Transcript No Slide Title

Transforming Healthcare to
Achieve High Reliability
Mark R. Chassin, MD, FACP, MPP, MPH
President and CEO, The Joint Commission
KalDer 22nd Annual Quality Congress
Istanbul, Turkey
November 13, 2013
What is The Joint Commission?
Private and not-for-profit
Roots go back to 1917: American College
of Surgeons created first program to set
standards for hospitals and inspect them
Hospitals and other health care organizations
pay us to evaluate the way they provide care
Joint Commission customers (2013):
• US: 20,000+ health care organizations
• JCI: 600+ organizations in 59 countries
Joint Commission US Customers
Program
Ambulatory Care
Behavioral Health
Certification
Home Care
Hospitals
Laboratory
Long Term Care
Total
2012
2034
1987
2861
6163
4454
1632
974
20,105
What Does
The Joint Commission Do?
1. Create and continuously update evidencebased safety and quality standards
2. Develop and deploy the most effective
survey methods for onsite evaluation
3. Create and maintain most effective system
of quality measurement in hospitals
4. We are also an improvement organization:
creating and delivering quality solutions
What Accreditation is Not
Accreditation is not a guarantee that:
• No errors will occur
• Preventable complications will
never harm patients
• High quality care will always be
delivered to every patient
Accreditation cannot solve all our
quality and safety problems
456 patients notified
141 patients notified
Current State of Quality
Routine safety processes fail routinely
• Hand hygiene
• Medication administration
• Patient identification
• Communication in transitions of care
Uncommon, preventable adverse events
• Surgery on wrong patient or body part
• Fires in ORs, retained foreign objects
• Infant abductions, inpatient suicides
How Have Others Done It?
“High reliability organizations” manage
very serious hazards extremely well
What do they all have in common?
• Highly effective process improvement
• Fully functional safety culture
Discover and fix unsafe conditions early
In health care, we most commonly
react after patients are harmed
High Reliability Science
Research has defined how HROs
produce sustained excellence over time
No health care organizations function
at this high level of sustained safety
No guidance on how to transform
organizations from low to high reliability
We have created a roadmap for health
care to get to high reliability
High Reliability Healthcare
Our team has learned a lot by working
with experts from HROs in many fields
(aviation, military, amusement parks)
We have created a model for healthcare
• Leadership, safety culture, RPI
• New resources, tools, and strategies
Some hospitals and systems are
beginning to commit to the goal
Joint Commission
High Reliability Resource Center
Milbank Q 2013;91(3):459-90
Robust Process Improvement
Systematic approach to problem solving:
(RPI = lean, six sigma, change management)
The Joint Commission has adopted RPI
• Improve processes and transform culture
• Focus on our customers, increase value
The Joint Commission is adopting all
components of safety culture
We measure RPI and safety culture and
report on strategic metrics to Board
What Can RPI Help You Do?
In general, lean tools help identify wasted
steps in processes that can be eliminated
• Reducing time, saving money
• 25% of nurses’ time to give medications
Six sigma tools focus on reducing the rate
of unsatisfactory outcomes (or “defects”)
• Reduce frequency of surgical infections
• Improving pain management
Change management is always essential
Center for Transforming Healthcare
www.centerfortransforminghealthcare.org
Center for Transforming Healthcare
Using RPI together with leading US
hospitals and health systems to solve
most difficult quality and safety problems
Project topics:
2009-10: hand hygiene, wrong site
surgery, hand-off communications, SSIs
2011: safety culture, preventable HF
hospitalizations, and falls with injury
2012: sepsis mortality, insulin safety
2013: C. difficile prevention
Participating Hospitals
Atlantic Health
Barnes-Jewish
Baylor
Cedars-Sinai
Cleveland Clinic
Exempla
Fairview
Floyd Medical Center
Froedtert
Intermountain
Johns Hopkins
Kaiser-Permanente
Mayo Clinic
Memorial Hermann
New York-Presbyterian
North Shore-LIJ
Northwestern
OSF
Partners HealthCare
Sharp Healthcare
Stanford Hospital
Texas Health Resources
Trinity Health
Virtua
Wake Forest Baptist
Wentworth-Douglass
Current State of Quality
Routine safety processes fail routinely
• Hand hygiene
• Medication administration
• Patient identification
• Communication in transitions of care
Uncommon, preventable adverse events
• Surgery on wrong patient or body part
• Fires in ORs, retained foreign objects
• Infant abductions, inpatient suicides
The Way We Do Improvement
Usual approach: best practices, toolkits,
protocols, checklists, “bundles”
• Typical best practice is “one-size-fits-all”
• Can produce modest improvement
• Difficult to get to zero
• Difficult to sustain
The “one-size-fits-all” approach works well
only for simple problems that do not vary
Toughest problems are not simple
A New Way is Delivering Results
Complex processes require more
sophisticated problem-solving methods
Three crucial and consistent findings:
• Many causes of the same problem
• Each cause requires a different strategy
• Key causes differ from place to place
RPI = lean, six sigma, change management
• Producing next generation best practices
• Solutions customized to your causes
1.
2.
3.
4.
5.
Some Important Causes of
Hand Hygiene Failures
Faulty data on performance
Inconvenient location of sinks or
hand gel dispensers
Hands full
Ineffective education of caregivers
Lack of accountability
 Each requires a very different
strategy to eliminate
Causes Differ by Hospital
Each letter = one hospital
Wrong Site Surgery
Joint Commission Universal Protocol 2003:
a simple, one-size-fits-all best practice
Today: Best estimate = 50 per week in US
Center project found many more risks:
• Scheduling: 39% of cases
• Pre-op area: 52% of cases;
25% with multiple risks
• OR: 59% of cases;
32% with multiple risks
Risks of Wrong Site Surgery
Scheduling: incomplete data, verbal
requests, lack of standardization
Pre-op area: missing documents,
inadequate patient ID, time pressures lead
to rushing, non-surgeon marks site, marking
inconsistent, use of non-approved markers
OR: mark covered by drapes, distractions,
time out performed without full participation,
staff are not empowered to speak up,
verification omitted with multiple procedures
Pre-op
scheduling
Risks of Wrong Site Surgery Vary
By Organization
Reducing the Risks
Hospitals and ASCs targeted specific
interventions to the risks they uncovered

Relative Risk Reduction
Scheduling:
46%
Pre-op:
63%
multiple risk cases 72%
OR:
51%
multiple risk cases 75%
Results are Consistent
More sophisticated improvement methods
(RPI) required for complex problems
• Identify specific causes and how they
vary among different organizations
• Target interventions to specific causes
• Avoid “one-size-fits-all” solutions
Same findings for every problem tackled:
wrong site surgery risk, SSIs, patient falls
This is the Center’s unique capability
Targeted Solutions Tool (TST)
Web-based tools: secure extranet channel
Educational, no jargon, no special training
Guides users to customized, proven solutions
Targeting only your causes means you don’t
use resources where they aren’t needed
2010: hand hygiene: 2012: wrong site surgery
and hand-off communication
Pilot tested hand hygiene internationally;
working to make available to JCI hospitals
Hand Hygiene TST: 3 Years
849 projects are using interventions
• Baseline = 58% (n = 110,255)*
*p<0.0001
• Improve = 84% (n = 584,025)*

Unit
Baseline Improve
• Adult critical care
62%
80%
• Emergency dept.
51%
80%
• Adult med-surg
51%
84%
• Long term care
61%
86%
20% have improved to greater than 90%
Healthcare-associated Infections (HAIs)
are an Enormous Quality Problem
HAI Mortality rate = 5.8%
HAIs occur frequently...
99,000
Patient deaths attributable to HAIs (US)
1,700,000
Documented cases of hospital HAIs
annually (US)
...and cost many billions
$28-34 billion
Costs of HAIs per year in the US
Hand hygiene failure is a major
contributor to HAIs
Source: Klevans et. al . Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep (2007);
122(2):160-166; CDC "The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention,"
R. Douglas Scott II, March 2009
Improving Hand Hygiene Reduces HAIs
Hand hygiene affects all HAIs
•C diff, MRSA, other MDRO
•Urinary tract (CAUTI)
•Central line (CLABSI)
•Ventilator pneumonia (VAP)
Average TST improvement
•35% drop in HAIs
•Impact is substantial
Using the TST Prevents HAIs, Saves
Lives, and Avoids Millions in Costs
...saving thousands of lives2...
Hospitals using the TST have
prevented tens of thousands of
HAIs1
25,000
Number of HAIs prevented by
hospitals using Hand Hygiene TST
1,450
Lives saved by hospitals using the
Hand Hygiene TST
...and saving hundreds of millions
of dollars in direct medical costs
$300-650 million
Costs saved by use of the TST Hand
Hygiene tool
Over 250 organizations have employed the TST Hand
Hygiene tool to reduce the risk of HAIs in their facilities
(1) Ranges from 18,000 – 30,500 (2) Ranges from 1,050 – 1,800
Note: Impact estimates through the end of 2012; Includes 196 organizations using the TST since May of 2010 with >100 observations;
Impact estimates exclude ambulatory care facilities employing the TST
Source: The Center for Transforming Healthcare TST user survey, BCG analysis
Impact of TST on
Typical US Hospital
TST improves HH, reduces HAIs by 35%
300 Beds
600 Beds
Expect 555 HAIs/yr Expect 1100 HAIs/yr
Annual impact:
Annual impact:
• 388 fewer HAIs
• 194 fewer HAIs
• 24 lives saved
• 12 lives saved
• $3.7M cost avoided • $7.5M cost avoided
Used TST to
achieve >95% hand
hygiene compliance
Bloodstream
infections fell by 2/3
C. Difficile Rate Declines as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
1.3
1.2
90
1.1
80
1
HH
0.9
C diff
0.8
70
60
0.7
0.6
50
0.5
40
0.4
2007
2008
2009
2010
2011
C. difficile Cases (per 1000 patient days)
100
C. Difficile Rate Declines as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
1.3
1.2
90
1.1
80
1
HH
0.9
C diff
0.8
70
60
0.7
0.6
50
0.5
40
0.4
2007
2008
2009
2010
2011
C. difficile Cases (per 1000 patient days)
100
MRSA Rate Decreases as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
2.5
90
2.0
80
HH
1.5
70
60
1.0
50
0.5
40
30
0.0
2008
2009
2010
MRSA Cases (per 1000 patient days)
100
MRSA Rate Decreases as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
2.5
90
2.0
80
HH
1.5
70
MRSA
60
1.0
50
0.5
40
30
0.0
2008
2009
2010
MRSA Cases (per 1000 patient days)
100
Memorial Hermann’s Story:
Getting to Zero
12 hospital system in Houston
Leadership committed to high reliability
Embarked on culture change initiative
Participated in CTH hand hygiene project
2010: MH committed to use TST to improve
hand hygiene throughout their system
Baseline (150 inpatient units) = 44%
• Range (12 hospitals): from 23% to 65%
• Aim: to exceed 90%
Jt Comm J 2013;39(6):253-57
TJC Hand Hygiene Compliance
Center for Transforming Healthcare
16000
14000
12000
95%
Baseline
Compliance
44%
90%
85%
80%
10000
75%
8000
70%
6000
65%
4000
60%
2000
55%
0
50%
Secret Observations
Compliance Rate
51
Adult ICU Central Line Associated
Blood Stream Infections (CLABSI)
Ventilator Associated
Pneumonias (VAP)
Michael Shabot, MD
Memorial Hermann System CMO
“We fully attribute to the Center for
Transforming Healthcare’s hand hygiene
TST the final drop in HAI rates to zero or
near-zero system-wide. After implementing
the hand hygiene TST, our hospitals began
to report zeros as their most common
monthly CLABSI and VAP result. Our
mothers were right after all! Feel free to
quote me. This actually saves lives.”
Summary
We must have much more ambitious goals
for healthcare improvement: high reliability
Our current approach to improvement is
not working nearly as well as it needs to
Lean, six sigma, and change management
(RPI) have far greater promise
Data documenting major impacts growing
Joint Commission is bringing this new
knowledge to all accredited organizations