Established in 2009, the Joint Commission Center for Transforming Healthcare aims to solve health care’s most critical safety and quality problems. The Center’s participants – the nation’s leading hospitals and health systems – use a proven systematic approach to analyze specific breakdowns in care and discover their underlying causes to develop targeted solutions that solve these complex problems. In keeping with its objective to transform health care into a high reliability industry, The Joint Commission will share these proven effective solutions with the more than 17,000 health care organizations it accredits.
The Joint Commission Center for Transforming Healthcare is introducing a first of its kind approach to identify, create and implement consistent safety solutions that address quality and safety challenges facing health care organizations. These challenges – such as health care-associated infections and medication and surgical errors – threaten lives and increase costs. The Center uses Lean Six Sigma and change management tools and methods to identify the most pressing safety problems, measure their impact, discover their causes, develop specific solutions that are targeted to each important cause, and thoroughly test the solutions in real-life situations. The Center relies on the extensive reach of The Joint Commission to spread the use of these solutions to improve the quality and safety of care at its more than 17,000 accredited health care organizations.
Background
Historically, The Joint Commission has led the way nationally and internationally to identify the highest priority health care quality and safety problems and to address them. With National Patient Safety Goals, core measures, and state-of-the-art accreditation standards, hospitals and other health care organizations know where they should be focusing their efforts to gain the greatest improvements in safety and quality. Many already devote sizable resources to this end. Yet, major shortfalls in quality and safety persist. The Joint Commission Center for Transforming Healthcare aims to address critical safety and quality problems, such as health care-associated infection (HAI), wrong site surgery, and medication errors. Health care-associated infection (HAI) is among the top 10 causes of death in the U.S. Nearly 2 million patients contract an HAI annually, and in hospitals, this adds nearly $9,000 in expenses per infected patient. Surgery performed on the wrong site, body part or patient occurs less frequently, but still at an unacceptable rate. Every day, there are about a half-dozen of these incidents in hospitals nationwide, and every one of them is preventable. More than 400,000 harmful medication errors occur in hospitals annually, adding an extra $3.5 billion to the cost of hospital care.
Although there is considerable agreement on the importance of these problems and on some strategies to address them, there is an even stronger demand for specific guidance on how to solve them. Health care organizations want highly effective, durable solutions that are ready to implement. A new approach is required to achieve the magnitude and breadth of improvement that is sought by The Joint Commission, by health care organizations, by patients and their families, by physicians and other clinicians, and by other public and private stakeholders. Measurement is integral to a successful approach to solving health care problems. It is only by measuring the impact of safety problems that causes can be identified and targeted solutions can be developed.
Proven effective solutions
The Center is developing solutions through the application of the same Robust Process Improvement™ (RPI) methods and tools that other industries have long relied on to improve quality, safety and efficiency. The leading hospitals and health systems in the Center’s network have a great deal of experience using RPI methods and tools such as Lean Six Sigma in the health care environment. Currently, the lack of convincing data is a key weakness of efforts to improve safety and quality. Because Lean Six Sigma projects are driven by highly reliable measurements, they provide an ideal source of data on the ultimate impact of the solutions that emanate from them. The solutions will be disseminated in a number of ways:
- The Center Web site will provide simple assessment tools for organizations without RPI capability to enable them to measure their processes, assess their specific causes of failures, and match interventions to their causes.
- In mid-2010, The Joint Commission Connect extranet will provide all Joint Commission accredited organizations with access to a new application that will provide a customized set of solutions targeted to the organization’s specific circumstances – at no additional cost.
- Joint Commission surveyors will offer applicable solutions during the on-site survey or review. Surveyors will discuss potential causes of failures and share information about targeted solutions that might work at the organization.
Current project teams
The Center’s network of participating hospitals and health systems includes the following organizations:
Hand hygiene
- Cedars-Sinai Health System - California
- Exempla Healthcare - Colorado
- Froedtert Hospital - Wisconsin
- Johns Hopkins Hospital and Health System - Maryland
- Memorial Hermann Healthcare System - Texas
- Trinity Health - Michigan
- Virtua - New Jersey
- Wake Forest University Baptist Medical Center - North Carolina
Hand-off communications
- Fairview Health Services - Minnesota
- Intermountain Healthcare - Utah
- Kaiser Permanente - California, Oregon
- Mayo Clinic - Minnesota
- NewYork-Presbyterian Hospital - New York
- North Shore-Long Island Jewish Health System - New York
- Partners HealthCare System - Massachusetts
- Stanford Hospital & Clinics - California
Rhode Island Universal Protocol Project
- Newport Hospital - Rhode Island
- Rhode Island Hospital - Rhode Island
These two hospitals are part of the Lifespan health system.
Center support
The Joint Commission Center for Transforming Healthcare is a 501(c)3 not-for-profit affiliate of The Joint Commission. The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Ecolab, GE Healthcare and Johnson & Johnson, as well as the support of the Federation of American Hospitals and Hospira.
For information on the Center or to make a donation to the Center, contact Terri Tye, ttye@jointcommission.org or (630) 792-5626.