When leaders at Johns Hopkins Health System set out to eliminate wasteful clinical practices across the organization, they started with blood transfusions.
Although the system had a number of areas it could have focused on first, unnecessary blood transfusions were on the industry's radar back in 2012, when Johns Hopkins began its effort.
Using a consistently applied and closely monitored set of procedures, Johns Hopkins was able to save $2 million a year and consume fewer bags of difficult-to-collect blood.
More importantly, the academic health system created a template for reducing waste across the organization, allowing its quality oversight managers to pick through other areas with a lot of potential for eliminating waste.
Today all clinical departments work on reducing low-value practices with support from the Johns Hopkins High Value Care Committee, which involves groups of clinicians across disciplines who look for literature available in their specialties that challenges established practices. "It has become an army at this point—across the whole institution we have people working on it," said Dr. Pamela Johnson, physician lead of the committee.
Like Johns Hopkins, other hospitals and health systems are picking apart just about everything they do clinically to try to eliminate waste, seeking efficiencies in sometimes unusual areas, such as vitamin deficiency testing and inpatient use of oxygen. After all, about 30% of healthcare spending each year is deemed wasteful, which includes spending on unnecessary care along with excess administrative spending and fraud, according to the National Academies of Sciences, Engineering and Medicine.
Johns Hopkins' initiative began about the time that the Joint Commission had named blood transfusions as one of the industry's most wasteful areas of practice. Some studies estimate that as much as 40% of U.S. blood transfusions are unnecessary.
The practice is a mainstay of healthcare and clinicians have been taught since medical school to give patients two units of blood whenever they require a transfusion. But recent research shows that one unit usually is just as safe and effective for patients who aren't actively bleeding. "No one questioned the rationale behind it," said Dr. Steve Frank, an anesthesiologist at Johns Hopkins.
With support from leadership, Frank began a blood management program to change how the system administered transfusions.
The initiative involved educating staff on the new policy, frequently using the phrase "Why give two when one will do?" An advisory alert was then established in the electronic health record to check blood units ordered and message clinicians if they went against the guidelines. The system even sends out monthly reports to each department showing their compliance with the transfusion guidelines. Physicians are notoriously competitive, so the tactic encourages doctors to keep the issue top-of-mind.
The program started at flagship facility Johns Hopkins Hospital in Baltimore and then was rolled out across the system's four other acute-care hospitals in 2015.
The same approach was taken with other targeted areas, including ongoing work to reduce unnecessary lab orders.
Johnson said it was the establishment of the High Value Care Committee in 2014 that signaled to clinicians that reducing low-value services was a priority systemwide. Clinicians across the organization were called on to join the effort, and it changed the culture, she said.
The providers now question traditionally held practices and guidelines, so that Johnson gets emails almost every week from doctors, advanced practice providers and nurses across the organization about opportunities they see to eliminate wasteful practices.
"Everyone is thinking about it across the whole institution," she said. "We are even making sure the future generation" of clinicians is well-trained in the practice.