1. What is High Reliability, and
How C H lth C
H Can Health Care G t Th
Get There? ?
Mark R Chassin, MD FACP MPP MPH
M k R. Ch i MD, FACP, MPP,
President, The Joint Commission
Charles C. Leighton, MD Memorial Lecture
Leonard Davis Institute
University of Pennsylvania
Philadelphia,
Philadelphia PA
May 4, 2012

2. 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

3. Future State
F t St t
Joint Commission Vision
All people always experience the
safest, highest-quality, best-value
health care across all settings.

4. A Model That Works
TJC hospitals have improved markedly on
core measures in use since 2002; many
are at high levels of consistent excellence
Acute MI: 2010 Hospital Performance
US avg(%) % > 90%
Aspirin on arrival 99 99
BB on discharge 99 98
Joint Commission Annual Report 2011

5. Rapid Improvement
p p
In 2000, few measures, no national
data collection or reporting
• No real world experience
real-world
• Resistance among hospitals
Today---all that has changed
In a very short time hospitals have
time,
made major progress toward
establishing consistent excellence

6. Improving Measurement
Joint Commission created first national
hospital quality measurement program
A great deal of real-world experience
real world
• Many measures work well; some don’t
• Must replace bad measures
No formal process to assess that
experience, learn from it, and act on it
TJC working h d t achieve thi goal
ki hard to hi this l

7. Measurement Drives Improvement
Measures used for “accountability”
(
(accreditation, ppublic reporting, p y
p g payment)
)
lead hospitals to do major work to improve
How does measurement drive improvement?
p
Measures with “clinical integrity” engage
clinicians---who work to improve because
p
they believe improving performance will lead
to better health outcomes for patients
Lack of clinical integrity:
• Turns clinicians away from improvement
y p
• Leads to workarounds and wasted effort

8. Accountability Measures
y
NEJM 2010; 363:683-8

9. Measures With Clinical Integrity:
“Accountability Measures”
Examples: Aspirin, beta blockers, and ACE
inhibitors for acute MI; surgical antibiotic
prophylaxis; new perinatal measures
Characteristics of Accountability Measures
• Large volume of research proves
relationship to improved outcomes
•PProcess i closely connected to outcome
is l l d
• Measure accurately assesses process
• No or minimal unintended adverse effects

10. Hospital Performance on
Accountability Core Measures
100
ercent of Hospitals >90% Performance
90
80
70
P
60
50
s
40
30
20
10
Pe
0
2002 2003 2004 2005 2006 2007 2008 2009 2010

11. Joint Commission Accountability
Measure Initiatives
Define accountability criteria for quality
measures (process and outcome)
Eliminate non-accountability measures
y
from Joint Commission programs
Accreditation requirement for minimum
performance: January 2012
Top Performers program recognizes
extremely high performance
Solution Exchange f ilit t l
S l ti E h facilitates learning
i

12. Joint Commission
Perinatal Core Measures
1. Elective deliveries: % elective of
1 El ti d li i l ti f
delivered newborns at 37-39 weeks
2. Cesarean section: % c-section, previously
nulliparous, singleton, vertex presentation
3. Antenatal steroids: % full course, 24-32 wks
4. Blood stream infections: % with bacteremia
5. Exclusive breast feeding: % newborns fed
only breast milk since birth

13. How Have Others Done It?
“High reliability organizations” manage
very serious hazards extremely well
• Commercial aviation, nuclear power
What do they all have in common?
• Highl effective process impro ement
Highly effecti e improvement
• Fully functional safety culture
y y
Discover and fix unsafe conditions early
“Collective i df l
“C ll ti mindfulness” ”

15. US Airline Safety
1990-2001
• 129 deaths per year
• 9 3 million flights per year
9.3
• Rate = 13.90 deaths per million flights
2002-2010
2002 2010
• 18 deaths per year
• 10.6 million flights per year
• Rate = 1.74 deaths per million flights

16. Safety: Airlines vs. Health Care
y
IOM “To Err is Human” estimate
• 44 000 98 000 d h i h
44,000-98,000 deaths in hospitals
i l
due to errors in care
• 34.4 million hospitalizations per year
• Rate = 1300-2800 deaths per million
p
hospitalizations
US Airlines: 2002-2010
2002 2010
• Rate = 1.74 deaths per million flights
Hospital care i 750 1600 ti
H it l is 750-1600 times l less safe
f

17. Airlines vs Health Care II
Care---II
Best study of errors and harm in hospital
care showed that 1% of hospital patients
were injured due to negligent errors
Hospital rate = 10,000 per million
US Airlines rate (death plus serious injury)
• 2002-2010 = 341 people/95.2M flights
• US Ai li
Airlines rate = 3 6 per million
t 3.6 illi
On this measure, hospital care is 2778
times less safe than air travel

18. 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 id
N guidance on h how t t
to transform
f
organizations from low to high reliability
How do we create blueprints for health
care to build high reliability?

19. Leadership
High
Reliability
Trust
RPI
Improve Report
Health
Care
Safety Culture

20. From Health Affairs
Health Affairs 2011;30:559-68

21. High Reliability Self-Assessment
Self Assessment
Leadership
• Board CEO, ph sicians
Board, CEO physicians
• Quality strategy, quality measures, IT
Safety culture
• Trust and accountability
• Identifying unsafe conditions or practices
• Strengthening systems, measurement
systems
Robust process improvement
• Methods, training, spread

22. Stages of Maturity
g y
High Reliability Self Assessment Tool (HRST)
• S i of questions, b
Series f i branching l i
hi logic
• All 14 components are assessed
Four stages of maturity for each component
• Beginning
• Developing
• Ad
Advancing
i
• Approaching

23. Imperative #1: Trust
Aim is not a “blame-free” culture
A true safety culture balances
learning with accountability
g y
Must separate blameless errors (for
learning) from blameworthy ones (for
discipline, equitably applied)
Assess errors and patterns uniformly
Establish one code of behavior

24. Sentinel Event Alert on
Intimidating Behaviors

25. What Behaviors are Intimidating?
g
Wide range: impatience to physical abuse
Most common?
• Refusal to answer questions, return calls;
q , ;
condescending language or voice;
impatience with q
p questions
• About ¼ of nurses and pharmacists
personally experienced these from MDs
more than 10 times in past year
Media misrepresented as “disruptive MDs”
disruptive MDs

26. Accountability
Health care also fails to apply disciplinary
pp y p y
procedures equitably and uniformly
Lack of uniform accountability also erodes
trust, stifles reporting of unsafe conditions
Belief in a completely “blame-free culture
blame-free culture”
further impairs progress toward accountability
Striking the balance is critical
critical:
• Learning from blameless errors
• Accountability for adhering to safe practices

27. Robust Process Improvement
Systematic approach to problem solving:
(RPI = lean, six sigma, change management)
l i i h t)
The Joint Commission is adopting RPI
p g
• Improve processes and transform culture
• Focus on our customers increase value
customers,
The Joint Commission is adopting all
components of safety culture
t f f t lt
We measure RPI and safety culture and
report on strategic metrics to Board

29. Center for Transforming Healthcare
www.centerfortransforminghealthcare.org

30. Center for Transforming Healthcare
Customers asking us for solutions
Delivering p
g products at no added cost
• TJC: $20M; 9 other major donors
• AHA BCBSA BD Cardinal Health
AHA, BCBSA, BD,
Ecolab, GE, GSK, J&J, Medline
2009: hand hygiene, wrong site surgery
2009 h d h i it
and hand-off communications
2010: colorectal surgery SSIs
2011: safety culture, preventable HF
y ,p
hospitalizations, and falls with injury

31. Participating Hospitals
Barnes-Jewish
Barnes Jewish Memorial H
M i l Hermann
Baylor NY-Presbyterian
Cedars-Sinai
C d Si i North Shore-LIJ
N th Sh LIJ
Cleveland Clinic Northwestern
Exempla OSF
OS
Fairview Partners HealthCare
Froedtert Stanford Hospital
Intermountain Trinity Health
Johns Hopkins Virtua
Kaiser-Permanente Wake Forest Baptist
Mayo Clinic Wentworth-Douglass

32. 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

33. Current State of Improvement
p
Usual approaches: best practices, toolkits,
protocols, checklists bundles
protocols checklists, “bundles”
• Describe a specific set of process steps
that
th t must b f ll
t be followed t solve a problem
d to l bl
• ICU central line protocol, VAP bundle
They produce consistent results only in
limited circumstances
• Process varies little from place to place
• Causes of failure are few and common

34. A New Approach is Promising
Best practices often fail to achieve
consistently excellent results, because:
y ,
• Complex processes require more
sophisticated problem solving methods
• Many causes for the same problem
• E h cause requires a diff
Each i different strategy
t t t
• Key causes differ from place to place
Next generation of best practices will use
RPI to produce solutions---customized to
p
an organization’s most important causes

35. Semmelweis’ Original Data
g
Monthly Death Rates
Handwashing
Program
1841 1842 1843 1844 1845 1846 1847 1848

36. Some Important Causes of
Hand Hygiene Failures
1. Faulty data on performance
2. Inconvenient location of sinks or
hand gel dispensers
3. Hands full
4. Ineffective education of caregivers
5.
5 Lack of accountability
 Each requires a very different
q y
strategy to eliminate

37. Causes Differ by Hospital
Each letter = one hospital

38. Some Important Causes of
Hand Off Communication Failures
1. Sender
1 “Sender” and “receiver” have
receiver
different expectations
2. Lack of teamwork and respect
3. Inaccurate or incomplete information
4. Receiver has competing priorities
5. Interruptions during hand-off
6.
6 Ineffective communication method

39. Causes Differ by Hospital
Each letter
E h l tt = one h
hospital
it l

40. Improving Transitions
Hand off
Hand-off communication failed to include
adequate information 41% of the time
Interventions reduced this rate to 17%
One hospital focused on the transition
from its inpatient units to a nursing home
Baseline Improve
Inadequate hand-offs 29% <1%
30-day readmissions
y 21%% 10%%

41. Joint Commission US Customers
Program 2011
Ambulatory Care 2000
Behavioral Health 1950
Certification 2450
Home Care 6050
Hospitals 4500
Laboratory 1650
Long Term Care 1000
Total 19,600

42. Wrong Site Surgery
Best estimate = 40 per week in US
Joint Commission Uni ersal Protocol
Universal
has not solved the problem
High rates of risks introduced in 3 areas:
• Scheduling: 39% of cases had risks
• Pre-op area: 52% of cases had risks;
25% with multiple risks
• OR: 59% of cases had risks;
32% with multiple risks

43. Risks of Wrong Site Surgery
Scheduling: incomplete data, verbal
requests,
requests lack of standardization
Pre-op area: missing documents,
inadequate patient ID, time pressures lead
ID
to rushing, non-surgeon marks site, marking
inconsistent,
inconsistent use of non approved markers
non-approved
OR: mark covered by drapes, distractions,
time out performed without full participation,
staff are not empowered to speak up,
verification omitted with multiple procedures
f

44. Defenses
Leadership Teamwork
Hiring Coordination
Training (among teams)
Personnel evaluation Staffing (levels
(levels,
availability, mix)
Policies, protocols
p
Equipment
E i t
Computer systems
Environment
Communication
Individuals
Supervision of
(
(knowledge, skills,
g , ,
trainees
t i
stress factors)

45. The Swiss Cheese Model
Errors
Defenses with Weaknesses
Harm

46. Reducing the Risks
Hospitals and ASCs targeted specific
interventions to the risks they uncovered
i t ti t th i k th d
 Relative Risk Reduction
Scheduling: 46%
Pre op:
Pre-op: 63%
multiple risk cases 72%
OR:
OR 51%
multiple risk cases 75%

47. Results are Consistent
More sophisticated improvement methods
(RPI) required for complex problems
• Measure and discover specific causes
• Identify how causes vary among
different organizations and settings
• Target interventions to specific causes
to maximize effectiveness
• Avoid wasting resources by targeting
This is the Center’s unique capability
Center s

49. Targeted Solutions Tool (TST)
g ( )
Uses secure, established extranet channels
• N added cost, voluntary, confidential
No dd d l fid i l
• Can assess performance across system
Educational, no jargon, no special training
Guides users to customized proven solutions
customized,
Targeting only your causes means you don’t
use resources where they aren’t needed
aren t
Hand hygiene and WSS available now; will
add h d ff communication l t thi year
dd hand-off i ti later this

50. Results Through March 2012
640 projects are using interventions
• Baseline = 51 4% (n = 72 248)* *p<0.0001
51.4% 72,248)*
• Improve = 75.0% (n = 187,238)*
 Unit Baseline Improve
• Adult critical care 51% 71%
• Emergency dept. 46% 74%
• Adult med surg
med-surg 46% 74%
• Pediatric critical care 62% 82%
• Long term care 54% 73%

52. C. Difficile Rate Declines as
Hand Hygiene Improves
100 1.3
C. dif
1.2
12
%)
fficile Cas (per 1
Hand Hygien Compliance (%
90
1.1
80 1
ses
HH 0.9
70
ne
C diff 0.8
08
1000 patient days)
60 0.7
0.6
06
50
0.5
40 0.4
04
2007 2008 2009 2010 2011

53. MRSA Rate Decreases as
Hand Hygiene Improves
MRS Cases (per 1000 patien days)
100 2.5
%)
Han Hygien Compliance (%
SA
90
2.0
80
s
HH
1.5
70
MRSA
ne
60
1.0
50
nd
nt
0.5
05
40
30 0.0
2008 2009 2010

54. The Joint Commission and
High Reliabilit
Reliability
Consistent excellence is the vision
Leadership + safety culture + RPI
All Joint Commission programs and activities
are aligning around this aim:
•AAccreditation, performance measurement
dit ti f t
• JCR education, publication, consulting
• Center-developed improvement solutions
Help customers improve no matter where
they are on the journey to high reliability