Pioneer in Improving Hospital Care Aims to Put People First

Miriam E. Tucker

March 31, 2015

NATIONAL HARBOR, Maryland — Peter Pronovost wants to change healthcare. Working at the Armstrong Institute for Patient Safety and Quality at Johns Hopkins School of Medicine in Baltimore, Dr Pronovost is considered a forerunner in the field, and has been credited with establishing checklists to reduce healthcare-associated infections.

But he's just getting started, the featured speaker reported here at the Society of Hospital Medicine 2015 Annual Meeting.

Checklists and other process improvements are an important step in taking quality to the next level, but transformative progress will only arise when patient desires are honored and the plight of healthcare workers revered.

Changing behavior can involve either coercion or inspiration, Dr Pronovost said. "No doubt we need a combination of both. We've been working on the coercion thing for years and it's not really moving the needle," he explained. "The inspiration piece — efforts led by people like you — has been wildly successful," he told the audience of hospitalists.

Dr Pronovost has been tasked with eliminating preventable harm in hospitals, which is a leading cause of death, improving clinical outcomes, and reducing waste.

"We were focusing on one harm at a time," he reported. "We needed to start thinking differently." And the radical concept of designing a health system that ends all harm was born.

That goal, along with making people feel valued, is key to influencing "peer norms, not by coercion, but by the power of communities," Dr Pronovost explained.

Inspiring Improvement Instead of Forcing It

The Comprehensive Unit-based Safety Program offers 1-day workshops, online learning, and remote coaching. It has been used to target problems such as hospital-acquired infections, patient falls, medication errors, and communication breakdowns.

"We don't fear change, we fear loss," he said. "Loss often has a real component, but there's often a much larger perceived component, which grows like wildfire if you don't manage the message." Too often, Dr Pronovost pointed out, professionals treat fear as a technical problem, so the feeling of loss grows and the opportunity to embrace positive new ways of doing things dissipates.

Most improvement projects fail because they scratch the surface by addressing a technical problem. "If you're going to be successful, you need to be students of this adaptive work," said Dr Pronovost.

He asked the audience to take out a piece of paper, write the words "I will," and commit to action. "The real test is what you do at the end of this day," Dr Pronovost told the audience.

"What we do in healthcare is determined by the stories we tell. Stories are the most powerful force for change in the world. They either pin us to our current performance or they propel us to new pinnacles. You change the story and you change everything," he said.

Pronovost is inspiring because he has "actually done this work," Burke Kealey, MD, outgoing president of the Society of Hospital Medicine, told Medscape Medical News.

"He saw central line infections that had to be fixed. It's more than just building a great set of goals or pathways. Those are critical, but there's so much more. It's the adaptive work — getting the buy-in and the culture work from the whole healthcare team — that will determine if we're successful or not," Dr Kealey said.

Another speaker at the plenary, Maureen Bisognano, MS, from the nonprofit Institute for Healthcare Improvement in Boston, talked about leading transformational change.

Bisognano described an innovation started by a nurse at a pediatric hospital in Glasgow, United Kingdom, which has spread to pediatric and adult hospitals around the world. Patients are asked to list or draw pictures of the things that matter to them.

One Nurse's Legacy

The results, she said, might not always be what you expect, and might have little to do with clinical care.

Bisognano told the story of a 37-year-old cancer patient who wanted to marry his fiancé in the hospital prior to the initiation of the next round of his treatment. Several different departments in the hospital came together to help arrange the wedding. The patient died three weeks later.

"Understand where patients and families are coming from and where they're going back to," Bisognano explained. "We have the power to redesign care around what matters to the patient."

Dr Kealey said he agrees. "All too often we can get focused on the health of the patients and all the problems that we see in front of us," he told Medscape Medical News. "Rarely do we really take that opportunity to sit down with the patient and ask what's important to them."

An innovation at the Cincinnati Children's Hospital involves "huddles" — 15-minute multidisciplinary troubleshooting sessions, held instead of the traditional postmortem model, that focus solely on planning for the next day.

Topics include not just patients' medical conditions and planned procedures, but also issues such as how to handle a child's respective parents who are going through a divorce.

"Looking at prediction brings up issues that can be fixed the day before," said Bisognano, who is on the board of that hospital. Cincinnati Children's Hospital is "seeing dramatic improvements in flow," as well as things that can sometimes come up as "big surprises" and throw off the system at other hospitals.

Another innovation, she said, is the collaborative admitting model used by ThedaCare's five-hospital community health system. Every patient is admitted by a pharmacist, a nurse, and a physician, each of whom has a specific role. The pharmacist does the actual admitting, the nurse creates the patient plan, and the physician orchestrates the clinical care. So far, the model has decreased the length of hospital stays, decreased costs, and reduced hassles, such as extraneous phone calls.

According to Bisognano, "this is the heroic idea for the future."

Dr Pronovost, Dr Kealey, and Ms Bisognano have disclosed no relevant financial relationships.

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