Seeing a Way Forward

Peter Pronovost, MD, PhDJohns Hopkins University

Bilateral cued finger movements

Translational Research Model

UnderstandingDisease Biology

T1Translating to Humans

ImprovedHealth

Outcomes

Identifying andComparing Effective

TherapiesT2

Translating to Practice

Implementing,Disseminating and

Sustaining Research,Monitoring Outcomes

Summarizingevidence andunderstanding

if and howthese therapieswork in practice

Formulating,Analyzing, and

TestingPre-Clinical

Models

Figure 1

Translation Superhighway

Pronovost

The Safety of Healthcare 2000 -2005

Median Improvement : 2000-2005

All Selected Measures (117) 1.9%

Heart Disease (n= 16) 5.6%

Cancer (n=15) 3.6%

Maternal & Child Health (n=12) 1.5%

Safety (n=25) 1.0%

Diabetes (n=9) 0.6%

National Healthcare Quality Report 2008

Disparities in Healthcare Quality are

Staying the Same or Increasing

n=number of core measuresNational Health Disparities Report 2008

Will you commit to eliminate preventable harm and suffering in

your unit, organization, state, or nation?

Are the citizens of Tennessee less likely to

harmed?

How do we know?

ICU Safety Dashboard2007 2008

How often did we harm (BSI)

How often do we do what we shouldHow often did we learn from mistakes% Needs improvement in Safety climateTeamwork climate

Pronovost JAMA 2007

Comprehensive Unit-based Safety Program (CUSP)

1. Educate staff on science of safety http://www.jhsph.edu/ctlt/training/patient_safety.html

2. Identify defects3. Assign executive to adopt unit4. Learn from one defect per quarter and implement

teamwork tools

Pronovost J, Pronovost J, Patient Safety,Patient Safety, 20052005

Translating EvidenceInto Practice

* Envision the problemwithin the larger health

care system

* Engage collaborativemulti-disciplinaryteams centrally(stages 1,2,&3)

and locally(stage 4)

1. Summarize the Evidence

Convert interventions to behaviors

2. Identify local barriers toimplementation: understandthe process and context of

work

3. Measure Performance

4. Ensure all patientsreceive the interventions

Identify Interventions associatedwith improved outcomes

Select interventions with the largestbenefit and lowest barriers to use

Enlist all stakeholders to shareconcerns and identify potentialgains/losses associated withintervention implementation

Observe staff performing theinterventions

"Walk the process" to identifydefects in each step of intervention

implementation

Measure Baseline Performance

Develop and pilot test measures

Select Measures(process and/or outcome)

Engage

Explain why the interventions are

important

Execute

Design an intervention “toolkit” targeted to barriers employing standardization,

independent checks and reminders, and learning from mistakes

Educate

Share the evidence supporting the interventions

Evaluate

Regularly assess performance

measures

Interventions to prevent Blood Stream Infections:

5 Key “Best Practices”

• Remove Unnecessary Lines• Wash Hands Prior to Procedure• Use Maximal Barrier Precautions• Clean Skin with Chlorhexidine • Avoid Femoral Lines

MMWR. 2002;51:RR-10

Seniorleaders

Teamleaders

Staff

Engage How does this make the world a better place?

Educate What do we need to do?

Execute What keeps me from doing itHow can we do it with my resources and culture?

Evaluate How do we know we improved safety?

Pronovost: Health Services Research 2006

Ensure Patients Reliably Receive Evidence

Ideas for ensuring patients receive the interventions

• Engage: stories, show baseline data• Educate staff on evidence• Execute

– Standardize: Create line cart– Create independent checks: Create BSI checklist– Empower nurses to stop takeoff– Learn from mistakes: review infections

• Evaluate– Feedback performance– View infections as defects

Break Through Idea

• Technical versus Adaptive• I thou versus I it• Material versus relationship