Solving Health Care’s Most Vexing    Issues with Robust Process          ImprovementTMJoint Commission Center for Transfor...
Learning Objectives The Health Care Quality Challenge Discuss why the Joint Commission created the Center for Transforming...
High Reliability for Safety                                                          © Copyright, The Joint Commission    ...
The Health Care Quality Challenge  More than 400,000 harmful, preventable bad  outcomes occur in hospitals every year   – ...
The story starts with…… 5© Copyright, The Joint Commission
Our story starts with……                                            © Copyright, The Joint Commission                      ...
TJC has historically led the way nationally andinternationally to identify and address thehighest priority health care saf...
Why the Center was Created  To transform health care into a high reliability  industry and to ensure patients receive the ...
The Center for Transforming HealthcareDeveloping Solutions with Leading Hospitals  The Center aims to address health care’...
10© Copyright, The Joint Commission
Share Solutions Freely  With the more than 17,000 health care  organizations it accredits globally  The Center relies on t...
12© Copyright, The Joint Commission
Applying Robust Process Improvement Methods The Joint Commission Center for Transforming Healthcare  – Developing solution...
The Center uses Lean Six Sigma andchange management methods to:– Identify and define the most pressing safety  problems– M...
The Center’s RPI Roadmap for Solving/Designing                                                  © Copyright, The Joint Com...
Project OneHand Hygieneto Reduce Health Care AcquiredInfections                                                     © Copy...
17© Copyright, The Joint Commission
Health Care-Associated Infection Statistics  Nearly two million patients in the U.S.  contract a health care-associated in...
19© Copyright, The Joint Commission
Hand Hygiene Compliance Data Not Collectedor Reported Accurately or Frequently Lack of a measurement system that provides ...
Achieving 50% Breakthroughand Continuing Trend                                  © Copyright, The Joint Commission         ...
22© Copyright, The Joint Commission
Safety Culture Does Not Stress HandHygiene Enough at All Levels  All levels of hospital staff are not aware of the  import...
Hands Full  Health care worker must carry essential supplies  (i.e., supplies, linens, food trays, medications)  into pati...
Health Care Workers Forget  Rushing  Workers have a great deal of information to  process  Hand hygiene is not routine; wo...
26© Copyright, The Joint Commission
27© Copyright, The Joint Commission
Habit  Always wash in and wash out upon entering  and exiting a patient care area and before  and after patient care  Make...
Active Feedback Coach and intervene to remind staff to wash hands Clearly state expectations about when to sanitize hands ...
No One Excused  Protect the patient and the environment –  everyone must wash in and wash out  Make it comfortable to wash...
Data Driven  Data provide a framework for a  systematic approach  Utilize a sound measurement system  Real score in real t...
Systems  Focus on the system, not just on  people  Make it easy - Provide easy access  to hand hygiene equipment and  disp...
Success and Sustaining….  Hospitals achieved and sustained the initial goal of  >50 percent improvement  The Center’s Hand...
The 3 Ms to Achieve 90% ComplianceMeasure accurately and frequently– Represent all healthcare opportunities– Keep score - ...
Achieving 50% Breakthroughand Continuing Trend                                  © Copyright, The Joint Commission         ...
HAI Reduced By Improving Hand Hygiene at aCenter Hospital                                                             Fitt...
Project: Wrong Sight Surgery  Includes hospitals in the Lifespan system:   – Project aims to improve safeguards to prevent...
Wrong Site Surgery Robust ProcessImprovement  The team from The Center and Lifespan using the  RPI Roadmap:   – Analyzed i...
Wrong Site Surgery Robust ProcessImprovement Site marking and process improved Standard Work structure in Time Out  – Defi...
Defects/(# of procedures x 15 opportunities)                     11                        /2                             ...
Project: Hand-off Communications  The Center’s next project targets breakdowns in hand-off  communications – the transfer ...
Hand-off Communications Project  Participants are currently measuring their  baseline quality in hand-offs relative to  pa...
Sponsors                        Leaders                      Key Sponsor                                                  ...
Thank You                                    Questions, please 44© Copyright, The Joint Commission
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Solving Health Care’s Most Vexing Issues with Robust Process Improvement

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Solving Health Care’s Most Vexing Issues with Robust Process Improvement

  1. 1. Solving Health Care’s Most Vexing Issues with Robust Process ImprovementTMJoint Commission Center for Transforming Healthcare Rick Morrow, Director, MBB © Copyright, The Joint CommissionLean Six Sigma and Process Improvement in Healthcare Summit May 12, 2010 1
  2. 2. Learning Objectives The Health Care Quality Challenge Discuss why the Joint Commission created the Center for Transforming Healthcare (CTH) “Walk the Talk” in Quality and Safety © Copyright, The Joint Commission Taking away ideas today you can implement How this work contributes to the greater good 2
  3. 3. High Reliability for Safety © Copyright, The Joint Commission Photo courtesy of SKF 3
  4. 4. The Health Care Quality Challenge More than 400,000 harmful, preventable bad outcomes occur in hospitals every year – Infections – Wrong site surgeries – Hand-off Communication issues Costs associated with unsafe care and poor quality in hospitals are unacceptable Strong demand from health care organizations for specific guidance on how to solve © Copyright, The Joint Commission Want highly effective, durable solutions and are ready to implement them 4
  5. 5. The story starts with…… 5© Copyright, The Joint Commission
  6. 6. Our story starts with…… © Copyright, The Joint Commission *American Society for Quality Progress Magazine 6
  7. 7. TJC has historically led the way nationally andinternationally to identify and address thehighest priority health care safety issues Health care organizations know where to focus with our: – National Patient Safety Goals – Core measures – State-of-the-art accreditation standards © Copyright, The Joint Commission Many health care organizations already devote sizable resources to this end, but major shortfalls in quality and safety persist 7
  8. 8. Why the Center was Created To transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve The Joint Commission Center for Transforming Healthcare was established in 2009 A new approach is required – to achieve the magnitude of improvement sought by health © Copyright, The Joint Commission care organizations, patients and their families, physicians and other clinicians, and by other public and private stakeholders 8
  9. 9. The Center for Transforming HealthcareDeveloping Solutions with Leading Hospitals The Center aims to address health care’s most critical safety and quality problems – health care-associated infection (HAI) – wrong site surgery – medication errors Teaming with top hospitals and health systems to use new methods to find the © Copyright, The Joint Commission causes of and put a stop to potentially deadly breakdowns 9
  10. 10. 10© Copyright, The Joint Commission
  11. 11. Share Solutions Freely With the more than 17,000 health care organizations it accredits globally The Center relies on the extensive reach of The Joint Commission to spread the use of these solutions The best way to contribute to society © Copyright, The Joint Commission 11
  12. 12. 12© Copyright, The Joint Commission
  13. 13. Applying Robust Process Improvement Methods The Joint Commission Center for Transforming Healthcare – Developing solutions – Through the application of the same Robust Process Improvement™ (RPI) methods and tools © Copyright, The Joint Commission – That other industries rely on to improve quality, safety and efficiency 13
  14. 14. The Center uses Lean Six Sigma andchange management methods to:– Identify and define the most pressing safety problems– Measure their impact– Discover the contributing factors to failure– Develop specific solutions targeted to each important cause, and © Copyright, The Joint Commission– Thoroughly test the solutions in real-life situations 14
  15. 15. The Center’s RPI Roadmap for Solving/Designing © Copyright, The Joint Commission 15
  16. 16. Project OneHand Hygieneto Reduce Health Care AcquiredInfections © Copyright, The Joint Commission © Copyright, The Joint Commission CTH Announcement – Pg. 16
  17. 17. 17© Copyright, The Joint Commission
  18. 18. Health Care-Associated Infection Statistics Nearly two million patients in the U.S. contract a health care-associated infection (HAI) annually With nearly 100,000 deaths each year, HAIs are the fourth largest killer in the U.S. Cause more deaths than AIDS, breast cancer and auto accidents combined HAIs add nearly $9,000 in expenses per © Copyright, The Joint Commission infected patient in hospitals and cost U.S. hospitals between $4 to $29 billion each year to combat 18
  19. 19. 19© Copyright, The Joint Commission
  20. 20. Hand Hygiene Compliance Data Not Collectedor Reported Accurately or Frequently Lack of a measurement system that provides an accurate source of hand hygiene compliance data. Inability to provide timely information to health care staff on compliance and causes of failure. Staff and physicians wanted to know how they were doing. Staff and physicians requested just-in-time feedback on performance. © Copyright, The Joint Commission Availability of data to everyone in the organization. Visual indicator of performance compared to goal. 20
  21. 21. Achieving 50% Breakthroughand Continuing Trend © Copyright, The Joint Commission 21
  22. 22. 22© Copyright, The Joint Commission
  23. 23. Safety Culture Does Not Stress HandHygiene Enough at All Levels All levels of hospital staff are not aware of the importance of hand hygiene and their role in improving compliance Hand hygiene compliance varies by health care worker role and responsibility Accountability for hand hygiene compliance varies across hospital staff based on role and perceived status © Copyright, The Joint Commission Reluctance by staff to hold colleagues accountable for non-compliance 23
  24. 24. Hands Full Health care worker must carry essential supplies (i.e., supplies, linens, food trays, medications) into patient care area No area to place supplies while performing hand hygiene – Phlebotomy process – Food tray delivery and pick up © Copyright, The Joint Commission – Taking Vital Signs 24
  25. 25. Health Care Workers Forget Rushing Workers have a great deal of information to process Hand hygiene is not routine; workers need repetition to make it a habit Health care worker forgets to wash hands upon room re-entry © Copyright, The Joint Commission Competing priorities 25
  26. 26. 26© Copyright, The Joint Commission
  27. 27. 27© Copyright, The Joint Commission
  28. 28. Habit Always wash in and wash out upon entering and exiting a patient care area and before and after patient care Make washing hands a habit – as automatic as looking both ways when you cross the street or fastening your seat belt when you get in your car © Copyright, The Joint Commission 28
  29. 29. Active Feedback Coach and intervene to remind staff to wash hands Clearly state expectations about when to sanitize hands to all staff members Communicate frequently – provide visible reminders and ongoing coaching to reinforce effective hand hygiene expectations Engage staff – real time performance feedback © Copyright, The Joint Commission 29
  30. 30. No One Excused Protect the patient and the environment – everyone must wash in and wash out Make it comfortable to wash hands with soap or use waterless hand sanitizer Hold everyone accountable and responsible – doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists © Copyright, The Joint Commission 30
  31. 31. Data Driven Data provide a framework for a systematic approach Utilize a sound measurement system Real score in real time Trained, certified independent observers Scrutinize the data Measure high-impact causes of hand © Copyright, The Joint Commission hygiene failures in your facility and target solutions to those causes 31
  32. 32. Systems Focus on the system, not just on people Make it easy - Provide easy access to hand hygiene equipment and dispensers Create a place for everything © Copyright, The Joint Commission 32
  33. 33. Success and Sustaining…. Hospitals achieved and sustained the initial goal of >50 percent improvement The Center’s Hand Hygiene solution system is being tested in a wide variety of hospitals now to validate value across the country The solution system portal is under development – Designed to provide free access to all accredited organizations – Guides step-by-step and does not require Lean Six © Copyright, The Joint Commission Sigma resources 33
  34. 34. The 3 Ms to Achieve 90% ComplianceMeasure accurately and frequently– Represent all healthcare opportunities– Keep score - the more real time the better– Ensure everyone can see the scoreManage to the Measure - Just-In-Time– Don’t pass up a chance to coach– Be a role modelMake it Easy– Wash In/Out – Protect the patient beyond just before and after patient contact – protect the environment, too– Layout – Dispensers and sinks in the workflow © Copyright, The Joint Commission – Reduce wasted entries and exits that don’t focus on the patient – Dedicated supplies, false alarms, etc. – A place for everything – when hands are full entering– Comfortable to wash – no irritating gels 34
  35. 35. Achieving 50% Breakthroughand Continuing Trend © Copyright, The Joint Commission 35
  36. 36. HAI Reduced By Improving Hand Hygiene at aCenter Hospital Fitted Line Plot HAI Prevelance per 1000 pt = 1.860 - 0.01388 Hand hygiene % compliance 2.5 S 0.462485 R-Sq 26.3% R-Sq(adj) 22.8% HAI Prevelance per 1000 pt 2.0 P Value 0.012 1.5 1.0 0.5 © Copyright, The Joint Commission 0.0 30 40 50 60 70 80 90 100 Hand hygiene % compliance 36
  37. 37. Project: Wrong Sight Surgery Includes hospitals in the Lifespan system: – Project aims to improve safeguards to prevent patients from wrong site, wrong side and wrong patient surgical procedures – Project includes all procedures performed in an operating room commencing with scheduling a surgical procedure and ending with confirmation that the intended operation was performed – Solutions for this project are targeted for © Copyright, The Joint Commission publication in June 2010 37
  38. 38. Wrong Site Surgery Robust ProcessImprovement The team from The Center and Lifespan using the RPI Roadmap: – Analyzed internal and external data – Prioritized failure modes and contributing factors – Created a quality and safety management system to measure the possible slips and close calls in the new processes – Decided on robust process improvements and controls – Chose the best ways to educate the entire staff – Created Standard Work and memory aides for staff © Copyright, The Joint Commission 38
  39. 39. Wrong Site Surgery Robust ProcessImprovement Site marking and process improved Standard Work structure in Time Out – Defined roles and accountability – Use of primary documents Physical verification added to focus the entire team on the site and procedure Surgeon “opens the door” for staff to speak up with © Copyright, The Joint Commission specific script and all members of team are given the opportunity to speak up 39
  40. 40. Defects/(# of procedures x 15 opportunities) 11 /2 0% 2% 4% 6% 8% 10% 12% 3/ 20 11 09 /2 5/ 20 11 09 /2 7/ 20 11 09 /2 9/ 20 12 09 /1 /2 00 12 9 /3 /2 00 12 9 Wrong Site Surgeries /5 /2 00 12 9 /7 /2 00 12 9 /9 /2 12 00 /1 9 1/ 20 12 09 /1 3/ Surgery’s New Measure - 20 12 09 Date /1 5/ 20 12 09 /1 7/ 20 11/23 - 12/31/2009 12 09 /1 9/ 20 12 09 /2 1/ % Defects per Opportunity 20 12 09 /2 3/ 20 Defects/Procedure 12 09 /2 5/ 20 12 09 /2 7/ Theory of Escaping Defects – Dr. Deming 20 12 09 /2 9/ 20 12 09 /3 1/ 20 40 09© Copyright, The Joint Commission
  41. 41. Project: Hand-off Communications The Center’s next project targets breakdowns in hand-off communications – the transfer and acceptance of patient care responsibilities achieved through effective communication The hand-off communications project involves safety experts and several leading hospitals: – Exempla Lutheran Medical – New York-Presbyterian Center Hospital – Fairview Health Services – North Shore-Long Island – Intermountain Healthcare Jewish Health System – The Johns Hopkins Hospital – Partners HealthCare and Health System System © Copyright, The Joint Commission – Kaiser Permanente – Stanford Hospital & Clinics – Mayo Clinic 41
  42. 42. Hand-off Communications Project Participants are currently measuring their baseline quality in hand-offs relative to patient safety, and the satisfaction of the receiver and sender Some are also measuring the patient satisfaction Project will result in improved patient safety and higher staff satisfaction in the hand-off © Copyright, The Joint Commission project 42
  43. 43. Sponsors Leaders Key Sponsor © Copyright, The Joint CommissionProgram Support for the Center is provided by: 43
  44. 44. Thank You Questions, please 44© Copyright, The Joint Commission

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