John Hopkins Hospital Quality Plan

Performance Improvement Plan For The John Hopkins Hospital
The John Hopkins Hospital Patient Care and Safety
I. Purpose and Quality Statement:
II. Patient safety can be defined as the measures to prevent errors and negative effects that often arise from healthcare actions (WHO, 2017). The healthcare sector has seen lots of changes and improvements in technology use, accompanied with effectiveness in service provision. There are new medicines and treatments in use too. Healthcare facilities handle older patients who show high level co-morbidities that call for hard decisions to be made regarding priorities in healthcare. Exerting more pressure on healthcare facilities economically results in healthcare settings that are overstretched.
Purpose of a quality plan (Tovey, Uren & Sheldon, 2015):
· Provides a comparison avenue with the performance system of an organization
· Postpones the action of disciplining staff as it gives them time to right their wrongs and improve their practice performance issues
· It is evidence to the world that the management is reasonable and fair in handling staff when there is need for change in behaviour
· Provides flexibility of action needed to deal with employees who need to change their behaviour and thus gives the management a chance to avoid action that could cause disenfranchisement among the employees.
· It facilitates a scenario where everyone gains from the work experience by focusing on the problems at hand and creating standards while promoting information sharing
· It supports the view that employees can differentiate what is right from what is wrong
· It fosters communication and focuses on the issues at hand, its solutions and consequences
· Records and documents the resources used for training and guidance as supplied by the management.
The Importance of quality plan
Accreditation is done through a voluntary participation. Reviewers evaluate the compliance status and rank it, based on set standards of performance (Alkhenizan & Shaw, 2014). Alkhenizan (2014) sought to find out how programs of accreditation influence healthcare service quality.
The above study showed that accreditation programs enhance service delivery (Alkhenizan & Shaw, 2014). Therefore, the programs should be encouraged.
Patient Care and Safety commitment at John Hopkins
The institutions mission statement and core values guide the care practice embraced by its staff and how they attend to their patients. It is geared towards provision of world class healthcare service. The mission statement also provides the foundation for the institution’s strategic plan. The mission statement outlines
Vision: to push practice boundaries of discovery, enhance medical practice education, transform healthcare provision and give humanity hope.
Mission: to improve community health and the world in general by anchoring its practice in set standards of excellence. John Hopkins provides education to medical students, healthcare professionals, scientists and the general public. It runs biomedical research programs and offers medicine that is patient centred in its procedures of diagnoses, prevention and treatment.
I. Core Values
II. Discovery and Excellence: aim to be the best by promoting discovery, creativity and information search to develop solutions that are innovative
III. Integrity and Leadership: mentor others as a role model and pursue the right course of action courageously
IV. Inclusion and Diversity : Accept varying opinions, backgrounds and experiences
V. Collegiality and Experience : learn to appreciate the unique skills and knowledge by others(John Hopkins Medicine, n.d.1)
VI.
VII. The major players in the patient care and safety plan at John Hopkins
Providers
Payers
Employers
Patients
Source: Patient Safety-Quality Improvement (2016)
QI Department: makes use implementation of strategy, the main analysis process, follow up and reporting as part of the QI process
Areas of focus: Making use of best practice standards and national measures, the Quality Improvement Program makes sure that the members in the plan are provided with the best service (John Hopkins Medicine, n.d.2). Data is analysed to develop the quality improvement programs and focuses on improving these areas:
· Service excellence
· Member safety and care quality
· Organizational quality
Initiatives for quality improvement are crafted after carefully considering of the potential positive service effects on members of the plan (John Hopkins Medicine, n.d.2). The QI projects and processes are evaluated regularly and updated. There is an annual evaluation of all the quality programs so as to establish any trends. The objectives for the forthcoming year are informed from the outcomes of the evaluation of the previous year’s programs (John Hopkins Medicine, n.d.2).
John Hopkins Accreditation Status
Statement of Accreditation
The John Hopkins University School of Medicine enjoys accreditation from the Accreditation Council of Continuing Medical Education (John Hopkins Medicine, n.d.3).
Credit Designation Statement: The University designates this live activity for a maximum of 7.25 AMA PRA Category 1 CreditsTM. Doctors should only claim the commensurate credit in line with the amount of input in the activity (John Hopkins Medicine, n.d.3).
Other Credits
ANCC
ANCC accepts AMA PRA Category 1 Credit TM from ACCME accredited organizations.
AAPA
The above organization accepts AMA PRA Category 1 TM from ACCME accredited institutions
American Academy of Nurse Practitioners and National Certification Program
The above organization accepts AMA PRA Category 1 TM from ACCME accredited organizations
Sibley Memorial Hospital is accredited by The Joint Commission on Health Care Organizations Accreditation and has a license from the District of Columbia, Department of Health (John Hopkins Medicine, n.d.3).
Mammography Units
The American College of Radiology Mammography Accreditation program has certified our mammography services. We are also certified by the Food & Drug Administration agency. We have, on board, qualified and registered radiologists with further certification in mammography. The mammography images are examined and interpreted by the radiologists at Sibley. These radiologists are certified by the American College of Radiology (John Hopkins Medicine, n.d.4).
Oncology Program
The oncology program is an American College of Surgeons and Commission accredited community cancer initiative (John Hopkins Medicine, n.d.4).
The Department of Pathology
We are accredited by the American College of Pathologists. Furthermore, the American Association of Blood Banks(AABB) has accredited out Blood Bank. We are registered by the FDA (John Hopkins Medicine, n.d.4).
Sleep Centre
The Sleep Centre at Sibley Hospital is accredited by the American Academy of Sleep Medicine (John Hopkins Medicine, n.d.4).
Information Management systems at John Hopkins (John Hopkins Medicine, n.d.5)
Your health information is safely guarded by the John Hopkins Hospital. The privacy guarantee is well explained in the Notice of Privacy and Practices at John Hopkins. The information provided on the institution’s website only relates to the confidentiality and privacy of the health information of patients in the USA with regard to The John Hopkins’ activities.
The Notice of Privacy Practices of the hospital provides guidance that the John Hopkins’ care centres may share patient information created or obtained about patients through Health Information Exchanges Participation ( HIEs) and as allowed by law(John Hopkins Medicine, n.d.5). For instance, information regarding past medical care and the medical conditions that affect you at the moment, and the medications can be accessed by the hospital or a primary care centre that you attend or your physician that may not be part of the John Hopkins fraternity ; if they are HIE participants too. Sharing health information may allow for faster access and improved coordination of healthcare services (John Hopkins Medicine, n.d.5).
The Regional Information System at John Hopkins Patients, Inc. (CRISP) is an internet based HIES in the region that allows us to participate (John Hopkins Medicine, n.d.5). We may share patient information via CRISP for payment, treatment, research purposes or healthcare operations. The system allows patients to opt out and block access to health information that relates to them. They can do it by either filling a form to opt out right on the crisphealth.org website or by contacting the CRISP support team via mail or fax John Hopkins Medicine, n.d.5). Other patient information as permitted by law will still be available through CRISP. It is clear that the information management systems at John Hopkins is compliant to required accreditation and rules.
John Hopkins Medicine meaningful-use
Eligible healthcare centres and hospitals can access bonuses if they demonstrate that they are making use of electronic health record systems for purposes of enhancing patient satisfaction, coordination of care, health disparities, safety and a list of other measures (John Hopkins Medicine, n.d.6). The healthcare facilities that flout the regulations are bound for penalties.
The standards of “Meaningful Use” dictate that an electronic health record system tracks a huge amount of listed patient data. Such data ranges from such aspects as important statistics, allergies, smoking status, and prescriptions to office visit records, instructions for discharge and compliance level (John Hopkins Medicine, n.d.6). It is a common trend for clinicians to make use of the electronic medical system standards all data points pointed out by Meaningful Use.
Mr. Peter Green who is the chief officer for medical information at John Hopkins Medicine demonstrates Meaningful Use and its purpose to patients, healthcare systems and providers. From a patient care view, the set standards and regulations for collection of data need seamless information sharing across different information systems (John Hopkins Medicine, n.d.6). It has been estimated that complying with “Meaningful Use” will provide over $100 worth of incentives for the next six years (John Hopkins Medicine, n.d.6).
John Hopkins Performance improvement tracking
Patient Experience – based on survey outcomes on patients, previously done, one can see how the care from John Hopkins Hospital was rated by others(John Hopkins Medicine, n.d.7).
Infection Prevention – They include such measures as the rate of CLABSIs, the percentage of healthcare staff observed washing their hands or making use of the hand sanitizer prior to and after caring for a patient (John Hopkins Medicine, n.d.7).
 Core Measures – The measures represent national care standards and standards of treatment for common health conditions. Compliance of the core measure is demonstrated by how frequently a healthcare facility follows each step (John Hopkins Medicine, n.d.7)
Surgical Volumes – There is evidence from various studies that there is a strong relationship between the frequency of a specific surgical procedure by a hospital and patient outcomes. We started sharing our surgical volumes for a range of common and high risk surgical procedures (John Hopkins Medicine, n.d.7).
 Quality of Care Ratings – The patient care star rating summarises how well the John Hopkins Home Care Group and Potomac Home Health Care fair on a scale of nine quality measures including ambulation (John Hopkins Medicine, n.d.7).
 Data Reading
Key Content Areas - each of the measures explains its importance, the improvement trail, and how family members and patients can help to enhance safety. The staff members of the clinics are shown sharing how they promote safety and better quality on daily basis.
Specific Hospital Data – data for each of the adult hospitals can be traced from the tabs on the top part of the graph. The graphs present an interactive experience and display numbers once a specific point on the line graph is selected.
Reporting Period- Quality measures and safety share quarterly data collected in recent time, and information generated up to three years back. Most measures show the recent quarter first in the form of a bar graph. A line graph below represents three years of data.
Comparison – we draw comparisons between our performance and the national averages reported publicly by Medicaid Services and Centres for Medicare(John Hopkins Medicine, n.d.7).
Graphical representation


Performance of John Hopkins in major areas of safety
Three hospitals run by the John Hopkins Medicine have been recognized in Top performer on main Quality Measures program by the Joint Commission that accredits and certifies U.S healthcare institutions. The designation for Top Performer is a reserve for only accredited healthcare facilities and hospitals that strictly adhere to best practice for treating people attending to patients who need surgery, suffer heart failure, heart attacks, pneumonia, stroke and other critical conditions(John Hopkins Medicine, n.d.6)
Recognition by the Joint Commission program, now in its third year, goes to The Johns Hopkins Hospital in Baltimore, Maryland; Sibley Memorial Hospital in Washington, D.C.; and All Children’s Hospital, a paediatric specialty hospital in St. Petersburg, Florida (John Hopkins Medicine, n.d.6).
Data on immunization performance
Source: https://www.hopkinsmedicine.org/patient_safety/core_measures.html#charts
Blood Clot prevention data
Source: https://www.hopkinsmedicine.org/patient_safety/core_measures.html#charts
The above data shows that John Hopkins has performed well in prevention of blood clot compared to the national and state performance. Immunization does not seem to perform as well. John Hopkins scores 91% against the national score of 94% and a state score of 97% as an average in immunization programs.
John Hopkins compliance with Accreditation standards
John Hopkins advises all staff including directors and all affiliates on how to detect, prevent and correct violations by employees at all levels of authority. It also guides on policies of institutions and violations of procedure (John Hopkins Medicine, n.d.8).
The compliance program was initiated in 1998 and was meant to
· Protect the organization, customers and employees
· Preserve the J. Hopkins integrity level
· Ensure that internal controls are maintained for purposes of adherence to ethical and legal standards
· Encourage consistent effort to do right
The John Hopkins Home Care unit was given the Gold Seal as accreditation by the Joint Commission Release in late 2012. This award was recognition for the groups compliance to quality standards set by the Joint Commission for home care (John Hopkins Medicine, 2012). It is evident . therefore that John Hopkins has had an impressive standards compliance record with accreditation organizations.
Patient safety and Quality Issues through Reimbursement Data
The charges levied on services and items provided by hospitals to patients are determined by the same hospitals (CMS.GOV, 2017). The payments include Medicare Severity Diagnosis Related Group fee, beneficiary primary payer, beneficiary part A coinsurance fee, beneficiary deductible amount among others(CMS.GOV, 2017). Inpatient users of PUF will be enabled to compare between charges at hospital level and payments nationwide and at the local markets for services that might be offered with regard to specific stays by inpatients.
Reimbursement carries a different meaning in healthcare circles. Prospective Reimbursement analysis(PRA) at John Hopkins supports the clinical research staff(Web Notes, 2015). The study analyses result in determining whether the charges levied on patients booked for clinical studies should be made as standard of care research; guided by contract, budget and protocol (Web Notes, 2015). The PRA process implementation has lead to almost 100% rise in clinical trial numbers began in 2013 against those of 2012. CRMS which is a single database for patients that are presently in clinical research programs includes 140 000 patients. It is also the main source of information associated with Epic (Web Notes, 2015). John Hopkins must readjust their processes to improve their tracking ability since they adopted Epic
Impact of Reimbursement data on accreditation status
According to accreditation requirements, it is illegal and unethical to use data belonging to patients in a way that will reveal confidential details. John Hopkins only uses patient data for research purposes. Accreditation assessment is influenced by how a healthcare facility handles patient information and reimbursement data. Reimbursement data can only be used for improving healthcare practice.
Impact of reimbursement policies on patient safety and quality initiatives
Reimbursement policies are anchored on the need to refund hospital amounts used in insured care. The central goal is to enable patients to access emergency services in healthcare facilities at reduced cost. The plan has widely improved healthcare service provision to the public, compared to when a patient pays directly.
Leadership involvement at John Hopkins in the dissemination and use of quality data at this healthcare institution
Your medical records can be mailed by John Hopkins to the address you provide on the authorization form. Make sure that you sign and date the form after filling it, completely, so that you prevent delays (John Hopkins Medicine, n.d.9). If someone is a court appointed guardian, a healthcare agent, holder of power of attorney or some other legally commissioned representative, they must attach such proof of their authority to deal on behalf of the Patient (John Hopkins Medicine, n.d.9). John Hopkins organizations may share information obtained through HIEs participation as allowed by the law.
Recommendation
Although John Hopkins has performed extremely well in managing hospital affairs, they have remained behind in such areas as provision of vaccine for Flu. Any health provider seeks to enhance the health of the community. John Hopkins has performed equally well in the later respect. However, there is need for the hospital to become more proactive in responding to the community health issues such as Flu.
The John Hopkins Hospital Goals Development
John Hopkins has set safety and the patients’ wellbeing as its priorities. Persistent research and consistent protection of patients through improvement practices should be at the forefront. The hospital will rise to patient protection excellence if it embraces improved provider order management, accurate labelling of specimens in the lab, infection control measures and rapid response training of teams.
New technologies for improvement of patient safety
John Hopkins excels in information management. The need to stay on top of the game cannot be overemphasized in the face of rising cyber crime. The data security systems have been reinforced through acquisition of advanced technologies. The system should be tweaked to allow patients to control the use of their health information. A patient should always be aware of who and where their information is being used.
Leadership strategies for community and stakeholder participation
The performance of any organization is influenced by how well it handles the issue of inclusivity. Al subscribed patients should be allowed to have their input in the development and crafting of safety and protection regulations. Participation of patients will ensure that their will is at the core of such regulations. The organization should consider CSR programs. A community needs assessment should be conducted with the involvement of community representatives.
Recommended policy changes
Any use of patient health information should be accompanied with consent at every instance. The patient is the primary stakeholder. Therefore, patient input cannot be wished away. Ways of acquiring a balanced opinion should be devised.
Evaluation plan
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The plan here involves developing a framework for patient protection that ensures full participation of patients with regard to the use of their health information. It includes granting them the full control in allowing or disallowing the use of their private data.
There is a need for consultation to acquire expert views on how to execute the plan and the overall financial effect of implementing such a plan. The main objective is to provide protection to patient information and to enable the patient more control over the use of their private health data.
Timelines
Dates/Duration
Objective
Jan to April 2018
Stakeholder engagement such as IT experts, budget teams, experts in data security and patients.
May to August 2018
Implementation modalities: logistics, framework, redesign of data collection and data policy, execution
September to December
Trial run of the new system: modifying and synchronizing
January 2019
Full implementation
Justification of Timeline
It is not possible to execute performance improvement in one day, particularly in situations involving complex data security technologies. In my view, the process of planning and subsequent implementation should be given at least 12 months.
Measure of Success
Once loopholes of patient information leakage have been sealed, and patients are fully involved in the sharing and use of their private information, there is a chance that more and more patients will be willing to allow the use of their private data. Such an eventuality will be an indicator of how confident the patients feel about the data security systems at John Hopkins.
Data Management processes changes for accreditation
In order for John Hopkins to be accredited, they must show the security of patient data from the point of collection, storage and transmission. The institution has been accredited by many major accreditation organizations for exemplary performance in information security. The institution has, among other steps, given patients the room to decide whether they wish their information to be used for research purposes and for sharing with other health institutions for health improvement.
There is increased urgency to improve security for patient data, owing growing cyber security threats.
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References
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WHO (2017). Patient Safety-World Health Organization. Retrieved 29, December, 2017, from http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/patient- safety