How Johns Hopkins melded medical knowledge with adaptive leadership skills to eliminate infections and slash errors in Michigan’s intensive care units.
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| Peter Pronovost, M.D. | Ronald A. Heifetz, M.D. |
Medical science knows how to prevent patient infections, but that’s not enough to dramatically improve patient safety in intensive care units. The more difficult hurdle is overcoming resistance: convincing hospital personnel--top administrators as well as front-line workers--to make patient safety a top priority and follow safe practices 100 percent of the time. It’s truly a leadership challenge.
Michigan hospitals have dramatically slashed infection rates in intensive care units statewide, saving lives and millions of dollars. They managed this by addressing two issues at once: technical problems and adaptive challenges.
- Technical problems are clearly defined and have known solutions, such as a diagnostic test or a drug. If a hospital can locate technical experts who know how to resolve the medical issues, they can fix the problem.
- Adaptive challenges are managerial and systemic problems that require creative solutions from stakeholders and participants. They are more difficult to solve and to identify clearly. They involve changing people’s hearts, minds and behavior.
Staving Off Infection
Nowhere are the technical and adaptive issues more challenging than in the intensive care unit. In ICUs, multiple caregivers are involved in both prescribing and administrating daily treatments to a single critically ill patient, increasing chances for error. Very sick patients have a limited ability to tolerate errors, yet because of their complex needs and the systems of care delivery, most patients admitted to ICUs suffer at least one preventable mistake.
Probably the most preventable and common result of a mistake is the catheter-related bloodstream infections (CRBSI), a costly and often lethal type of health care-acquired infection. Each year in the United States some 28,000 people die from these infections, with an estimated cost of $2.3 billion.
First at Johns Hopkins, then in participating hospitals across Michigan, CRBSIs in ICUs have been virtually eliminated and treatment errors slashed by combining best practices in both medicine and leadership.
This has saved millions of dollars and prevented untold suffering. In 103 Michigan ICUs, CRBSIs were reduced 66 percent. The state was at the 50th percentile from these infections; it is now at the 5th percentile. Patient infections in ICUs fell from a median of 2.7 per 1,000 catheter-days in 2003 to 0 in 2005. Estimated cost savings are $170 million a year statewide.
Two-Pronged Approach
The Johns Hopkins University Quality and Safety Research Group developed a program to improve ICU care, using Johns Hopkins Hospital as the learning lab to test and refine interventions and evaluation tools. By tackling both technical and adaptive problems, Johns Hopkins Surgical ICU reduced CRBSIs from 11 per 1,000 in 1998 catheter-days to 0 in 2002.
Could the results be replicated on a broad scale? In Michigan, the idea was to apply the Johns Hopkins experience and use the state hospital association as the node for dissemination. John Hopkins partnered with the Michigan Health & Hospital Association’s Keystone Center for Patient Safety & Quality in a research project funded by the federal Agency for Healthcare Research and Quality. The ICU safety program covered 108 ICUs at the time of project launch in February 2004; 127 ICUs are active project participants.
The adaptive components of the change model were:
- Engaging senior leaders, project leaders and front-line staff by making current reality visible and exploring what is important.
- Creating a system in the context of a hospital’s resources and culture in which patients reliably receive safe care.
The technical components were:
- Educating staff on the evidence-based interventions that reduce CRBSIs.
- Evaluating whether staff made a difference.
Some simple, technical steps dramatically improved safety. At the time Peter Pronovost, M.D., at Johns Hopkins asked Michigan hospitals to use chlorhexidine soap, which cuts infection rates in half, 80 percent of hospitals lacked this effective and inexpensive intervention. Within four weeks, nearly all the ICUs had this soap.
Other steps involved the more complicated process of changing behavior. All participants in a change process must understand where others are coming from, and the pressures others face, and be able to reframe approaches to the work to ensure full participation. Partnerships between group members, often formed outside formal meetings, frequently produced the change in mind-set necessary to make a difference.
This project both rigorously measured culture and evaluated the impact on what we called the Comprehensive Unit-Based Safety Program. Though culture is often discussed, it is often not systematically measured, and if measured, there has been little or no evaluation of the interventions to improve it. This is the first time, in any industry, that broad improvements in safety culture have been achieved with a focused intervention.
Model of Change
Though the evidence for reducing these infections was clear, it was less clear how to implement the evidence to ensure that all patients received the best care. It required a leadership model in which we surfaced the adaptive challenge that often called for changes in values (the need for teamwork) and attitudes. We asked people for ideas--we asked them, given their resources and culture, how they could design a system that ensured all patients received this intervention.
While the impact on safety that resulted from this work is dramatic, equally important is the evolutionary model of change that’s been proven in Michigan hospitals. Informed by multiple theories of change, in particular adaptive leadership, the model showed how tackling both medical and management issues simultaneously can dramatically improve patient care and safety.
Peter J. Pronovost, M.D., Ph.D., is a professor of anesthesia and critical care at Johns Hopkins Medical Center Baltimore. Ronald A. Heifetz, M.D., is a principal of Cambridge Leadership Associates in Cambridge, Mass., and a faculty member of Harvard University’s John F. Kennedy School of Government, also in Cambridge, Mass.
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This article 1st appeared on March 27, 2007 in HHN Magazine online site.
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