Beryl Rosenstein, M.D.

As one of the top-rated academic health systems in the United States, executives at Baltimore-based Johns Hopkins Medicine assumed they delivered the safest care possible. However, when data from an internal survey on patient safety revealed a gap between such perception and reality, leadership knew changes were necessary.

“We started thinking about how we could get hospital leaders involved in knowing what goes on at the front line and understanding patient care at the grassroots level,” says Beryl Rosenstein, M.D., vice president for Medical Affairs at Johns Hopkins Hospital.

After brainstorming, Johns Hopkins developed an initiative calling for senior leaders to adopt a hospital unit. This entailed holding monthly meetings with the staff, going on rounds, and acting as they unit's advocate.

Since 2003, around 35 leaders have adopted units, where they help manage issues that can be as simple as needing a new computer or an extra EKG machine, or as complex as preventing patient falls or deploying order entry. “Whether they are improvement changes, which don't require a big investment, or capital-intensive changes that take place over a longer period of time,” says Rosenstein, “I think just having the executives there gives the frontline staff a sense that they really care and that things can change.”

Stephanie Reel

Chip Davis, M.D., vice president for Innovation and Safety at Johns Hopkins Medicine, agrees. “We found that senior leaders can knock down barriers and move things along that perhaps the units themselves haven't been able to,” he says.

The goal, Rosenstein says, was also to make the organization seem a bit smaller, although it was no simple feat. John Hopkins Medicine is a $4.1 billion system that includes the Johns Hopkins School of Medicine and three facilities: Bayview Medical Center, Howard County General Hospital, and Johns Hopkins Hospital, which houses 1,017 beds and employs 1,714 full-time attending physicians and 1,089 residents and fellows.

With an organization of that size, it can be easy for staff to feel they are just a number. That's where the Center for Innovations in Patient Care and Quality comes into play. Led by Davis, who serves as executive director, the Center was created to improve care by providing staff with the means to correct system flaws and direct organizational change through initiatives like the adopt-a-unit program, also referred to as Comprehensive Unit Safety Program (CUSP).

Rosenstein says the initiative, which was led by Peter Pronovost, M.D., a professor of anesthesiology and critical care medicine, is “part of a broader institutional commitment to improve patient safety.” (See sidebar). Units that have benefited from CUSP include the Pediatric Intensive Care Unit (PICU), the Blood Bank and the Wilmer Eye Institute.

Case #1: The PICU

Three years ago, during a week in which her workload was uncharacteristically light, Stephanie Reel, CIO and vice president for Information Services at Johns Hopkins Medicine, spent a few days in the PICU. Reel learned, through shadowing a nurse, that the unit needed more needle containers in places that were easily accessible.

“I made a phone call that night and they got extra n eedle stick containers,” Reel says. “It was a very easy thing, but it was something that the nurse said would make the environment safer, so we did it.” By making herself available, even for seemingly minor issues, Reel was able to earn the staff's trust. As a result, Reel says, more clinicians started attending the monthly meetings she held in the unit and offering suggestions for improvement.

Ivor Berkowitz, M.D., the PICU's medical director, asked Reel to install video conferencing at the community hospital so he could consult with patients before they were transported to Johns Hopkins Hospital. “We were able to put inexpensive video technology in the other hospital's emergency room,” Reel says. “It was an example of something we were able to do fairly quickly to hopefully make a difference in a child's outcome.”

Another benefit of the initiative is its effect on larger IT projects. When Johns Hopkins was rolling out physician order entry, Reel was able to monitor the progress nurses and clinicians were making with the new system, which helped her both as CIO and as an adopted leader of the PICU. “We wanted to make sure that order entry was making it safer for patients in the ICU,” she says. So when the nurses explained that if they could view two sets of information simultaneously, it would improve their decision-making, Reel gave the green light to deploy dual-monitored computers-on-wheels in the unit. “It was the right decision for that particular group,” she says.

Steve Mandell

According to Davis, it was an example of how the safety program and a large-scale IT implementation coalesced in a way that benefitted both. “The two really dovetailed nicely together,” he says. “Having doctors, nurses and IT people all working through these things together makes a huge difference, rather than having a solution that's designed somewhere in IT world and then dropped into a clinical world.”

Case #2: The Blood Bank

According to Steve Mandell, senior director for Clinical Information Systems at John Hopkins Hospital, the Blood Bank is different from the other adopted units at Johns Hopkins for one very simple reason - there are no patients. Its function, he says, is to provide services to the departments that care directly for patients.

As the unit's adopted leader, Mandell, who previously served as a vice president of IT for the American Red Cross, says he focused on helping his staff identify where and how sentinel events can occur, and what actions can be taken to prevent them. Through regularly held discussions, Mandell says he learned of operational issues that “interfered with their sense of confidence in the way they're being taken care of.”

For example, the staff was using outdated computers. “The blood bank staff is highly dependent on knowing the operating room schedules, which are all electronic, so even though they were able to get to the schedule, they weren't receiving real-time notices that cases were delayed or cancelled,” he says.

With Mandell's help, the unit worked with the operating room on a system that would notify them if a case was delayed or cancelled, which resulted in improved workflow and decreased waste of perishable products.

The ordering of blood products brought up another issue. Certain cases required a specific amount of product that had been cross-matched by type and was readily available. Therefore, a system was deployed with order sets that enabled providers to specify exactly what they needed in terms of volume and severity. In addition, a Web viewer of the blood product inventory is being developed to keep providers informed on order status.

“Now, instead of getting calls all night long before the surgery as to whether or not the blood is ready, the providers will be able to use a Web interface that's linked to a system that they're familiar with,” Mandell says. This way, “They don't have to learn new log-ins, and they'll be able to see what's available, what products are in the manufacturing process and which events specifically detect a cross-match for their particular patient.” That, Mandell says, will hopefully improve the communication and reduce phone calls, giving staff “more time to do high quality work.”

Case #3: Wilmer Eye Institute

Ever since Mike McCarty, chief network officer at Johns Hopkins Hospital, first adopted the Wilmer Eye Institute three years ago, his leadership philosophy has focused on tackling safety and quality issues.

One by one, McCarty has addressed several concerns within the unit:

• In the rest rooms, handicap toilets were installed that are more easily accessible.

• An alert system was implemented that lets patients call a clinician at night when the Institute's emergency room isn't highly staffed.

• Adjustments were made to the pneumatic tube system so that samples could be sent more quickly to the laboratory.

While most ideas are generated from the monthly meetings held by McCarty, occasionally one is lifted from another department within Johns Hopkins. For instance, a system was recently implemented in which prior to arriving at the hospital, patients are sent packets of information on their upcoming surgery with reminders of what documentation they should bring.

This concept, says McCarty, was borrowed from the endoscopy unit. However, the Eye Institute took it a step further and assigned a staff person to each incoming patient. With the new procedure, the point person calls the patient before and after the appointment to give instructions and get feedback. “It gives patients a common face and a voice that they get to know. It's really proven to be successful,” says McCarty. “We've just done a lot of simple things that have improved patient flow, patient satisfaction, and in some cases, patient safety.”

Going forward

Six years after the program took off, Rosenstein believes it has exceeded expectations - and he has numbers to back it up. According to data gathered from clinician surveys, the staff's impression of management's commitment to patient safety “has gone up significantly in the past few years. We think one of the key reasons is that the executives and hospital leaders are out on the units,” he says.

Davis agrees, adding that both leadership and the clinicians on the front lines have benefitted from the project. “The nurses and physicians have individuals they can turn to if they have problems,” he says. Davis says he believes this has helped build trust in leadership, which has led to a more open exchange of ideas. “We've heard examples where everyone from head physicians to environmental service workers are coming up with great ideas,” he says. “If you have an idea, we want to hear it. We really are trying to break down those barriers. This is about what we can do to create the safest place in the world to receive care - period.”

Because of the success it has generated, the adopt-a-unit project is expected to expand throughout the organization. As Johns Hopkins works toward opening a new multi-tower facility in 2011, the organization is determined to apply lessons learned from CUSP in the new building.

“We want to see the program grow even more,” says Mandell. “One of the things that we hoped for is by having a safety executive on the units, we could cut through red tape; because we are the red tape. It's also helped us more profoundly understand what's happening on the front lines and how hard it is. It helps us rededicate ourselves if we really do want to be among the best of the best - that every piece of the entity, every subsystem has got to be optimized in ways to support the whole system,” he says. “We've got to work collaboratively or we can't do our work together.”