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When implementing a unified, whole care delivery system, a strong organizational framework that includes the participation of all staff members — from the board room to the community practice — is critical, Johns Hopkins researchers report.
An article, published online ahead of print, in Academic Medicine describes the model used by Johns Hopkins Medicine to coordinate high-quality care across the institution’s two hospital outpatient centers and more than 39 primary and specialty care outpatient sites. The effort mapped improvement initiatives to a dozen government-required performance metrics, such as breast cancer screenings, childhood immunizations, diabetes management and prenatal care. One year after the plan’s implementation, participating ambulatory care centers improved in all measures.
The work has implications not only for community physician groups but also for larger health systems seeking to improve their performance on the Centers for Medicare and Medicaid Services’ value-based purchasing metrics.
“This study is a great addition to the literature on providing high-quality, evidence-based practices of care,” says Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality, senior vice president for patient safety and quality for Johns Hopkins Medicine, and one of the study authors. “There has been limited discussion as to how to standardize quality of care in the outpatient setting. Our model is a road map that will allow health systems to sync performance across diverse settings without losing the institution’s autonomy.”
While ambulatory services have long been connected to larger health systems, the authors found challenges can arise when trying to coordinate care across multiple centers. Unlike inpatient care settings, where quality performance is regulated by the hospital, each ambulatory care practice often has its own organizational structure.
“We needed to create a process that allowed us to share best practices across both community and academic settings, and still address the critical domains of patient safety and quality,” says Steven Kravet, president of Johns Hopkins Community Physicians and lead author on the paper.
To manage the complex environment, Johns Hopkins patient safety experts and leaders tweaked a model used by the health system to reach 96 percent compliance on six best practice measures at five of its member hospitals. Created by the Armstrong Institute, the model is based on a mathematical system that features endlessly repeating patterns. Safety and quality improvement programs were created, communicated and replicated at every outpatient location to ensure all offices were working to achieve the same performance goals.
The study authors attribute Johns Hopkins’ success to developing systemwide groups that enlisted the shared wisdom of staff members to identify and solve problems. Senior leaders from primary care, medical specialty and surgical practices from the outpatient hospital and community settings formed a joint council. Together, the group standardized protocols, monitored performance using novel dashboards and evaluated potential risks associated with care delivery. Work groups comprising patient safety experts, physicians, nurses and administrators from across all settings identified the causes of setbacks and barriers to improvement. Each practice then tailored patient safety programs to ensure local acceptance. The process allowed the institution to maintain its individuality while also meeting the mandates from federal regulatory groups.
“All clinicians want to provide safe, quality care,” says Jennifer Bailey, senior director of quality and transformation for Johns Hopkins Community Physicians. “It was really important that we allow each entity to contribute to our process so that we can successfully transfer and share knowledge without losing our practices’ unique culture and structure.”
To support transparency and accountability, each outpatient site was responsible for reporting on its performance. Practices whose performance dropped below set goals were asked to submit an action plan to senior health system leaders to correct issues. Continued failures were escalated, with some requiring a safety audit and a presentation about corrective measures to the Johns Hopkins Medicine board of trustees.
The efforts were led by the Armstrong Institute and the Office of Johns Hopkins Physicians. Established in 2011, the Armstrong Institute works to improve clinical outcomes while reducing waste in health care delivery both at Johns Hopkins and around the world. The Office of Johns Hopkins Physicians coordinates and oversees the physicians and staff members responsible for the nearly 2 million nonancillary ambulatory visits conducted annually across the health system.
More details about Johns Hopkins’ approach to improving performance in the accountability measures are available online and in the March print edition of Academic Medicine.