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T1 - An interview with Peter Pronovost.
AU - Pronovost, Peter J.
N1 - Funding Information: Interviewed by Steven Berman Peter J. Pronovost, M.D., Ph.D. Peter J. Pronovost, M.D., Ph.D., the year’s John M. Eisenberg Patient Safety and Quality Research Award recipient, is a nationally recognized authority in patient safety. He is an Associate Professor in Anesthesiology and Critical Care Medicine, Surgery, Nursing and Health Policy and Management at Johns Hopkins University, Baltimore, and has been the Medical Director of the Johns Hopkins Center for Innovations in Quality Patient Care since its inception in July 2002. Dr. Pronovost has spearheaded major changes in Hopkins’ intensive care units by translating evidence-based research into practical tools that improve the delivery of health care. Safety programs at Hopkins have resulted in decreases in medication mistakes, the time a patient spends in the intensive care unit (ICU), and bloodstream infections during hospitalization. These successes led to grants in Michigan and several other states to implement statewide field-tested best practices in hospitals that minimize the chance of medical errors and enhance patient protections in ICUs. Dr. Pronovost’s interest in patient safety was prompted by a personal tragedy. During Dr. Pronovost’s fourth year as a medical student at Johns Hopkins, his father died as the result of an error made by a hospital in New England. Since then Dr. Pronovost has focused his career and his research on patient safety and has been a major force in propelling safety to the top of Hopkins’ priority list. Peter J. Pronovost, M.D., Ph.D. photo courtesy of Tony Brown; www.imijphoto.com Congratulations on the award, Peter . Thank you very much. Receiving this award is a tremendous honor. It’s especially meaningful to me because my wife, Marlene Miller, worked for John Eisenberg at the Agency for Healthcare Research and Quality (AHRQ) and because AHRQ has funded much of this research. John’s vision and courage to carry out that vision continue to inspire me and many other health services researchers. Although the award is going to me, it was really won by the many people who have made this research possible. They include members of the Johns Hopkins University Quality and Safety Research Group; my staff and colleagues at the Hopkins Hospital, School of Medicine, and Bloomberg School of Public Health; the Institute for Healthcare Improvement; VHA; and hundreds of hospitals that are working to implement our interventions. (See Table 1 , above, for a list of Dr. Pronovost’s current projects on quality and safety in ICUs.) I must also thank Marlene and my children, Ethan and Emma, who have graciously put up with me working many nights so this work could be possible. How did you get involved in the Leapfrog Group’s requirement that ICUs be staffed by intensive care physicians? It started, interestingly, with my Ph.D. thesis, in which I found that daily rounds by an intensivist produced a threefold reduction in mortality for high-risk surgical patients. 1,2 About a month after it was published—during my first month on the Johns Hopkins faculty—Arnie Milstein, the Leapfrog Group * * The Leapfrog Group is a consortium of more than 145 large health care purchasers committed to a common set of purchasing principles through which to leverage dramatic improvements in the safety, quality, and overall value of health care. The Leapfrog Group was the recipient of the 2003 John M. Eisenberg Patient Safety Award for Advocacy for “developing national purchaser consensus around a series of focused patient safety goals and leveraging their implementation in hospitals.” 3 medical director, called to say he’d read the paper and wanted to discuss making the use of intensivists in ICUs a Leapfrog Group patient safety standard. 4 This would mean that large purchasers of health care would create incentives to ensure that ICU patients are cared for by intensivists. He invited me to General Motors to address CEOs and medical directors of the largest managed care companies involved in contracts with the automaker. At the meeting, Harry Pearce, General Motor’s Executive Vice President, made a startling comparison. He explained that when a General Motors worker dies on the job, work stops for a week or two while the company investigates the cause and corrects any system failures that contributed to the accident. As a result, he added, the company has a very safe work environment. Yet GM has not secured the same degree of safety when their employees receive health care; indeed, every day a GM employee dies from the lack of an intensivist and that was not tolerable anymore. General Motors and other large purchasers decided to create purchasing standards and one of those, based to a great extent on our research, was that ICUs be staffed by intensivists. Since then, hospitals’ efforts to implement ICU physician staffing and improve ICU care have had a relatively dramatic impact on patient outcomes. Indeed, we’re currently conducting research, funded by The Commonwealth Foundation, on how hospitals throughout the United States have responded to The Leapfrog Group’s ICU Physician Staffing (IPS) Patient Safety Standard. What are some of the tools you’ve developed to improve quality and safety? Well, there are many, but let me start by focusing on one that carries particular importance. It’s a Web-based Intensive Care Unit Safety Reporting System (ICUSRS) funded by the Agency for Healthcare Research and Quality. 5 We’re conducting a project with 30 ICUs that are using the reporting system to improve patient safety by identifying and eliminating system failures that lead to health care errors. 6 Caregivers will submit incident reports on near misses and adverse events. Our research team will analyze them and send reports back to participating units to help improve patient safety. We also disseminate our lessons broadly through the Society of Critical Care Medicine. 7 At this point we’re still in the first phase of collecting the incident reports. We are just beginning to understand how caregivers and administrators use these data to improve patient safety. It’s safe to say that more research is needed to understand how to code and, just as importantly, to make sure that people use the data to make improvements. Still, this error reporting system is an excellent example of using a scientific approach to improve quality and safety. I’ve also had a hand in developing the Comprehensive Unit-based Safety Program (CUSP) and daily goals. Despite the awareness of the need to improve safety, little evidence suggests that safety has improved. We designed and validated an eight-step CUSP in a surgical ICU (SICU) at Johns Hopkins Hospital (JHH) and disseminated the intervention in a second ICU (Weinberg Intensive Care Unit, or WICU 8,9 ). [See Table 2 on page 662.] Culture of safety improved in post versus pre-intervention period in both ICUs. The percentage of responders reporting a positive safety climate on a safety culture survey developed by Sexton 10 increased from 35% to 52% in the first ICU and from 35% to 67% in the second ICU ( p < .05). The identification of safety concerns and partnering with leadership led to the incorporation of medication reconciliation at time of discharge and use of short-term goal sheets. Medication reconciliation identified 134 preventable errors in a 16-week period at time of unit transfer in the first ICU and 450 preventable errors in a 26-week period at time of unit transfer in the second ICU. Medication errors in patient transfer orders decreased from 94% to zero. 11,12 One year after CUSP implementation, length of stay (LOS) decreased from an average of two days to one day in one ICU and from three days to two days in the other ICU. Nursing turnover decreased from 9% to 2% and from 8% to 2%. Hundreds of hospitals around the world are using this program. What about the daily goals? An estimated 85% of errors across industries result from communication failures. In one study, we used a one-page daily goals form to improve the effectiveness of communication during patient care rounds in the ICU. 13 All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percentage of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared to measurements of understanding following implementation of a daily goals form. At baseline, fewer than 10% of the residents and nurses understood the goals of care for the day. After we implemented the daily goals form, more than 95% of nurses and residents understood the goals of care for the day, and LOS in the ICU decreased from a mean of 2.2 days to 1.1 days. The daily goals form, which helps caregivers manage the work of patient care and improve communication among the care team, has broad applicability in acute care medicine. We have now developed several additional tools to improve teamwork and communication. How did the Center for Innovations in Quality Health Care come about? As an outgrowth of some of the work and research we’re doing in the ICU, in 2002 university president Bill Brody, Johns Hopkins Medicine dean/CEO Ed Miller, and Hopkins Hospital and Health System President Ron Peterson created the Center for Innovations in Quality Patient Care, of which I am the Medical Director. I am extremely fortunate to be at Hopkins because these leaders have a strong commitment to improve patient safety and quality of care. The Center for Innovations in Quality Patient Care is the learning lab for Johns Hopkins. It helps support functional units and clinical departments’ efforts to improve quality and safety by developing training and teaching modules and, more importantly, the tools to measure their successes. We take quite a different approach to problem solving than the traditional method of identifying an issue, appointing a committee, and methodically working toward a consensus-arrived conclusion. In fact, our process is much like the Toyota Production Method models, which allows us to employ innovative, rapid-cycle projects to improve patient care. When it comes to protecting patients from harm, time means everything. I would like to say that we bring science to the delivery of health care. How do you measure system performance? Well, as you know, this is a difficult issue in health care in general. Many measures lacked validity, and there are arguments over whether we should measure processes—what we do—or outcomes—the results we get. It is known that the results of outcome measures are influenced by such variations as quality, patient demographics and case mix, how we define and collect the data, as well as random error. What we see is that the variations in case mix and the methods of data collection often differ widely among hospitals, making comparison difficult in the absence of standard and rigorous tools to collect data. On the other hand, within a hospital, methods of data collection and case mix are relatively constant over time and provide a rich information source for looking at performance over time. We’ve taken consistent data at Hopkins and focused on four measures. The first is “How often do we learn from our defects?” The second is “How often do we carry out what we’re supposed to do?” In other words, in areas where there are evidence-based measures, how often are we adhering to them? The third is “How often do we harm patients?” Finally, “How well do we improve the culture?” To answer the question of how often we do what we are supposed to, we developed a five-step model that combines evidence-based medicine and quality improvement. We asked teams to pick a patient population and outcome, such as catheter-related bloodstream infections in critically ill patients, to find out what the evidence says we should do for them. Most of this literature has been synthesized in the form of practice guidelines or systematic reviews. This is where we extend current knowledge by culling out the main features of the guideline and measuring whether we’re doing what the evidence says to do. A lengthy guideline, for example, can be boiled down to the following five processes: ■ Don’t use lines if you don’t need them ■ Wash your hands ■ Use full barrier precautions when you’re inserting lines ■ Clean the insertion area with chlorohexadine ■ Avoid the femoral site, if possible So, we created a checklist for these five procedures and converted a verbose guideline into a simple tool that has been broadly implemented in hospital units. Consequently, we’ve seen pretty profound results. One of the insights that we’ve seen from this approach is that when you create a system that reliably delivers the processes or interventions that work, spectacular performance improvement follows. A number of Hopkins ICUs, for example, have gone for over six months (several as long as a year) without a catheter-related bloodstream infection. We’ve seen hospitals working with the Institute for Healthcare Improvement and VHA replicate this evidenced-based checklist and achieve similar results. Now, we’re putting the same tool into several states’ hospitals. Can you elaborate more on these statewide efforts? We’ve been fortunate to receive Agency for Healthcare Research and Quality funding to initiate a statewide effort in Michigan in which hospital ICUs are using our safety programs to reduce mortality, LOS, catheter-related bloodstream infections, and ventilator-associated pneumonia, as well as to improve safety culture. We have packaged several of the interventions I’ve already described into a program that includes both interventions and evaluation tools. 14 We’ve provided our well-tested measurement and intervention tools, which work in academic and community hospitals. Participation is purely voluntary, but we’ve found that hospital administrators and health care professionals uniformly are committed to this patient safety project, as they recognize without the ability to evaluate the process and document outcomes, their efforts would be compromised and likely not continue. This intervention has really taken off. We started in July 2003 with 40 hospitals in Michigan and are now up to 110 ICUs from more than 70 hospitals. These hospitals, in partnership with the Michigan Hospital Association, are conducting outstanding work. We are replicating the project in New Jersey and Maryland and are in discussion with several other states. This experience tells us that state hospital associations provide a good scale for replication. We hope that by 2006 the project could be in all 50 states. You mentioned learning from defects; can you discuss your general approach for how we may accomplish this? As I’ve learned from experience and discussions with colleagues from the Institute for Healthcare Improvement, the science of reliability, or reducing defects, which is well established in other high-risk industries such as aviation and nuclear energy, has great potential in health care. Those industries’ experiences tell us that our defect rates will never decrease until we standardize a process through the use of guidelines. Unconstrained performances by individual caregivers pose too great a risk for defects or errors. Even so, health care still tends to resist standardization, and physician autonomy clearly remains an issue that we need to address. Once we standardize, we need to create independent checks for critical steps in the process, and finally, we need to learn from our defects. This type of approach may move us from our current level of 1 defect per 10 patients to 1 defect per 10,000 patients. 15,16 If health care is to embrace standardized practices and processes, it needs to build a culture that breaks down traditional hierarchies that impede change, while at the same time, nurtures collaboration—a culture of safety where people speak up when they have concerns and listen when others do. For example, I can illustrate this point by going back to the catheter-related bloodstream infection checklist that we developed at Hopkins. In the surgical intensive care unit, nurses initially were reluctant to halt a procedure when the checklist wasn’t followed by a physician or resident. “We’ll get our heads bitten off for doing that” was a familiar comment. But once I made it clear to physicians that nurses can and will take charge of the checklist, the culture began to change. Once a culture is changed, it opens up the opportunity to redesign work processes. Take for example, a glucose management protocol, which our surgical ICU nurse manager developed on the basis of evidence that showed that this could reduce morbidity and mortality. One of the problems we found in reducing defects is that we hadn’t defined the defect. There are many variations in how it can be defined, but the point is that you need to pick one. We defined our defect to be 3 blood glucoses out of range within 24 hours of admission. When that defect arises, a physician is notified and the patient is put back on the glucose protocol. To learn from that defective situation, the nurse manager holds weekly glucose rounds, where she reviews patients who are on the protocol, discusses with staff what the barriers to adherence were and how we might change things so they do adhere. I believe that this model is very practical and could be broadly applied throughout health care. Where do you see the future of patient safety? I see both encouraging and discouraging signs. The encouraging signs are that, through discussions with hundreds of health care senior executives, there is general awareness that patient safety is an issue. There is also commitment to fix the problem, although uncertainty about how to do this. The research community needs to help produce practical interventions and methods to evaluate their impact. The discouraging sign is that the field is in its infancy. We need to view the delivery of health care as a science and this will require research funding. Current funding for patient safety research is insufficient to produce the new knowledge that is needed. If we are to cross this quality chasm, federal funding for health services research must significantly increase. Otherwise, we will continue to produce a system where we identify interventions that improve outcomes yet use those therapies only half the time.
PY - 2004/12
Y1 - 2004/12
UR - http://www.scopus.com/inward/record.url?scp=14944380617&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=14944380617&partnerID=8YFLogxK
U2 - 10.1016/s1549-3741(04)30077-8
DO - 10.1016/s1549-3741(04)30077-8
M3 - Article
C2 - 15646097
AN - SCOPUS:14944380617
VL - 30
SP - 659
EP - 664
JO - Joint Commission journal on quality and safety
JF - Joint Commission journal on quality and safety
SN - 1549-3741
IS - 12