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High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Getting an ROI from Robust Process Improvement (RPI)

Feb 23, 2018 | Comments (0) | 600 Views

GrazmanBy David Grazman, PhD
MPPCenter Business Development Director 
Joint Commission Center for Transforming Healthcare

As a growing number of health care organizations make progress on their own journeys toward zero harm and high reliability, our Center team frequently hears from organizations struggling with how to bring their leadership fully on board with high reliability or challenged by making safety culture survey results actionable every day. 

It’s a reasonable question. According to a 2013 article in the Journal of Patient Safety, less than 1% of published articles contain substantial cost or outcomes related to investment in quality improvement.


Reducing Error, Saving Millions
The return on investment (ROI) from preventing errors or harm from happening in the first place can be clearly demonstrated on a project-by-project basis, and at an organization or system-level when the right infrastructure is in place. I discussed this more in a podcast, The ROI of RPI.

Ten years ago, the Joint Commission embarked on its own RPI journey – believing our business processes would be improved by adopting these tools and building an improvement culture. We built our own training program and have trained close to 70% of our work force in RPI. The higher quality, fewer defects and less rework that we’ve experienced as a result of utilizing RPI in our daily work has yielded a 2:1 return on our investment. 

Our results mirror what we’re learning about how RPI is used in some health care organizations. At Mount Sinai Medical Center in New York, the use of RPI tools exposed billing issues with:

  • cardiac stents

  • pacemakers

  • implantable devices. 

A multidisciplinary team used RPI at another organization to redesign their process, bringing the error rate from 63 percent to 5.6 percent, which translated into $5 million in additional revenue. Another health care system attributes their ability to reduce all harm in their organization by 50% to their adoption of Robust Process Improvement® as the way that they collectively improve how they work.  We’ve seen projects with similar results focused on challenges including:

  • surgical site infections

  • supply chain issues

  • staffing improvements 

While adopting RPI and the establishment of an improvement culture takes time, effort, and dedication, its ROI is hard to argue against. Every process – quality, business or otherwise – can be improved by removing waste and improving quality, and organizations who’ve adopted RPI as their improvement methodology are also reporting:

  • increased morale

  • higher staff retention

  • enhanced safety culture 

  • a virtuous cycle of engagement as a result of the voices of patients and staff are both heard and acted upon. 

High Reliability Framework
While it does save money, Robust Process Improvement® is really about achieving zero harm.

High reliability relies equally on:

  • Leadership commitment

  • Safety culture

  • Robust Process Improvement® (RPI)

Over the coming months, we’ll highlight successes those “on the journey” are experiencing as they make progress on these.  

If we’re discussing return on investment, let’s narrow our focus to Robust Process Improvement (RPI) – the last domain of the high reliability model. It is fundamental to progressing towards zero harm and continues to be a major focus of the Center’s work. In fact, the Center’s Targeted Solutions Tools®, which are used by almost 1,000 organizations, are built on the RPI methodologies of:

  • lean

  • Six Sigma

  • change management 

Organizations that use the TST® continue to demonstrate that RPI tools and methods can drive substantial improvements to some of health care’s most pressing challenges --- hand hygiene compliance and preventing falls among them.  RPI is the most effective approach we’ve seen to help health care organizations reach zero harm because it:

  • looks for the root causes to the specific issue at hand

  • targets particular solutions 

  • ensures sustainability over time.  

Looking for ways to enhance your organization’s approach to improvement? We can help. Contact us by email at dgrazman@jointcommission.org or 630-792-5471.

Watch this space. 

David Grazman, PhD, business development director at The Joint Commission Center for Transforming Healthcare, has more than 15 years’ experience leading structured change systems. He has served numerous hospitals and health systems as a consultant, educator and facilitator on a host of issues ranging from corporate and divisional strategy and planning, to improving clinical operations, quality and patient flow across the care continuum, to educating on health care industry trends and public policy.

TST® Hand Hygiene observations have gone MOBILE

Feb 13, 2018 | Comments (0) | 2599 Views

By John Cullinan
Director, Application Development and Data Analysis
The Joint Commission Center for Transforming Healthcare

Great news for current and prospective TST® Hand Hygiene users: You can now record your hand hygiene observations on any mobile device. The Targeted Solutions Tool (TST)® is an innovative application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers.

Health care organizations that are using the Targeted Solutions Tool for Hand Hygiene have:

  • decreased health care-associated infections.

  • increased hand hygiene compliance in 12 short weeks

It’s arguable that hand hygiene has never been as important as it is now, with the Centers for Disease Control (CDC) attributing 1 in 10 deaths to flu. 

Hand Hygiene 2.0

We’re very excited for this development. As you know, mobile devices have become more and more prevalent and accepted in the healthcare environment.  Mobile devices allow for healthcare solutions to be more user-friendly and accessible.  In 2017, the Center partnered with a group of accredited organizations to develop an application that allows you to record hand hygiene observations on your phone or tablet.  Initial reaction and adoption by organizations has been very positive, so we wanted to get the word out to all of our TST® users.  

The new TST® Hand Hygiene Mobile application:

  • eliminates completion of the paper observation form and the paper form data entry

  • streamlines mobile data entry process to minimize the number of clicks and keystrokes.

  • records observations directly to the specific project without delay

  • recognizes the screen size of your device (phone, tablet or laptop) and adjusts itself to best fit the screen you are using.

Utilize The TST® Hand Hygiene Mobile application from Google Play or the Apple App Store in one of several ways:

  • Search for Targeted Solution Tool® ineither store. 

  • You can also access the Hand Hygiene Mobile application from the https://www.centerfortransforminghealthcare.org/tst.aspxvia a link on the bottom of the page. This option gives you the data entry benefits without downloading the app to a device. You can also use this method to enter observations with a laptop or to record them on the paper form.

 To use the Hand Hygiene Mobile application you will need:

  • A TST login and password.

  • A network connection your device can access.

The Hand Hygiene Mobile application is a new and easy way to record hand hygiene observations and improve performance, but it’s not the only way. The paper form is still and will remain available.  This option gives you the data entry benefits without downloading the app to a device. You can also use this method to enter observations with a laptop or to record them on the paper form.

If you have any questions or recommendations concerning the Hand Hygiene Mobile application, please send an email to cth@jointcommission.org

John Cullinan is director of data analytics and applications at The Joint Commission Center for Transforming Healthcare. He is responsible for the development and implementation of the Center’s for Transforming Healthcare’s Targeted Solution Tools® to allow accredited organizations to identify barriers and implement solutions to important healthcare issues such as hand hygiene, wrong site surgery, hand-off communication and preventing falls. Cullinan has been with the Joint Commission since 1996 holding various management positions prior to assuming his current position in 2009.  Prior to the Joint Commission, Mr. Cullinan had 20 years’ experience in IT project management in the interstate natural gas pipeline and life insurance industries.

Embedding Safety Culture Training Into Quality Improvement Projects and Organizational Processes

Dec 15, 2017 | Comments (0) | 2617 Views

This is the eighth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic. This post examines the ninth tenet:  Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.

Coleen SmithBy Coleen Smith, MBS, RN,
Director of High Reliability Initiatives
Center for Transforming Healthcare

With everyone going 100 mph in their jobs anymore, team training can be one of the first things to slip off the priority list. 

Committing to embedding safety culture team training in your quality improvement projects can strengthen your safety systems, and it isn’t hard to accomplish once you get it on the calendar. 

This theory was tested by research teams at University of Nebraska Medical Center in 2012, and they found that hospitals with team training on patient safety culture had higher scores on the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety (HSOPS). The subsequent adoption of team behaviors led to better baseline performance on items reflecting the “essence” of safety culture, including:

  • leadership

  • situation monitoring

  • mutual support

  • communication


Meaningful Training
As anyone who’s participated in unit “retreats” knows all too well, and as the University of Nebraska researchers found, the primary determinant of team performance is what an organization does after training to sustain behaviors.

That raises the issue of training session content.  TeamSTEPPS, developed by the Department of Defense in collaboration with AHRQ, is a teamwork system that is widely used among hospitals striving to improve safety culture. It is a training program that can improve communication and teamwork skills. TeamSTEPPS can:

  • help clarify team roles and responsibilities

  • provide tools that help resolve conflicts and improve information sharing

  • supply all of the training materials, free of charge, for organizations

Teaching Debriefing
One of the most essentials tools of TeamSTEPPS is also one of the easiest to implement. The “Briefs, Huddles and Debriefs” module allows teams to test conflict resolution. For the tools to work correctly, though, they really must be embedded in our daily routines. 

This exercise really comes into play after an incident, such as a fall. Training in an effective debrief can really help the team identify and address safety concerns with one another. It’s a skill that isn’t typically learned in college or new employee orientation. Teaching employees that it’s acceptable to make statements like “I’ve noticed we haven’t been great about putting the bed alarm on; I think that is an opportunity for us” can be empowering and help promote safe culture.

While it’s essential to practice difficult conversations, sometimes having a “template” can help get the ball rolling.

The “CUS” tool, part of TeamSTEPPS, gives individuals the language for communicating worries with a supervisor when it’s really necessary.

  • I am Concerned!

  • I am Uncomfortable!

  • This is a Safety issue! 

If safety’s being compromised, managers don’t care about semantics. What they do care about is mitigating a patient safety event, hopefully before it happens, and without alarming patients and families. Learning these simple statements can save time and sometimes every second counts. Since they are “I” statements, they don’t feel accusatory. This helps everyone focus on safety.  

Simulation & Communication
Hospitals and other health care settings with access to simulation labs have an advantage because they can practice real-world scenarios that may test safety culture. If your organization has the technology to allow role-playing during a simulated emergency or an agreement with colleges permitting use of their lab, this is an opportune environment to test not only expected procedures but also behaviors and communications styles.

Here too, the greatest aspect of simulation is the debrief. Emergencies bring out the default communication style in any individual, which may be too aggressive or hierarchical. The debrief is the time to tell a participant about their communication style and allow practice in improving it. Debriefing dialogue is a natural progression of training. This is a component of formal change management and part of the high reliability model. Dedicating time to this type of training speaks volumes about leadership’s commitment to patient safety.

One of the biggest challenges we have, in life as well as healthcare, is communication. Recognizing this as a gap area within safety culture and implementing some training and simulation exercises can help your organization to impact safety culture. Don’t get frustrated—it can take a while to change your culture. This is a great place to start!

Coleen Smith, MBA, RN, is director of high reliability initiatives for the Joint Commission Center for Transforming Healthcare. In this role, she is responsible for the development, coordination and implementation of activities supporting the adoption of high reliability practices in health care. Smith joined The Joint Commission in 2004 and the Center in 2011. Prior to her current role, she held the role of Project Lead and Robust Process Improvement Black Belt in the Center. Smith has also held positions in the areas of quality improvement, leadership and clinical pediatric specialty care at Rush University Medical Center in Chicago, Rady Children’s Hospital in San Diego and Lurie Children’s Hospital of Chicago. 

The Art of Handoff Communication

Dec 07, 2017 | Comments (0) | 4101 Views

Klaus NetherBy Klaus Nether, D.H.Sc., MMI, CSSMBB
Executive Director, High Reliability Product Delivery
Joint Commission Center for Transforming Healthcare

Hospitals continue to struggle with the art of handoff communication—the process of communicating patient information from one caregiver to another—or from one team of caregivers to another—for the purpose of ensuring the continuity and safety of a patient’s care. 

Communication was one of the top root causes of sentinel events reported to The Joint Commission from 2011 through 2013. And, ineffective handoff communication has been a primary contributing factor in many studies of causes leading to medical errors. 

How can we prevent ineffective handoff communication? A new Sentinel Event Alert from The Joint Commission reviews contributing factors to handoff communication failures, solutions, research, quality improvement efforts and The Joint Commission’s related requirements. The alert also offers seven recommendations to improve handoff communication, as outlined in the blog post “Two-Way Communication is Key.”

Targeted Solutions Tool® for Handoff Communications 
In addition, the Sentinel Event Alert recommends the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool® (TST®) for Handoff Communications as one instrument to help health care organizations improve handoffs. 

The TST® is an innovative application, free to Joint Commission accredited health care organizations, that guides organizations through a systematic approach to accurately measure current performance, identify specific root causes for failures, and offer proven solutions targeted to the specific root causes identified.

The TST® for Handoff Communications:

  • facilitates the examination of the current handoff communication between two settings of care from the viewpoints of both the senders and receivers involved in the process

  • provides a tested and validated measurement system that produces data that supports the need for improving the current handoff communication process

  • identifies areas of focus, such as the specific information needed for the handoff communication process that is being measured

  • includes customizable forms for data collection

  • offers solutions specific to the root causes identified 

Case Study: Bartlett Regional Hospital
The TST® is proven to be effective. A study from the March 2016 issue of The Joint Commission Journal on Quality and Patient Safety details how a community hospital—Bartlett Regional Hospital, Juneau, Alaska, a 73-bed, Level 4 trauma center—improved its handoff communication process between the emergency department and four private physician groups admitting and delivering patient care.

After implementing the TST® and its targeted solutions for the hospital’s identified root causes, the defective rate of handoffs decreased by 58.2 percent. Defective handoffs previously occurred at a rate of 29.9 percent (32 defective handoffs/107 handoff opportunities) during baseline before dropping to 12.5 percent (13 defective handoffs/104 handoff opportunities) in the improve phase. The number of related adverse events related to handoff communication declined as the handoff communication defective rate improved. 

It’s not just Bartlett Regional Hospital who found success using the systematic approach found in the TST® for Handoff Communications. One health care organization reduced readmissions by 50 percent, while another reduced the time it took to move patients from the emergency department to an inpatient unit by 33 percent. 

I often hear from health care organizations that they do not have additional resources to allocate to improve handoff communication. Rest assured—improved handoffs can happen with only minimal resources. In fact, most organizations do not require any additional staff and need to make only minor changes to the roles and responsibilities of existing staff to use the TST®

To get started on improving handoff communication at your organization today, visit the Joint Commission Center for Transforming Healthcare’s website. Knowing the art of handoff communication can result in significant improved outcomes for your organization. 

Introducing High Reliability Healthcare: The Blog

Dec 07, 2017 | Comments (0) | 1376 Views

Annemarie BenedictoBy Annemarie Benedicto, MPP, MPH
Vice President, Center for Transforming Healthcare

For almost 10 years, the Joint Commission Center for Transforming Healthcare has singularly focused on the mission of transforming health care into a high reliability industry.  We’ve spent that time studying what high reliability has meant in other industries—like nuclear power and commercial aviation—and translating those concepts and lessons into meaningful tools, training programs and thought leadership for hospital leaders, physicians, nurses and other providers.

We’ve seen what works -- and what doesn’t. Of course, if it was easy to identify what works and apply it across the healthcare spectrum, every organization would have zero patient safety events. Our work is just getting started! On behalf of the team at the Center for Transforming Healthcare and our colleagues across the Joint Commission enterprise, we’re proud to announce the launch of this new blog – High Reliability Healthcare. 

In this space, we plan to share thoughts, lessons learned, questions and observations related to our mission and work to transform health care into a high reliability industry. We will voice what we observe from our vantage point and will share what we’re seeing out in the world as others continue on their high reliability journey.  We hope that you’ll find these blogs valuable in your own process improvement work and we look forward to hearing about your experiences in high reliability. 

Tangible Results

Since 2008, we’ve collaborated with health care organizations to tackle some of the most challenging and persistent health care quality issues such as:

  • preventing falls

  • improving hand hygiene

  • eliminating wrong-site surgeries 

We’ve worked with others to document over and over how the application of Robust Process Improvement – a blended methodology of Lean Six Sigma and formal Change Management – allows organizations to set their sights on zero harm and actually achieve it. It’s an exciting time in healthcare as the potential of high reliability health care is being realized more and more by a small number of health care organizations across the country. 


Anne Marie Benedicto is the vice president of the Joint Commission Center for Transforming Healthcare. She is an expert in Robust Process Improvement (RPI®) and high reliability methods applied to health care clinical and business processes. Benedicto was previously the chief of staff and executive vice president of support operations for The Joint Commission from 2008 through 2015. In that role, she was integral to the building of the company’s internal RPI® program, a systematic, data-driven methodology that incorporates Lean Six Sigma and formal change management. She also led the organization’s first RPI® training within a health care facility. In addition, she directed Center operations from 2008 through 2013, overseeing the development of solutions sets for hand hygiene, hand-off communications and wrong site surgery, and the design of electronic applications such as the Targeted Solutions Tool (TST®). Prior to joining The Joint Commission, Benedicto was the administrator for both the Office for Excellence in Patient Care at the Mount Sinai Medical Center and the Mount Sinai School of Medicine Department of Health Policy. She also held finance-related positions at the New York City Health & Hospitals Corporation, including reimbursement director for Bellevue Hospital Center. Most recently, Benedicto was assistant vice president of hospital operations at Montefiore Medical Center in New York.