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Hopkins: 'Cascading Accountability' Boosts Ambulatory Quality, Safety

News  |  By Alexandra Wilson Pecci  
   March 14, 2016

Johns Hopkins Medicine coordinates high-quality care across ambulatory care centers, using a model it says has resulted in improved metrics associated with breast cancer screenings, immunizations, and diabetes management.

Johns Hopkins Medicine's commitment to quality care is evidenced by a governance, oversight, and accountability model that is cascading throughout its ambulatory medicine sites.

"Hopkins has always had an emphasis on quality and safety that was really borne from our inpatient experiences," says Steven Kravet, MD, president of Baltimore, MD-based Johns Hopkins Community Physicians.

Yet how to ensure that the quality of care remains high, even as the organization grows, and in particular, grows on the ambulatory side? Like many health systems and hospital operators, JHM is seeing more growth in its ambulatory services than its inpatient services. And outpatient services are being distributed not only throughout the community, but beyond it.

In the wake of rapid outpatient growth, JHM recognized the need for better ambulatory quality and safety processes to maintain the high-level of care that's become the inpatient standard. So it developed a model to coordinate high-quality care across its ambulatory care centers, which resulted in improvements in metrics pertaining to breast cancer screenings, childhood immunizations, diabetes management, and prenatal care.

Kravet is lead author of a paper in the March issue of Academic Medicine that outlines the JHM model's structure and success.

JHM has two hospital outpatient centers and more than 39 primary and specialty care outpatient sites where nearly two million non-ancillary ambulatory visits are conducted annually across the health system, the paper notes. Often, each ambulatory care practice has its own organizational structure.

To ensure consistent quality, JHM created a governance, oversight, and accountability model that cascades throughout the ambulatory sites. It consists of:

An Ambulatory Leadership Dyad
The dyad consists of a senior physician leader in the role of ambulatory chief quality officer (CQO) and a masters-trained nurse in the role of a senior director for ambulatory quality. The CQO was selected from the Office of Johns Hopkins Physicians (OJHP), which coordinates and oversees ambulatory physicians and staff. CQO dyad organizes and oversees analytics and dashboards for the quality metrics.

The Ambulatory Quality Council
The AQC comprises key leaders from each ambulatory practice setting, the OJHP, and JHM's Armstrong Institute for Patient Safety and Quality. Some of the practices are represented by a physician and an administrative leader, while others are represented by a physician, an administrative leader, and a senior nurse.

"It's created a table to hear what's going on in ambulatory, even when it's distributed throughout the community," Kravet says.

The AQC is also divided into four workgroups which share best practices, and each workgroup is devoted to a different theme:

  • Performance measures
  • Value
  • Patient safety/risk
  • Patient care/experience

This "cascading accountability model… provided a quality structure for all JHM ambulatory practices. As part of this model, the JHM Quality Board Committee created a quality and safety accountability system, establishing goals and measures for the CQO dyad. The Ambulatory Quality Council then defined its goals, set standards, monitored performance, and reported to the JHM Quality Board," the paper says.

Kravet says this approach brings people together to create an accountability model, set standards, facilitate processes, and distribute knowledge in a practical way. In a way, it's reminiscent of how franchises operate: Each is an independently owned business, but must adhere to the model and standards of the overall organization.

"The same measures… are then pushed down to the unit level," Kravet says. "We distribute the dashboards and the expectations."

In addition, the paper says that "if an ambulatory practice continues to report substandard performance metrics, its leaders as well as the ambulatory practice chief quality officer are required to create an action plan and present it to the Board of Trustees."

Since it was implemented in early 2014, the model has resulted in improvements in a dozen government-required performance metrics. "An additional benefit was an improvement in Medicaid value-based purchasing metrics, which are linked to several million dollars of revenue," the paper says.

"It has created a great sense of accountability," Kravet says. It's broken down silos by putting patients at the center of care and encouraged stakeholders to have a voice in shaping and sharing goals. 

Moreover, the model is scalable, and the authors believe it can be expanded to "other ambulatory practices within and outside JHM, including to regional and international partners," the paper reports.

"Patient safety is something that everyone can galvanize around," Kravet says. "When people are part of the design, they have greater buy-in into the accountability."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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