Transforming Healthcare to Achieve High Reliability Mark R
Transforming Healthcare to Achieve High Reliability Mark R. Chassin, MD, FACP, MPH President and CEO, The Joint Commission Kal. Der 22 nd Annual Quality Congress Istanbul, Turkey November 13, 2013
What is The Joint Commission? z. Private and not-for-profit z. Roots go back to 1917: American College of Surgeons created first program to set standards for hospitals and inspect them z. Hospitals and other health care organizations pay us to evaluate the way they provide care z. 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 z. 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 z. Accreditation cannot solve all our quality and safety problems
456 patients notified
141 patients notified
Current State of Quality z. Routine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of care z. 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? z“High reliability organizations” manage very serious hazards extremely well z. What do they all have in common? • Highly effective process improvement • Fully functional safety culture z. Discover and fix unsafe conditions early z. In health care, we most commonly react after patients are harmed
High Reliability Science z. Research has defined how HROs produce sustained excellence over time z. No health care organizations function at this high level of sustained safety z. No guidance on how to transform organizations from low to high reliability z. We have created a roadmap for health care to get to high reliability
High Reliability Healthcare z. Our team has learned a lot by working with experts from HROs in many fields (aviation, military, amusement parks) z. We have created a model for healthcare • Leadership, safety culture, RPI • New resources, tools, and strategies z. 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 z. Systematic approach to problem solving: (RPI = lean, six sigma, change management) z. The Joint Commission has adopted RPI • Improve processes and transform culture • Focus on our customers, increase value z. The Joint Commission is adopting all components of safety culture z. We measure RPI and safety culture and report on strategic metrics to Board
What Can RPI Help You Do? z. 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 z. Six sigma tools focus on reducing the rate of unsatisfactory outcomes (or “defects”) • Reduce frequency of surgical infections • Improving pain management z. Change management is always essential
Center for Transforming Healthcare www. centerfortransforminghealthcare. org
Center for Transforming Healthcare z. Using RPI together with leading US hospitals and health systems to solve most difficult quality and safety problems z. Project topics: z 2009 -10: hand hygiene, wrong site surgery, hand-off communications, SSIs z 2011: safety culture, preventable HF hospitalizations, and falls with injury z 2012: sepsis mortality, insulin safety z 2013: C. difficile prevention
Participating Hospitals z. Atlantic Health z. Barnes-Jewish z. Baylor z. Cedars-Sinai z. Cleveland Clinic z. Exempla z. Fairview z. Floyd Medical Center z. Froedtert z. Intermountain z. Johns Hopkins z. Kaiser-Permanente z. Mayo Clinic z. Memorial Hermann z. New York-Presbyterian z. North Shore-LIJ z. Northwestern z. OSF z. Partners Health. Care z. Sharp Healthcare z. Stanford Hospital z. Texas Health Resources z. Trinity Health z. Virtua z. Wake Forest Baptist z. Wentworth-Douglass
Current State of Quality z. Routine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of care z. 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 z. 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 z. The “one-size-fits-all” approach works well only for simple problems that do not vary z. Toughest problems are not simple
A New Way is Delivering Results z. Complex processes require more sophisticated problem-solving methods z. Three crucial and consistent findings: • Many causes of the same problem • Each cause requires a different strategy • Key causes differ from place to place z. 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 z. Joint Commission Universal Protocol 2003: a simple, one-size-fits-all best practice z. Today: Best estimate = 50 per week in US z. 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 z. Scheduling: incomplete data, verbal requests, lack of standardization z. Pre-op area: missing documents, inadequate patient ID, time pressures lead to rushing, non-surgeon marks site, marking inconsistent, use of non-approved markers z. 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 z. Hospitals and ASCs targeted specific interventions to the risks they uncovered z Relative Risk Reduction Scheduling: 46% Pre-op: 63% multiple risk cases 72% OR: 51% multiple risk cases 75%
Results are Consistent z. 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 z. Same findings for every problem tackled: wrong site surgery risk, SSIs, patient falls z. This is the Center’s unique capability
Targeted Solutions Tool (TST) z. Web-based tools: secure extranet channel z. Educational, no jargon, no special training z. Guides users to customized, proven solutions z. Targeting only your causes means you don’t use resources where they aren’t needed z 2010: hand hygiene: 2012: wrong site surgery and hand-off communication z. Pilot tested hand hygiene internationally; working to make available to JCI hospitals
Hand Hygiene TST: 3 Years z 849 projects are using interventions • Baseline = 58% (n = 110, 255)* *p<0. 0001 • Improve = 84% (n = 584, 025)* z Unit Baseline Improve • Adult critical care 62% 80% • Emergency dept. 51% 80% • Adult med-surg 51% 84% • Long term care 61% 86% z 20% have improved to greater than 90%
Healthcare-associated Infections (HAIs) are an Enormous Quality Problem HAI Mortality rate = 5. 8% HAIs occur frequently. . . 1, 700, 000 Documented cases of hospital HAIs annually (US) 99, 000 Patient deaths attributable to HAIs (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 lives 2. . . Hospitals using the TST have prevented tens of thousands of HAIs 1 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 z. Expect 555 HAIs/yr z. Expect 1100 HAIs/yr z. Annual impact: • 388 fewer HAIs • 194 fewer HAIs • 24 lives saved • 12 lives saved • $3. 7 M cost avoided • $7. 5 M 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 70 HH 0. 9 C diff 0. 8 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 70 HH 0. 9 C diff 0. 8 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 Cases (per 1000 patient days) Hand Hygiene Compliance (%) MRSA Rate Decreases as Hand Hygiene Improves
MRSA Cases (per 1000 patient days) Hand Hygiene Compliance (%) MRSA Rate Decreases as Hand Hygiene Improves
Memorial Hermann’s Story: Getting to Zero z 12 hospital system in Houston z. Leadership committed to high reliability z. Embarked on culture change initiative z. Participated in CTH hand hygiene project z 2010: MH committed to use TST to improve hand hygiene throughout their system z. 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 95% Baseline Compliance 44% 14000 12000 90% 85% 80% 10000 75% 8000 70% 6000 65% 4000 60% 2000 55% 0 50% 12 c- De 2 t-1 Oc 12 g- 12 Compliance Rate Au n- Ju 2 r-1 12 b- Ap Fe 11 c- De 1 t-1 Oc 11 11 g- Au n- Ju 1 r-1 11 b- Ap Fe 0 10 c- t-1 De Oc Secret Observations 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 z. We must have much more ambitious goals for healthcare improvement: high reliability z. Our current approach to improvement is not working nearly as well as it needs to z. Lean, six sigma, and change management (RPI) have far greater promise z. Data documenting major impacts growing z. Joint Commission is bringing this new knowledge to all accredited organizations
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