees committed to transparently reporting results and developing a robust accountability plan for JHHS. To meet these promises, the Armstrong Institute created an electronic dashboard to report core measure performance by month for the year to date. Each hospital had a dashboard that displayed measures 96% in green and measures < 96% in red and could generate tailored reports (e.g., measures only for Delmarva award, calendar year). The JHHS leadership and Trustees developed a formal accountability plan, which was supported by the five hospital presidents and boards. The plan had an escalating four-step performance review process, with each step activated when a hospital performed below the 96% target on any given measure. Measures in the accountability plan were then reviewed quarterly at the JHM Quality and Safety Board Committee. Sustainability Once a hospital maintained at least 96% compliance on a core measure for four consecutive months, they initiated the sustainability phase for that measure. The hospital improvement team met with the Armstrong Institute team to review the sustainability criteria and examine the team s failure modes analysis and executed interventions to ensure they had a process that would sustain compliance. If any risks were found, the hospital team addressed them then drafted a sustainability plan using the A3. The completed plan for sustaining the core measure was signed by clinical, quality and executive leads and then submitted for review to JHM s 3

4 Quality, Safety and Service Executive Council and Patient Safety Quality Board Committee. VI. Measurable Outcomes In 2011, none of the five Johns Hopkins Health System hospitals received either the Delmarva Foundation Quality Award nor the Joint Commission Top Performer Award. In 2012, four of the five hospitals received one or both of the awards. In 2013, four of the five hospitals again received one or both of the awards. From 2011 to 2013, the Johns Hopkins Health system improved by 31% on the targeted measures where workgroups were launched and the components of the conceptual model implemented (chart below note that only seven measures are reported on as the methodology changed between 2011 and 2012 for the two immunization measures, and so the data is not comparable across years ). CY 2014 continues to show improvement, though final data is not yet compiled. 80% The Johns Hopkins Health System Percent of Seven Targeted Core Measures with Annual Aggregate Performance 96%± 70% 60% 50% 40% 30% 20% 10% 45% 69% 76% 0% CY 2011 CY 2012 CY 2013 Johns Hopkins Health System 4

5 VII. Sustainability Often, despite dedicated efforts to provide better care, improvement efforts are not sustained; the effort stops and performance reverts to baseline. A key component of our conceptual model was a sustainability plan for each core measure. We believe that this integrated conceptual model can be applied to other performance measures. For example, we are currently applying this model to improve performance on patient satisfaction scores, emergency department wait times, and health care associated infections. The model also supports long-term solutions by using the Lean Sigma framework to recommend hardwired stops that minimize workarounds and support sustainability. VIII. Role of Collaboration and Leadership In supporting local work, we learned the value of collaborating with clinical teams when strategizing around improvement work. As demonstrated through other studies, understanding clinical priorities and workflow realities is essential to process improvement. For model, physicians, nurses, technicians, clinical abstractors, information technology staff, quality staff, and leadership from Johns Hopkins Hospital participate in core measure work groups and describe the work flow and priorities in their areas. We also developed a new and explicit accountability plan with an escalating review process. This model established accountability at the board level, while continuously encouraging and supporting local innovation and improvement. This balance between interdependence and independence was important, highlighting the need to engage leadership while simultaneously supporting work at the frontlines. We were initially concerned that attempts to formalize an accountability plan would meet resistance, and were pleased that not only was it not resisted, it was supported. We attribute this support, in part, to hospital leaders participation in creating the accountability plan, to the Armstrong Institute for supporting the work of hospitals and teams, and to empowering local hospitals and units who know best how to improve their processes and work within their cultures do the work. Hospital leaders agreed to use the accountability plan for future improvement efforts. Also, the hospital presidents and department directors welcomed having the accountability focused where care was delivered. 5

6 IX. Innovation Governance Structure One of the components of our conceptual model is accountability, and the execution of a new governance structure to oversee quality of care across JHM. The governance structure provided a much-needed platform to help health system and hospital leaders manage quality of care efforts throughout a complex health system. Within this structure, a board committee was created that answered to the JHM Board of Trustees and also served as a subcommittee for each hospital board, connecting all entities and engaging them in common goals. Furthermore, as health systems expand, especially academic health systems, it is unclear who is overseeing quality in the many places where care is delivered and how that oversight links from bedside, through departments and entities, to a board structure. Our new governance is allowing this to occur in areas beyond the core measures. For example, AI and other JHM leaders are examining the oversight of all ambulatory surgery facilities, an area our safety leaders identified as high risk. In this effort, AI leaders are working to clearly define the roles and responsibilities for the president of ambulatory practice, the community hospital president, and the academic surgery department chair, in overseeing quality of ambulatory surgery throughout JHHS. This work is complex, and the JHM quality board committee provides both a home and an urgency to clarify the oversight of quality. Fractal Quality Improvement Infrastructure Another key aspect of this conceptual model is its interconnectedness, in which, like a fractal, groups are linked horizontally and vertically throughout the health system. The board reports focused on overall attainment of the goal. Leaders and work groups used the Lean Sigma A3 tool to communicate performance and present to quality leadership when the accountability plan was activated. The A3 tool was used to communicate failure modes, best practices and lessons learned in the core measure workgroups, and to create the foundation for the sustainability plan. By using a common communication tool, we tied individual work groups to hospital performance and to health system performance, ultimately allowing the board to evaluate performance and be accountable. Each aspect of the model worked together with the other strategic elements, and this helped support system-wide implementation and acceptance. 6

7 X. CONTACT PERSON a. Tiffany Callender b. Quality and Innovation Manager c. d