Ambulatory medicine is a vital and growing area of health care in the United States. At Johns Hopkins Medicine (JHM) ambulatory care in academic and community settings has expanded in size and complexity, resulting in more than 2 million visits annually. Leaders of JHM recognized the need for a governance and accountability system to oversee the quality and safety of ambulatory care. In fact, they started this journey back in 2011, forming the Armstrong Institute to coordinate improvement efforts across JHM and creating a governance structure for these efforts that started in inpatient services.1
In response to our burgeoning ambulatory medicine service, leaders of JHM created the Office of Johns Hopkins Physicians (OJHP) to coordinate and oversee the standards of care delivered to patients in all ambulatory settings. Providers of the OJHP include the clinical faculty from the Johns Hopkins University School of Medicine (n > 2000), doctors, nurse practitioners, physician assistants, and nurse midwives from Johns Hopkins Community Physicians (n > 400), providers from Sibley Memorial Hospital and Johns Hopkins All Children's Hospital (n > 50), and providers from several specialty group practices (n > 20). Collectively through all of our entities, these providers deliver care at more than 1000 unique practices in regions spanning Maryland, the District of Columbia, and Florida.
ESTABLISHING THE QUALITY AND SAFETY STRUCTURE
In 2013, the Armstrong Institute worked with the OJHP to develop a new model of oversight and accountability for quality of ambulatory care. Details of how this governance structure was formed have been published.2 The initial model has evolved with more ambulatory entities participating and the new domain of health care equity added to the scope. Furthermore, as the OJHP role in ambulatory governance matured, there was a purposeful decision to align the accountability for quality and safety through the OJHP as well as the JHM Patient Safety and Quality (PSQ) Board Committee (Figure). The model remains organized like a fractal in which each ambulatory entity has a similar quality improvement structure, and these structures are linked, aligning goals, creating shared accountability, and communicating at all levels within an entity and across all entities.
The Ambulatory Quality and Safety Joint Council was formed in February 2014 and comprises key leaders from each ambulatory entity. An early activity of the council was to compose a charter to establish the scope of work and define the roles of its members. This charter linked to the cascading accountability model that provided a quality structure for ambulatory practices.
In the governance structure, the JHM PSQ Board Committee creates and coordinates the accountability system for patient safety and quality, establishing goals and measures. The Ambulatory Quality and Safety Joint Council defines its goals, sets standards, monitors performance, and reports to the JHM PSQ Board Committee as well as the OJHP Ambulatory Oversight Committee (the highest governing committee of the OJHP).
The Council's work focuses on 5 agenda areas that the JHM Quality Board Committee established to organize all quality efforts. These areas are (1) patient safety/risk within the local environment, (2) externally reported measure performance, (3) patient care/experience, (4) value (balance between cost and quality), and (5) health care equity (recently added in the past year). Each area has a workgroup that functions like a clinical community, with stakeholders from every entity and members sharing best practices, using peer support to drive improvements, and often involving subject matter experts. It is in these workgroups where horizontal shared learning among peers occurs and where the true engagement of the fractal model thrives. In this way, the Ambulatory Quality Council creates shared leadership accountability on a vertical line, and is the facilitator arm, providing direction and resources for local performance improvement committees at each entity.
BENEFITS OF GOVERNANCE AND OVERSIGHT OF QUALITY
With this governance structure, there is now improved alignment of individual ambulatory entity practices with the JHM PSQ Board Committee. Through our workgroups we now have a structure and process to improve across all domains. We have defined goals for safety, such as development of comprehensive unit-based safety program teams and benchmarks for closing encounters and following up on diagnostic tests. Furthermore, we created a robust process to oversee environmental safety and infection control, including checklists to ensure new procedures are safely performed. We now have outcome goals, such as achievement of mammogram completion rates and other health maintenance for patients regardless of their insurance coverage. Our targets are now consistent with national benchmarks and improved rates for patient experience, as measured through the Clinician and Group Consumer Assessment of Healthcare Providers & Systems survey. We also have defined value targets and improved rates of reduction in emergency department visits and readmissions to the hospital. Lastly, the newest workgroup on health care equity has begun to define measures of health care disparities by race, starting with blood pressure control. In each example described earlier, we now have clearly defined goals and measures, mechanisms for peer learning and sharing of best practices and protocols, and transparent reporting of performance to ensure accountability. A positive byproduct has been solidifying clinical relationships between providers within the academic and community divisions.
FUTURE DIRECTIONS
Given that JHM is an academic health system, we hope to include quality-related education in undergraduate and graduate programs across the schools of medicine and nursing. We hope to leverage our infrastructure to meet the needs of our training programs. Where there are expectations from national accreditation agencies, to ensure that residents and fellows are being measured on the quality of the care they deliver. Lastly, given the importance of developing a clinically integrated network that expands beyond our own practices, the ambulatory structure also provides clarity about how the oversight of quality in newly aligned practices will be integrated into JHM.
CONCLUSION
The future of US health care innovation will continue in ambulatory practices, as care appropriately moves to the lowest cost settings. Culture, governance, transparency, and accountability are among the drivers suggested to be linked to an organization's ability to achieve high quality. Our ambulatory quality and safety governance model is an example of a high-reliability approach to govern this transformation, providing structures for horizontal peer learning and vertical lines of accountability. Ultimately, together as an ambulatory community, we can collaborate to partner with patients and their loved ones and others to eliminate preventable harm, to continuously improve patient outcomes, and to eliminate waste in health care.
Steven J. Kravet, MD, MBA
Johns Hopkins Community Physicians
Office of Johns Hopkins Physicians
Johns Hopkins University School of Medicine
Baltimore, Maryland
Jennifer Bailey, MS, RN
Johns Hopkins Community Physicians
Office of Johns Hopkins Physicians
Armstrong Institute for Patient Safety and Quality
Johns Hopkins Medicine, Baltimore, Maryland
Peter Pronovost, MD, PhD
Armstrong Institute for Patient Safety and Quality
Johns Hopkins Medicine, and Johns Hopkins University
School of Medicine, Baltimore, Maryland
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