Reinventing the care process

The science of innovation

A conversation with Peter Pronovost, MD, PhD
Professor at Johns Hopkins University School of Medicine; Medical Director, the Armstrong Institute for Patient Safety and Quality

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A practicing anesthesiologist and critical care physician, teacher and researcher, Dr. Pronovost has been hailed as the country’s leading patient-safety crusader.

Q: You are passionate in your crusade for patient safety. What led you on this quest?

A: My interest in many ways began ignobly. My father died young –– a painful death that was the result of a misdiagnosis. I was convinced that patients deserve better than our system gives them — not because doctors and nurses don’t care but because we work in a broken health care system.

A few years later, as a doctor at Johns Hopkins, I had to look into the eyes of the mother of an 18-month-old who died needlessly at my hospital after what started as a catheter infection.

That’s really what ignited our effort at Johns Hopkins to tackle one cause of harm, the central line-associated bloodstream infection (CLABSI) in the ICU. These types of infections kill as many people each year as breast cancer or prostate cancer.

I needed a system designed to help me avoid those infections. But more importantly, I needed to change my mental model, from believing these infections are inevitable to believing that they are preventable — and it’s my responsibility to prevent them.

Q: How is that shift in mindset and the related accountability driven through an organization?

A: At Johns Hopkins, we’ve implemented a fractal model for organizational learning and accountability. Our governance structure for overseeing quality follows this model. Within a cascading vertical fractal structure, each hospital and department follows Johns Hopkins Medicine goals — to partner with patients, their families and others to 1) eliminate preventable harm, 2) optimize patient outcomes and the patient experience and 3) reduce waste.

These safety programs work best when they’re led by clinicians, informed by good science and guided by measures that clinicians believe are valid.

Q: You've talked about how difficult it is to bring innovation. What are the greatest barriers to change?

A: In health care, the field of quality and safety has run away from science rather than embracing it. Health care relies on safety by the heroism of our clinicians rather than on design of safe systems.

It is the only industry that spends billions of dollars on a technology that the users — clinicians — largely dislike or at best tolerate. The value in these technologies is in predicting who is at risk, coupling this knowledge with the right decision support system, and then continuously learning from — and improving — the process.

Q: What is the role of hospital boards and executives in addressing the safety challenge?

A: They need to create structures that tap into clinicians’ professionalism — and support them with systems of measurement that accurately gauge results.

Health care costs are our budget crisis. I don’t think it will be solved by health reform or regulators. It will be solved by provider organizations — by engaging the pride and the norms of their clinicians and working with private industry to design technologies that reduce harm and improve productivity.

This problem must be solved. As providers, we’ve been too passive. It’s time for us to stand up and lead through this health care crisis. I hope our leadership teams will take on the charge.