How a Hospital Playbook Is Preventing Harm in Parkinson’s Patients

People living with Parkinson’s disease are particularly vulnerable to preventable harm during hospitalization. Peter Pronovost, M.D., Ph.D., chief quality and transformation officer at University Hospitals Cleveland Medical Center, recently spoke with Healthcare Innovation about how hospitals are beginning to apply CMS’s Age-Friendly Hospital Measure based on the 4Ms Framework—What Matters, Medication, Mentation, and Mobility — with a playbook geared particularly to the needs of Parkinson’s patients. 

Provonost is lead author on a paper on this topic just published in the Joint Commission Journal on Quality and Patient Safety. The paper includes disease-specific hospital care recommendations developed by the Parkinson’s Foundation. As the paper explains, effective Jan. 1, 2025, CMS’s Age-Friendly Hospital Measure requires hospitals participating in Medicare’s Hospital Inpatient Quality Reporting Program to attest to having processes that comply with the 4Ms Framework for Age-Friendly Care or risk a 29% reduction of their Medicare payment update.

One example of a workflow change from the playbook is the implementation of standard processes for reducing delays in medication administration according to patients’ at-home medication regimen and prioritizing people with Parkinson’s in medication administration processes.

Healthcare Innovation: Could you give a quick primer on the 4Ms framework?

Pronovost: It’s really framed as activities that, if not performed, people suffer harm. For example, doing what matters. There's pretty compelling data that people, especially the elderly, often get care they don't want, and it often doesn't benefit them, and they don't have a say in it. And people suffer horribly from medication mismanagement, especially medicines that confuse them, and medication errors or mismanagement is the No. 1 cause of harm in hospitals. Mobility — people, especially older patients, sit in bed and just languish there. So the 4Ms was a way to make it something that's simple and actionable. 

Most of our quality and safety work is driven by what you're admitted for, such as a heart attack. But what that framework misses is people who have other conditions — like Parkinson's or severe mental illness  — that you may not be admitted for, but which may impart more risks than the disease you're there for, and we're blind to them. For example, most people with Parkinson's disease aren't admitted for Parkinson's disease, but the risks of having Parkinson's disease are often far more than what they've been admitted for, and we didn't have a framework for identifying and addressing those risks. So much of the work that we've done with the playbook for Parkinson's has been finding ways to identify people with Parkinson's who were admitted and then making sure that we take care of those 4Ms such that they don't suffer additional harm.

HCI: Do you think that even before this framework, health systems had a general understanding that Parkinson's patients were at higher risk than the general population for harm incidents in the hospital?

Pronovost: It’s highly variable. Part of the reason that the Parkinson's Foundation's work has been so important is, I would say, across America there wasn't that recognition that Parkinson's disease patients were so vulnerable. Hospitals may know that they're a little bit sicker, but I would say there were precious few hospitals that had any kind of formal program targeting Parkinson's — for instance, making sure their medicines are on time. Part of the work that we've published with them and work we are doing with some of the other health systems has really galvanized the hospitals to think about subpopulations that are more vulnerable, like Parkinson's disease patients who need special safety programs to keep them from avoiding harm.

HCI: Has University Hospitals done some of this work, and are there some workflow challenges in rolling this out across a large health system?

Pronovost: Yes, we certainly have, and we published a study showing that when Parkinson's patients are mobilized, they have a much shorter length of stay, and they're much more likely to go home vs. going to a rehab facility or skilled nursing. To do that study, we had to find a way to identify Parkinson's patients, so we had to work with Epic to build tools to find it. 

We are now doing a study to show if you do the whole bundle — appropriate mobility, medication management, all the 4Ms —  could we get even further additive benefits? I mean it is kind of common sense that you could, but we want to study and demonstrate it so that we encourage other hospitals to do that. 

That requires some new workflows and some culture change. For example, many hospitals have a medication policy that says it may be an hour or two late and still be within a performance range, because pharmacists are busy, and things come up. Well, if you have Parkinson's disease, that doesn't work. If you have Parkinson's disease, it has to be within what their normal schedule is. If that's every three hours, you’ve got to figure it out. In some of the early conversations, people said we can't do that. We said that we have to do it. Let's figure it out. Of course, once you open your mind to the possibilities, you can see that there are feasible ways. You can find ways to ensure that patients get their medicines on time.

That led to us developing measures to monitor our people getting their medicines on time, and not just for Parkinson's, but for a whole list of time-critical medicines. And the same thing with ambulation. Sometimes if a patient needs more support to ambulate, like a Parkinson's patient or a very obese patient, they may get ambulated less often just because of the constraints of personnel. But we are quite hopeful that putting these structured programs in is going to be great for helping patients get through a hospitalization without suffering harm. 

Whether it's Parkinson's disease or just elderly patients, having a fall in the hospital is often the path to their death. They fall, they go to a nursing home, and they never really recover. They get more debilitated and get an aspiration pneumonia, and they are on a breathing machine. There’s pretty immense suffering that occurs because some of these things aren't happening, and we think they're largely preventable by doing these measures.

HCI: The Parkinson's Foundation seems to have some specific data about the risk of harm for Parkinson’s patients. Is there a national Parkinson’s patient registry, so they can see things like the impact of hospital medication management? 

Pronovost: Right now, there isn't a national registry. Epic has a lot of tools where you could look at data by diagnosis and see the variation in outcomes. Epic is working on that, and I think it would be immensely valuable. Most of that literature comes from individual studies, so you could look at what's the length of stay for someone with Parkinson's vs. without, or a fall rate in Parkinson's vs. without, or the cost per hospitalization, but it's not an ongoing database, and we think that would be immensely valuable, because you could also see who's doing really well.

HCI: The Age-Friendly Hospital Measure is brand new from CMS, but maybe they plan to measure the impact of the 4Ms over time.

Pronovost: I suspect they will, and kudos to CMS, because this is an area of high harm. The measures are complex and they require some work. I have no doubt that hospitals that do this will reduce harm in their patients. 

When we're measuring safety or quality, we tend to focus on measuring just the outcomes, but in this case, both the structure and the process are important, too.  If you're early in a program, structural measures are really important. You have to build the program and put these things in place. Because if you don't, measuring the outcome is kind of useless. But we know that if we do things like mobility, they'll lead you to the outcome that you want.

HCI: The Parkinson's Foundation said that their plan is to invest in research, shared learning, education and training to support the adoption and realization of its recommendations in the coming years. Are they envisioning a consortium or learning collaborative set up around this?

Pronovost: The Parkinson's Foundation has stood up a number of collaboratives. There's a best practices collaborative. There's a research collaborative. One of the things we're working on with CMS is within the Age-Friendly Hospital Measure, making a subgroup of Parkinson's patients, so that nationally we would have a forum to get these recommendations rolled out.

HCI: You have noted that hospitals are seeking disease-specific playbooks to better protect and meet the complex needs of older adults. Other than Parkinson’s, are there some other diseases it would be helpful to have playbooks around? 

Pronovost: Yes. For example, when patients with severe mental illness get hospitalized, they also have a lot of risk, similar to ones Parkinson’s patients face. They have aspiration because they're often sedated. They have medication management issues, and a lot of clinicians aren't comfortable with those medications because there are not a lot of hospitalized patients on them. 

Also, some populations of people, like frail people, are at higher risk of falling or getting further de-conditioned. CMS, or the healthcare industry, needs to start thinking of sub-segmenting patient risk. Just because you're hospitalized, not everyone has the same thing. Things like urinary tract infections or catheter infections are important, but there are also subpopulations that are at materially higher risk and we need to have programs to defend against that. 

HCI: Is there anything else about this work with the Parkinson's Foundation that you want to stress? 

Pronovost: I would just say I so applaud their advocacy and their commitment to science. They saw the literature that patients with Parkinson's are suffering and turned it into a program with evidence and interventions, and now with emerging evidence that those interventions work. Linking it with CMS Age-Friendly Measure allows it to be scaled across the country to materially reduce harm.

 In this work, the evidence is often not the barrier. It's getting people to implement the evidence. Do you have the workflow? Do you have the tools? In some of my earlier work with a checklist for catheter infections, the magic wasn't the items on the checklist, it was getting clinicians across the country or the globe to use the checklist. It's much like that now. How do we get hospitals across the country to use this 4Ms framework and make sure that they're keeping Parkinson's patients healthy?