The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice.

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The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice Peter J. Pronovost, MD, PhD, Christine G. Holzmueller, Nancy E. Molello, MSB, Lori Paine, MS, Laura Winner, MBA, Jill A. Marsteller, PhD, MPP, Sean M. Berenholtz, MD, MHS, Hanan J. Aboumatar, MD, MPH, Renee Demski, MSW, MBA, and C. Michael Armstrong, for the Armstrong Institute for Patient Safety and Quality Team

Abstract Academic medical centers (AMCs) could advance the science of health care delivery, improve patient safety and quality improvement, and enhance value, but many centers have fragmented efforts with little accountability. Johns Hopkins Medicine, the AMC under which the Johns Hopkins University School of Medicine and the Johns Hopkins Health System are organized, experienced similar challenges, with operational patient safety and quality leadership separate from safety and quality-related research efforts. To unite efforts and establish accountability, the Armstrong Institute

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merican medicine performs lifesaving miracles every day. Medicine today also has a less miraculous side. Preventable harm may be the third leading cause of death, although sadly, we still cannot accurately measure the number of needless patient deaths,1 and some patients report being disrespected or not heard during their care.2 Medicine today squanders nearly $1 trillion dollars, or $9,000 per U.S. household on unnecessary medical care.3 Academic medical centers (AMCs) can play an important role in addressing the preventable harm and resource waste that are debilitating health care. AMCs are forming academic health systems, Please see the end of this article for information about the authors. Correspondence should be addressed to Peter J. Pronovost, Armstrong Institute for Patient Safety and Quality, 750 E. Pratt St., 15th Floor, Baltimore, MD 21202; telephone: (410) 502-6127; fax: (410) 6374380; e-mail: [email protected]. Acad Med. 2015;90:1331–1339. First published online May 18, 2015 doi: 10.1097/ACM.0000000000000760

Academic Medicine, Vol. 90, No. 10 / October 2015

for Patient Safety and Quality was created in 2011. The authors describe the development, purpose, governance, function, and challenges of the institute to help other AMCs replicate it and accelerate safety and quality improvement. The purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste in health care. A governance structure was created, with care mapped into seven categories, to oversee the quality and safety of

merging with or buying hospitals, clinical practices, and other health care facilities. Academic physicians, other researchers, staff, and administrators are advancing the science of health care and training future physician leaders to improve quality of care and value.4 Despite their potential, AMCs often have fragmented quality improvement and patient safety governance, management, and work processes with little accountability, thus failing to leverage the tripartite mission of research, education, and patient care, and sometimes falling short of delivering safer care and better value for patients. Johns Hopkins Medicine (JHM), the AMC under which the Johns Hopkins University (JHU) School of Medicine and Johns Hopkins Health System are organized, experienced these challenges, and for most of its existence, operational patient safety and quality leadership were separate from quality- and safety-related research. To unite and synergize operational and research efforts and expand capacitybuilding activities, a Johns Hopkins

all patients treated at a Johns Hopkins Medicine entity. The governance has a Patient Safety and Quality Board Committee that sets strategic goals, and the institute communicates these goals throughout the health system and supports personnel in meeting these goals. The institute is organized into 13 functional councils reflecting their behaviors and purpose. The institute works daily to build the capacity of clinicians trained in safety and quality through established programs, advance improvement science, and implement and evaluate interventions to improve the quality of care and safety of patients.

Health System and Johns Hopkins Hospital trustee, C. Michael Armstrong, made a generous gift to JHU to create the Armstrong Institute for Patient Safety and Quality in 2011. The Armstrong Institute united several key groups working under JHM. In this article we describe the purpose, governance, organization, and function of the Armstrong Institute. Development and Purpose of the Institute

In creating the Armstrong Institute, its leaders sought to be purpose driven, principles led, people centered, process disciplined, and performance focused. A Development Committee, comprising members of the research group based in the JHU School of Medicine; researchers from the Bloomberg School of Public Health, School of Nursing, Carey Business School, and Applied Physics Laboratory; and the operations group from the Johns Hopkins Health System, representing a range of disciplines, ranks, and perspectives, was chartered to create the institute. Committee members led focus groups with School of Medicine

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Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

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faculty who were interested in patient safety and quality improvement, staff, and patients to define the institute’s purpose, values, and goals. The committee’s work was critical to building the Armstrong Institute foundation, including its governance and leadership system, management structure, organizational design, key behaviors, operating procedures, and leadership philosophy. The vision was essentially set by Mr. Armstrong, JHM leadership, and Dr. Peter Pronovost. The Armstrong Institute’s purpose is “to partner with patients, their loved ones, and all interested parties to end preventable harm, to continuously improve patient outcomes and experience, and to eliminate waste in health care.”5,6 The Executive Committee for the Armstrong Institute includes leaders from each of the internal functional councils (Figure 1). An initial action was to establish key behaviors to achieve the institute’s vision. After extensive discussions with Armstrong Institute staff and leaders, the Executive Committee identified three sets of behaviors they believed should guide the institute’s work, and to which everyone would be accountable: I am humble and curious. I will respect, appreciate, and help others. I am accountable for continuously improving myself, my organization, and my community. These behaviors are used

when selecting people to join the institute and holding staff accountable, and in reward and recognition systems. Each behavior was carefully selected, worded, and supported by theory for engaging a large number of professional staff in the complex matrix of an academic health system.7 Although JHM values included excellence and discovery, many felt both resulted from being humble and curious. Armstrong Institute staff wanted a set of core behaviors, and worded them as I statements, seeking personal commitment and including staff in the institute’s design. The first behavior was internal, the second was interpersonal, and the third was organizational. The Executive Committee asked its council managers and staff to define a set of behavioral expectations that demonstrated they were living the core behaviors, and for which they would be held accountable. For example, leaders are expected to listen without pretense or presupposition to others (representing the humble and curious behaviors) and to visit one outside organization annually and share learning (humble and accountable). Employees are encouraged to have personal development goals (respectful and accountable), and managers are expected to routinely recognize staff for their efforts (appreciative).

Armstrong Institute leaders follow a humble and respectful leadership style, a style that is discussed during the interview process and continues through ongoing formal and informal leadership development. For example, leaders had to read and discuss several books describing this leadership style. The institute director routinely iterates through e-mails and in-person meetings the purpose, principles, and leadership style of the institute and reminds everyone to avoid the word “I,” which implies power over others. Through these efforts, leaders and even staff understand that influence happens through informal authority, based on trust, and trust is based on others’ perceptions that leaders are caring and competent.8 Institute leaders believe change happens at the speed of trust, and they deliberately build relationships, ensuring that interventions are done with rather than to others, using language that empowers rather than overpowers others, promoting a participatory and open leadership process. Governance The JHM Board of Trustees established the JHM Patient Safety and Quality Board Committee and sought to ensure that it exercised the same discipline as the JHM board finance and audit committees. Just as the finance committee is accountable for every dollar received

Armstrong Institute for Patient Safety and Quality

Armstrong Institute Executive Committee

Team Building/ Internal Improvement Council

Research Facilitation Council

Service Excellence Council

Product Development/ Marketing Council

Educational Development Council

External Performance Council

Clinical Communities Council

Lean Sigma Council

Quality Analytics Council

Common Preventable Causes of Harm Council

Patient/ FamilyCentered Care Council

Quality and Safety Council Includes: Risk management and regulatory compliance

Service Line Protocols Council

Figure 1 Internal organization of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, with functional councils. The Executive Committee is chaired by the institute director and comprises the leaders of 13 councils. Each council has internal staff or faculty with expertise or interest in the area of focus. The Team Building and Internal Improvement Council solely supports internal efforts. The remaining councils function to organize the institute’s work to support efforts across the health system.

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and spent throughout JHM, the JHM Patient Safety and Quality Board Committee should oversee the quality and safety of care for every patient treated at all JHM entities. Thus, we are working on a consolidated quality and safety statement for JHM, similar to the finance and audit committees. The JHM Patient Safety and Quality Board Committee also created a subcommittee of four trustees that meet with all the entity presidents several days before the full board meeting to review all safety and quality metrics, freeing up discussion time at the full board meeting, which is a process similar to the finance committee. Figure 2 illustrates how the quality and safety governance structure for JHM was consolidated when the Armstrong Institute was formed. JHM is the academic health system under which the JHU School of Medicine, six inpatient hospitals, and affiliated organizations (e.g., surgery centers, primary care practice) reside. Given the organizational structure of JHM, care was organized into the seven care categories shown. The JHM Patient Safety and Quality Board Committee is chaired by the JHM Board of Trustees chair and has membership from JHM trustees and leaders from the JHM entities; details have been previously published.9 The Armstrong Institute communicates the oversight committee’s strategic goals throughout JHM and supports personnel throughout the hospitals and affiliated organizations to meet these goals.

Committee agenda Reflecting the purpose, the JHM Patient Safety and Quality Board Committee and the quality committee for each organizational care category (Figure 2) have the same four-part agenda: patient safety (internal risk), performance on externally reported measures, patientexperience-centered care, and value; this agenda cascades through each organization, hospital, and department. Patient safety We assess internal patient safety risks across the academic health system. Each quarter, the Armstrong Institute’s patient safety leader works with clinical leaders, risk managers, and regulatory leaders to identify what is considered JHM’s greatest internal risk and what we might do to mitigate that risk. The objective at board meetings is intelligence gathering and “problem sensing” to find weaknesses in systems rather than “comfort-seeking” behaviors that focus solely on positive reassurance.10 Armstrong Institute leaders gather patient safety concerns from many sources and discuss these concerns with the JHM Patient Safety and Quality Board Committee. These sources include error reports, risk management, regulators, department clinical leaders (who survey faculty and residents), and Comprehensive Unit-based Safety Program (CUSP) team leaders (who survey frontline staff). CUSP functions

to improve teamwork and culture and to organize and manage safety and quality improvement work; details have been previously published.11,12 Risk concerns are selected using qualitative and quantitative data. The Armstrong Institute also produces a proactive safety report for each entity (e.g., hospital) and each department, seeking to identify risky providers, risky units, and risky systems. The physician analysis looks at frequency of complaints, claims, and code of conduct behaviors. Risky physicians are continuously addressed by JHM leaders through one-on-one meetings. The unit analysis is done annually and triangulates unit vulnerability on employee engagement scores, safety culture assessment, patient complaints, code of conduct behaviors, and risk management concerns. The systems analysis is done quarterly and evaluates claims, error reports, department-based sentinel events, and top safety concerns self-identified by unit/department faculty and staff. Following an evaluation, units and departments produce an improvement plan, discussing how they will defend against their internal risks, working with their unit CUSP teams to reduce risks. Externally reported measure performance We routinely address performance on externally reported measures throughout JHM and measures in

Johns Hopkins Medicine Patient Safety and Quality Board Committee

Armstrong Institute for Patient Safety and Quality

In-patient

Pediatrics

Population health

Home care

Johns Hopkins International

Ambulatory practices

Ambulatory surgery centers

Figure 2 Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, quality and safety governance structure, to organize quality and safety of care for all patients treated at a Johns Hopkins Medicine facility. Johns Hopkins Medicine is the academic health system for the Johns Hopkins University School of Medicine, 6 inpatient hospitals, a 40-site primary care practice, 8 ambulatory surgery centers, 2 home health care companies, an insurance company, and an international health company that manages over 14 hospitals around the world. Given the complexity of the health system, care was organized into the seven categories shown.


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which the JHM Patient Safety Quality Board Committee has determined we must excel. For example, the board has focused on Centers for Medicare and Medicaid Services core measures, hand hygiene, hospital-acquired conditions, patient safety indicators, quality-based reimbursement measures, central-lineassociated bloodstream infection, surgical site infections, and more recently, patient experience. Some measures are done monthly (e.g., core process measures), whereas others are done quarterly (e.g., infections). Patient-centered care We focus on several areas to enhance patient- and family-centered care. First, patients and families are involved in our governance. For example, each hospital has a patient and family advisory committee. The committee chairs convene quarterly to learn and share, and the chair of this convened group sits on the JHM Patient Safety and Board Committee. Second, we seek to involve patients in decisions about their care, such as through patient participation on rounds. Third, we work to improve patient experience, as measured through the Hospital Consumer Assessment of Healthcare Providers and Systems, using the same accountability model that manages core measure improvement across JHM.5 Finally, we seek to improve patient relations through service recovery and a common platform to manage complaints and monitor responses. Value To improve value, we engage clinicians in clinical communities (described below) for which the Armstrong Institute provides technical support. Institute staff and researchers work closely with the Johns Hopkins Health System Finance Department, using their cost accounting and clinical data systems to provide detailed cost data, identifying variation in practice and opportunities to reduce costs, and developing measures of value. Moreover, institute staff support the clinical communities in protocol development, project management, robust process improvement methods, and integrating costs, the electronic medical record, and quality data to help clinicians improve value. Each local quality council for the hospitals, ambulatory clinics, and other

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care structures also follows the same fourpart agenda used by the JHM Patient Safety and Quality Board Committee. Although they can select what safety- and value-related issues to monitor, they must monitor any external measures linked to the JHM goals and any areas identified as the greatest safety risk that are relevant to them. In addition, all entities must demonstrate national leadership in patient safety and quality through metrics that are relevant to them. For example, home care elite status is a metric that represents national excellence for our home care company. Functioning

The Armstrong Institute seeks to contribute to the JHU School of Medicine’s tripartite mission by building the capacity of clinicians trained in quality and safety, advancing improvement science, and implementing and evaluating interventions to improve the quality of care and safety of patients. The Armstrong Institute convenes improvement efforts across JHM. The institute is organized into functional councils that help achieve its purpose (Figure 1; Table 1 describes council tasks). One novel council is clinical communities. Clinical communities support peer and organizational learning and change norms by convening a multidisciplinary team of stakeholders from hospitals and affiliate organizations to form a cross-entity community that works on safety and quality improvement in specific areas.13 Clinical communities also support vertical accountability because each community reports to the JHM Patient Safety and Quality Board.14 Since September 2011, 33 clinical communities have assembled and meet monthly to deliberate actions; Gould and colleagues have described the first 14.15 Table 2 provides the first 15 communities, a list that continuously grows. These communities have accelerated clinical integration across JHM, and many have occurred organically and without formal reporting structures. The institute also convenes stakeholders across the health care industry, including policy makers, device companies, other provider organizations, and researchers, and collaborates on patient safety and quality improvement. We sponsored the

Forum on Emerging Topics in Patient Safety in September 2013, convening experts from many industries to share insights on culture, measurement, implementation science, and other topics. We received a grant from the Agency for Healthcare Research and Quality to convene the top performing hospitals on each domain of the Hospital Consumer Assessment of Healthcare Providers and Systems survey to better understand and share how to improve care (175 participated), and hosted two national Quality for Medical Education workshops with the American College of Medical Quality (total 163 participants). Recently, we partnered with the Pew Charitable Trust on a project to improve the usability of the hospital electronic medical record. Capacity building A major strategic goal of the Armstrong Institute is to build capacity among faculty and staff across JHM to fulfill its purpose. Leaders of the institute developed an aspirational three-tier model of skills and competencies. Level 1 covers the basic safety, service, and quality knowledge that all employees should understand. This includes training modules on the science of safety, patient- and family-centered care, and teamwork and communication. Level 2 involves more advanced programs for individuals (e.g., nurse manager) who formally dedicate some portion of their work time to quality improvement, and includes a certificate in safety. The institute offers a variety of quality-related training programs to help individuals and Hopkins entities acquire these skills (Table 3 describes programs and number of attendees). A common theme of Level 2 training involves implementation skills and how to use data for implementation. Level 3 is designed for faculty and staff who seek a career in patient safety and health care quality. This involves completion of a formal degree program or advanced training, such as a black belt in Lean Sigma or a master TeamSTEPPS trainer course.16 The JHM Bloomberg School of Public Health offers a variety of programs, and many faculty members in the Armstrong Institute teach in these programs. We also seek to define skills within organizations, departments, and units. We are working to mimic a fractal to ultimately build an infrastructure for



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Table 1 Functional Councils and Tasks, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine Functional council External Performance Council

Tasks • • • •

• • • Clinical Communities • Council15 • • • • •

evelop strategies to be national leaders in externally reported patient safety and quality measures D Identify clinical champions and educate faculty/staff on external performance measures Train all health system quality improvement leaders and managers to use Lean tools for every core measure workgroup Work with state hospital associations and Health Services Cost Review Commission on quality metric methodology changes Identify challenges impacting performance and share lessons learned/best practices Ensure health system preparedness for future trends in performance measures Collaborate across JHM to achieve national leader strategy Foster relationships and collaboration among leads and community members Develop and implement system-wide policies Enhance vertical core support Add patient and family members to communities Develop and incorporate data-driven processes to measure progress toward goals Support Armstrong Institute/finance partnership to enhance value

Quality Analytics Council

• • • • • •

E stablish cross-disciplinary analytics community for JHM Add nationally reported measures to the JHM quality dashboard Help JHM build a clinical data warehouse with data trust governance Build a quality improvement appstore platform to share applications across JHM Develop a JHM data transparency Web site for public consumption Develop a JHM innovation engine, partnering Armstrong Institute training programs with a technology development center (Patient Safety and Quality Leadership Academy)

Common Causes of Preventable Harm Council

• U tilize literature and subject matter experts to assess common causes of preventable harm • Build consensus to prioritize common harms across JHM • Implement components of national leader strategies for high-priority harms (e.g., convening workgroups, identifying consistent system of measurement, developing accountability plan) • Continually assess how to reduce harm across JHM • Focus on health-care-acquired pressure ulcers • Explore Implementation Science Training Day for clinical champions and staff at each hospital • Continue work to standardize measures and interventions; explore system-wide efforts for remaining harms

Quality and Safety Council

• • • • •

Implement culture assessment and interventions to improve safety across JHM Analyze event reporting data to identify trends, solutions, and opportunities to improve Create infrastructure that supports strategic implementation of CUSP teams across JHM Help identify annual objectives and targets for JHM strategic priorities for quality and safety Build workforce capacity to inform, analyze, and improve systems of care

Lean Sigma Council

• • • •

Improve quality and safety of patient care Build capacity for robust process improvement to achieve high reliability Advance the science of health care improvement Work with JHM leadership to identify strategic objectives and align resources accordingly

Educational • Implement educational efforts to support Armstrong Institute’s mission of preventing harm, improving patient outcomes Development Council and experience, and reducing health care costs • Ensure the institute’s education programs are synergistic, maximally coordinated, and supportive of building capacity efforts within JHM • Sustain existing education programs • Hold first “Building Capacity within JHM” retreat; synthesize retreat findings to inform institute’s capacity-building efforts • Develop metrics to help JHM leaders build capacity within their organizations for effective improvement work • Establish database to track education offerings and trainees over time (work with Armstrong Institute’s Clinical Analytics program) • Develop evaluation strategy to assess and capture impact of education programs

(Table continues)


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Table 1 (Continued) Functional council Patient and Family Centered Care Council

Tasks • • • • • • •

Identify nationally adopted best practices to improve HCAHPS score Create best practice bundle and share best practice stories Improve HCAHPS scores by 3% or achieve at least 75th percentile Advance science in field of service excellence Create national leader strategy to improve HCAHPS scores Create standard database for patient relations Ensure Patient and Family Advisory Council at each entity

Service Line Protocols • Align protocol work with clinical communities and accountable care organization Council • W ork with value/finance and clinical analytics to create datasets to focus work • Utilize existing quality infrastructures • Create clinical community operations committee to convene Armstrong Institute, Office of Johns Hopkins Physicians, finance, supply chain, etc., to define priorities and coordinate work activities Research Facilitation Council

• • • • • • •

dvance research and situate it within the larger Armstrong Institute context A Incorporate research evidence and methods into Armstrong Institute/JHM’s daily operations Support research-related needs, development, and goals of Armstrong Institute faculty and staff Sponsor networking events Link operations and research groups for projects Test use of virtual server space Develop mentorship/affiliation structure

Product Development/ Marketing Council

• S upport internal communications for Armstrong Institute to achieve strategic plan and national leader strategy • Develop suite of products and services to spread patient safety across JHM • Conduct needs assessment for/support or development of new educational/capacity-building offerings (e.g., workshops). Specifically, CUSP hospitals coming off national project (CUSP suite of workshops/offerings); teamwork and communication; and international symposium • Develop cohesive Web site that supports Armstrong Institute branding and research needs • Support Learning Lab: implement usability testing marketing plan; develop “operations” for commercial usability testing lab • Create Armstrong Institute annual report and other marketing products

Team Building/ • Ensure internal workflow and processes of Armstrong Institute are efficient Internal Improvement • F oster teamwork among Armstrong Institute faculty and staff Council • Demonstrate employee appreciation • Perform or support community outreach activities • Improve health and wellness of Armstrong Institute employees • Continue to improve workplace safety Abbreviations: JHM indicates Johns Hopkins Medicine; CUSP, Comprehensive Unit-based Safety Program; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.

quality management and organizational learning.14 Fractals are small, similarly shaped parts that connect to support and shape a larger object.17 Translated to health care, every level of the organization (hospital, department, and unit; or group practice, region, and clinic) would have skilled professionals, resources, goals, measures, and accountability for quality improvement and learning, balancing interdependence and independence. For example, the hospital and large clinical departments would have quality and safety leaders with Level 3 skills, and units and clinical areas would have individuals with Level 1 and 2 skills and CUSP teams.

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Further, there would be vertical connections among the organizational levels to support accountability and horizontal connections among units to support peer and organizational learning. The governance structure for JHM will ultimately provide the vertical connections, and CUSP and the clinical communities will offer horizontal connections. JHM leaders have implemented an incentive program for accountability, in which 30% of each clinical director’s bonus is determined by performance on a mix of department and health system quality and safety measures. Each clinical director’s patient safety and

quality goals and performance are now transparently shared with other directors. Advancing improvement science A large part of the Armstrong Institute’s work, and approximately 80% of its budget, is from sponsored research projects. The institute has a diverse group of researchers representing all JHU schools and over 18 disciplines, in such areas as medicine, nursing, public health, engineering, arts and sciences, and the Applied Physics Lab, and collaborations with other universities. The institute has 140 core and affiliated faculty (secondary appointments) with careers focused on



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Table 2 Armstrong Institute Convening Cross-Entity Clinical Communities for Safety and Quality Improvement Across Johns Hopkins Medicine Clinical community

Start date

Intensive care unit Hospitalists

September 2011 November 2011

Medication safety

December 2011

Postanesthesia care unit

January 2012

Neonatal intensive care unit

March 2012

Patient-centered care across maternity services

November 2012

Cleaning, disinfection, and sterilization

February 2013

Surgery

June 2013

Congestive heart failure

July 2013

Diabetes

November 2013

Psychiatry and behavioral sciences

November 2013

Spine

January 2014

Joint replacement

February 2014

Blood management

February 2014

Patient and family advisory councils

June 2014

improvement science.4 Our research projects span 44 states and 6 countries. We use a variety of quantitative, qualitative, and engineering research methods, from developing strategies to translating guidelines into practice in hospitals and community practices, to implementing programs that teach frontline health care workers to identify safety hazards and prevent patient harm, and that embed academic researchers in patient safety and operations teams to help with improvement projects. The ethical oversight of quality improvement and patient safety is evolving. Research projects within the Armstrong Institute are submitted to our institutional review board (IRB). Nonetheless, there is ambiguity about what requires IRB review, and everyone is instructed to err on the side of caution and submit their project for review. The institute director is working with the vice dean of research to resolve this ambiguity. Moreover, a core faculty member in the institute is a member of the JHU School of Medicine IRB and provides guidance on IRB issues. Implementing and evaluating interventions within JHM One priority of the Armstrong Institute is to use JHM as a learning laboratory to improve care. To accomplish this, we try to pair researchers and operational teams so that researchers can apply their theories


and experience firsthand to see whether projects are feasible, and operations staff can access the latest theories and conduct more robust evaluations. For example, working with frontline staff and Armstrong Institute operations staff, our organizational psychologists help identify risky units, our political scientists conduct interviews on these risky units to elicit reasons for harm, our human factors engineers identify and mitigate risks, especially around usability of technologies, and experts in implementation science work in these settings to reduce preventable harms. We also have a learning laboratory wherein we integrate Applied Physics Laboratory engineers, engineering faculty, clinicians and safety researchers, and technology companies to use systems engineering and human factors approaches to design care systems that eliminate harm, continuously improve patient outcomes and experience, and eliminate waste.18,19 Challenges

We faced several challenges when establishing the Armstrong Institute. Because the institute is multidisciplinary, people needed to have a working knowledge of many different disciplines to effectively collaborate. This took time and encouragement on the part of some individuals to learn new terminology and perspectives and to recognize how other

disciplines could complement rather than compete with their discipline. Also, aligning leaders from different entities, schools within JHU, and clinical departments, with competing priorities, along a shared vision took time to build trusting relationships. Finally, we had to create the structure, the mixing bowl, to convene a diverse group of stakeholders to do the work, without micromanaging the work. We also face ongoing challenges with the operations of the institute. Our infrastructure is often insufficient to meet the demand. For example, clinical communities were so well received that many groups want to form one. Yet communities require project management, data analytics, and guidance in methods of improvement science, demands that far exceed our supply of support services.15 Another challenge is tackling value measurement, an area that is underdeveloped in our institute and more broadly in health care. Health policy in the United States is aligned around pay for value, rather than volume, but our health care system has few measures of value, and no national entity has been charged with developing these essential measures. The institute brings researchers, clinicians, and finance leaders together to create measures of value, but it is a labor-intensive process, and extracting valid data from our electronic medical record is difficult. It is inefficient and ineffective to expect each AMC to create its own value measures. AMCs could collaborate to develop scientifically sound, usable, important, and feasible value measures. Finally, as we understand the work before us, we recognize that the JHM quality management infrastructure14 is far from fully developed. We need skilled clinicians with devoted time and accountability in every department, division, and unit. The institute created a vice chair for patient safety and quality role for each department and tasked these individuals with managing patient safety, performance on external measures, patient-centered care, and value for their department. Vice chairs report to their respective department director and to the Armstrong Institute director. Although a huge advance for JHM, we still need skilled staff with time and resources in large divisions and in units to lead their quality improvement efforts. These division and unit leaders would meet

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Table 3 Training Programs Developed and Implemented by the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Between Fiscal Years 2012 and 2014a Total no. of attendees

Course name

Course description

Patient Safety Certificate Program

Participants learn key concepts, tools, and skills to reduce preventable patient harm at the level of the unit/clinic, clinical department, and hospital, including performance improvement approaches and change agent strategies. [5-day, in-person program; or 13 self-paced, interactive online modules; 163 attendees] (Previously a 3-day patient safety practitioner training program; 63 attendees) Participants learn to initiate, plan, and lead a multidisciplinary project, preparing them to be future leaders in eliminating harm and creating a culture of caring in clinical settings. [9-month program for JHM staff; started FY15; 33 attendees] (Previously two programs: Patient Safety Fellowship FY12 to FY14, 27 attendees; Resident Scholars Program in Patient Safety and Quality FY13 to FY14, 34 attendees)

Patient Safety and Quality Leadership Academy

229

94

Analytics Leadership in Patient Safety Program

Participants learn the technologies, theories, and methodologies of health care data compilation, analysis, and use, preparing them to be leaders in clinical analytics. [9-month program for JHM clinicians and administrators]

43

Comprehensive Unit-based Safety Program (CUSP) Implementation Workshop

Participants learn how to engage their organization and frontline providers in implementing CUSP and tackling hazards that threaten their patients. [2-day workshop]

418

Lean for Healthcare

Participants learn how to apply Lean tools, systems, and principles in health care organizations to identify and eliminate non-value-added activity, improve flow, and provide value at lower costs. [2-day workshop]

737

Lean Sigma Prescription for Healthcare 5-Day Green Belt Course

Participants learn how to use Lean Sigma to develop data-driven interventions for chronic operational problems in health care, combining Lean methods (reduce waste and improve flow and value) with Six Sigma statistical analysis to identify the causes of defective processes. [5-day workshop]

363

Improving Patient Safety with Human Factors Methods Workshop

Participants learn through discussion and hands-on exercises how human factors engineering concepts can identify and mitigate patient safety hazards in their workplace. [2-day workshop]

116

Evaluating Quality Improvement and Patient Safety Projects

Participants learn to critique evaluations of quality improvement and safety projects, to design robust evaluations, and to conduct small-scale qualitative studies. [2.5-day course; attendees from first class]

Leadership in Patient Safety and Quality

Health care leaders learn how to guide their organizations to reduce preventable harm, improve patient outcomes, and eliminate waste in health care delivery. [Two 4-day-long residencies; jointly led by Johns Hopkins faculty, Armstrong Institute clinicians, and Johns Hopkins Carey Business School; attendees from Residency I]

13

Leading Adaptive Change Workshop

Participants learn ways to engage groups to solve problems, initiate behavior change, devise innovative solutions, and create sustainable improvement in their organizations. [3-day workshop; collaboration with Plexus Institute]

30

Fellows’ Course in Hospital Epidemiology and Infection Control

Participants are led through an interactive series on basic health care epidemiology, infection prevention strategies, health-care-associated infections, and problem pathogens. [3-day summer course; collaboration with Johns Hopkins Department of Healthcare Epidemiology and Infection Prevention, attendees from first class]

75

8

Abbreviations: JHM indicates Johns Hopkins Medicine; FY, fiscal year. a Fiscal years are for the period July 1, 2011, to June 30, 2014.

regularly with the department vice chair, extending the fractal structure from the JHM board to the bedside.14 Given the financial strain on AMCs, it is essential to demonstrate the business case for these roles. The move to paying for value and the growing amount of revenue that is at risk in pay-for-quality programs provide strong incentives to create this infrastructure. Concluding Remarks

As health systems merge and better value is required, AMCs must lead the way in advancing improvement science, building capacity, and realizing improvements

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in the quality of patient care. The Armstrong Institute is a structure within JHM that seeks to accomplish these objectives. Its faculty and staff partner with clinicians and managers across JHM to oversee the quality and safety of care throughout JHM, conduct research, and train frontline staff. Our governance, structure, and functions are dynamic, evolving, and emerging to realize our goal of zero harm, continuously improving patient outcomes and experience, and zero waste. Other AMCs could establish similar structures and lead efforts at their institutions or across their health systems to improve quality of care and enhance value. To begin, form a quality board

committee, clearly define its purpose and core behaviors, and have it function like your organization’s finance and audit committee. Also, map everywhere care is delivered, whether one hospital or a health system, and provide representation on the quality board committee to ensure that there is oversight and accountability for quality of care and patient safety.9 Finally, AMCs could invite other schools in the university to participate in the work, and community hospitals could invite a local university to join their work. Acknowledgments: The authors wish to list past and current members of the Armstrong Institute for Patient Safety and Quality Team: Adrian Alday, Kisha Ali, J. Matthew Austin, Lana Bailey,



Article Noah Barasch, Angelina Barbosa, Jody Bigley, Tina Brown, Timothy Burroughs, Julie CadyReh, Tiffany Callender, Howard Carolan, Patrice Carrington, Bickey Chang, Xinxuan Che, Jeffrey Clay, Cheryl Connors, Karen D’Souza, Jennifer DiMattina, Aaron Dietz, Kelsey Edwards, Parissa Eggleston, Joseph Oluyinka Fawole, Molly Federowicz, Patricia Francis, Leslia Gaines, Vipra Ghimire, Maria Giraldo-Jimenez, Christine Goeschel, Lois Gould, Ayse Gurses, Eric Hadhazy, Roshanak Hakimian, Christina Halligan, Elizabeth Hanahan, Eston Harden, Valerie Hartman, Conradine Hewitt, Richard Hill, Deborah Hobson, Robert Hody, Shu Huang, Olufunmilola Ijagbemi, Eileen Kasda, Paula Kent, Adjhaporn Khunlertkit, Gi Kim, Erin Kirley, Ekaterina Koroleva, Eun Su Lee, Kyun Hee Lee, Jo Leslie, Myles Leslie, Annette Levering, Jennifer Lofthus, Lisa Lubomski, James Manfuso, Linda Marcellino, Gladys Mbah, Desmond McNelis, Beverly Meiswinkel, Mohd Nasir Mohd Ismail, Mohammad Naqibuddin, Mahiyar Nasarwanji, Daniel Nelson, Stephanie Peditto, Julius Pham, Richard Powers, Steven Ragsdale, Nishi Rawat, Dianne Rees, Erica Reinhardt, Michael Rosen, Eldonia Ross, Melinda Sawyer, Dhwani Shah, Kayla Singer, Terry Singer, India Smith, Kathleen Speck, Valentina Staneva, Shannon Swiger, Tisha Sydnor, Stephanie Tabisz, Kathryn Taylor, David Thompson, Steven Tropello, Terry Tsai, Haddis Tujuba, Cheryl Turco, Mary Twomley, Anabel Urteaga-Fuentes, Laura Vail, Patricia Wachter, Sallie Weaver, Kristina Weeks, Bradford Winters, Rhonda Wyskiel, Anping Xie, Ting Yang, and Kathleen Ziolkowski. Funding/Support: None reported. Other disclosures: P.J. Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc. (improve blood pressure control); honoraria from various health care organizations for speaking on patient safety and quality; book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; fees to be a strategic advisor to the Gordon and Betty Moore Foundation; and stock and fees to serve as a director for Cantel Medical. Dr. Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians. S.M. Berenholtz has received support from the Agency for Healthcare Research & Quality, National Institutes of Health, and World Health Organization for work on other studies and receives honoraria and travel expenses from various hospitals, professional societies, and hospital associations for consulting and speaking on patient safety and quality improvement topics. The remaining authors have no conflicts. Ethical approval: Reported as not applicable.


P.J. Pronovost is senior vice president of quality and safety, Johns Hopkins Medicine; director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; and professor, Departments of Anesthesiology and Critical Care Medicine and Surgery, School of Medicine; professor, Department of Health Policy and Management, Bloomberg School of Public Health; and professor, School of Nursing and Carey Business School, Johns Hopkins University, Baltimore, Maryland. C.G. Holzmueller is senior medical writer and editor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and senior research program coordinator II, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. N.E. Molello is administrator, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

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L. Paine is director of patient safety, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Johns Hopkins University School of Medicine, Baltimore, Maryland.

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L. Winner is director of Lean Sigma deployment, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.

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J.A. Marsteller is associate professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. S.M. Berenholtz is professor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Departments of Anesthesiology and Critical Care Medicine and Surgery, School of Medicine, and Department of Health Policy and Management, School of Public Health, Johns Hopkins University, Baltimore, Maryland. H.J. Aboumatar is assistant professor, Department of Medicine, Johns Hopkins University School of Medicine, and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. R. Demski is senior director of quality improvement, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Johns Hopkins Health System, Baltimore, Maryland. C.M. Armstrong is chairman, Johns Hopkins Medicine Patient Safety and Quality Board Committee, and, until October 2013, was chairman, Johns Hopkins Medicine Board of Trustees, Baltimore, Maryland.

References 1 Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 pt 2):365–368. 2 Centers for Medicare and Medicaid Services. Hospital Compare. http://www. cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/ HospitalQualityInits/HospitalCompare.html. Accessed March 24, 2015. 3 Fineberg HV. Shattuck Lecture. A successful and sustainable health system—how

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to get there from here. N Engl J Med. 2012;366:1020–1027. Marshall M, Pronovost P, Dixon-Woods M. Promotion of improvement as a science. Lancet. 2013;381:419–421. Pronovost PJ, Demski R, Callender T, et al; National Leadership Core Measures Work Groups. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39:531–544. John Hopkins Medicine, Armstrong Institute for Patient Safety and Quality. About the Armstrong Institute. http://www. hopkinsmedicine.org/armstrong_institute/ about/. Accessed March 24, 2015. Lencioni P. The Advantage: Why Organizational Health Trumps Everything Else in Business. San Francisco, Calif: Jossey-Bass; 2012. Heifetz RA. Leadership Without Easy Answers. Cambridge, Mass: The Belknap Press of Harvard Press; 1994. Pronovost PJ, Armstrong CM, Demski R, et al. Creating a high reliability health care system: Improving performance on core process of care measures at Johns Hopkins Medicine. Acad Med. 2014;90:165–172. Dixon-Woods M, Baker R, Charles K, et al. Culture and behavior in the English National Health Service: Overview or lessons from a large multi-method study. BMJ Qual Saf. 2014;23:106–115. Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36:252–260. Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Assessing and improving safety culture throughout an academic medical centre: A prospective cohort study. Qual Saf Health Care. 2010;19:547–554. Aveling EL, Martin G, Armstrong N, Banerjee J, Dixon-Woods M. Quality improvement through clinical communities: Eight lessons for practice. J Health Organ Manag. 2012;26:158–174. Pronovost PJ, Marsteller JA. Creating a fractal-based quality management infrastructure. J Health Organ Manag. 2014;28:576–586. Gould LJ, Aboumatar H, Blanding RJ, et al. Clinical communities at Johns Hopkins Medicine: Applying lessons from the frontline to enhance quality and institutional collaboration. Jt Comm J Qual Patient Saf. In press. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. TeamSTEPPS: National Implementation. http://teamstepps.ahrq. gov/. Accessed March 24, 2015. Mandelbrot B. The Fractalist: Memoir of a Scientific Maverick. New York, NY: Pantheon Books; 2012. Pronovost PJ, Bo-Linn GW, Sapirstein A. From heroism to safe design: Leveraging technology. Anesthesiology. 2014;120:526–529. Pronovost PJ, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308:769–770.

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