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High Reliability Healthcare

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Systemic solutions to analyze underlying causes of specific care breakdowns and improve overall quality.

Embedding Safety Culture Training Into Quality Improvement Projects and Organizational Processes

Dec 15, 2017 | Comments (0) | 1919 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) | 2412 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) | 1112 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.

Using Unit-Level Safety Culture Survey Results to Make Quality Improvements

Oct 20, 2017 | Comments (0) | 2473 Views

Smith_C_09-13By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the seventh 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 seventh and eighth tenets: 7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement. 8. Use information from safety assessments and/or surveys to develop and implement unit- based quality and safety improvement initiatives designed to improve the culture of safety. 

With a previous blog post centered on tools hospitals can use to determine an organizational safety culture baseline, this post focuses on how to use the information gained from these survey tools to make improvements.

It’s important to make safety culture survey results relevant to individual units. Rather than only sharing hospital-level results, leaders who develop ways to share unit- or department-level results with  area managerscan start conversations leading to unit buy-in and successful quality and safety improvement initiatives.

Presenting area leaders with the survey data provides them with an opportunity to spend time finding out why team members responded the way they did and for both leadership and unit members to fully understand how the data can lead to better quality and safety. The results of the survey may not be a surprise to unit leaders, but these results may not have routinely been shared with staff with an explanation on how to interpret the results. This can be accomplished by sitting down with unit members and having an open conversation led by an approachable individual that they trust.

‘Why did you say what you said?’
Edgar Schein, an organizational culture expert and former professor at the MIT Sloan School of Management, wrote a book titled “Humble Inquiry: The Gentle Art of Asking Instead of Telling.” Schein says that the mistake many organizations make is that they only ask people what they think and then tell them what they said. It’s important to take it a step further – ask them “why did you say what you said?”

For example, if units score low on a certain aspect of safety culture, try and understand why they scored low. The “why” will vary by unit, and it’s very important to understand the why before moving into an improvement initiative. In addition to comparing the latest data with previous results, look at factors such as unit response rate, the make up of respondents by job function, and whether or not there have been changes occurring within the unit, such as staff turnover, layoffs, or a change in unit leadership. And since many survey responses tend to be dominated by nurses – due to the sheer number of them – having discussions at the unit level about safety culture provides an opportunity to hear the viewpoints of other unit team members.

Unit discussions provide opportunity to reinforce the importance of reporting
These discussions also provide organizations with an opportunity to reinforce their commitment to just culture in regard to reporting of errors or unsafe conditions. Most hospitals still struggle to remove team members’ fear of disciplinary action or retribution  – that something bad will happen after areport. Discussions about safety culture survey results give leadership an opportunity to thank unit members for their frank feedback and to express how valuable it is to the organization. 
In the 2016 User Comparative Database Report for the Hospital Survey on Patient Safety Culture the average percentage of respondents reporting events in the previous 12 months was 45%. Fifty-five percent stated they had not reported any events and only 19% had reported more than two events.  An average of 75% responded in the positive to the question “When a mistake is made that could harm the patient, but does not, how often is this reported?” This demonstrates the belief and perception that colleagues are reporting, but that most staff do not report. . To create a true safety culture in the health care industry, leaders still need to work on establishing a just culture in which honest mistakes are seen as learning opportunities.

There are many opportunities for improvement – let your survey data help you set priorities and gain unit buy-in
There are many aspects of care that have great opportunity for improvement – handoffs, transitions of care, and teamwork across units, for example. There’s a perception among unit members that they are doing a great job within the units but not so great a job handing things off and having communication beyond their unit.

Safety culture surveys give organizations the information they need to develop unit-level action plans to help improve areas of opportunity. Not every unit will work on finding solutions to the same problem, but each unit should work on improving an aspect of safety culture they determine to be a high priority. 

Hospitals can then aggregate these individual unit efforts to demonstrate their organizational commitment to having a safe and just culture. Leaders can take the first step toward building this organizational-wide culture by examining unit-level data and having frank discussions with unit team members on how to make improvements. The data are a start – the discussion and buy-in from team members are the crucial next steps to improving quality and safety.

Use Insight Gained From Safety Culture Surveys to Make Improvements

Aug 22, 2017 | Comments (0) | 2468 Views

Smith_C_09-13By Coleen Smith,
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the sixth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic.  In this post, we examine the sixth tenet: Determine an organizational baseline measure on safety culture performance using a validated tool.

Joint Commission-accredited hospitals must regularly evaluate their safety culture using valid and reliable tools, according to Standard LD.03.01.01, Element of Performance 1. How they choose to meet this performance standard is up to them. For many hospitals, it’s an ongoing challenge to accurately assess safety culture without burdening employees with another survey.

Two survey tools designed to help meet this accreditation requirement and mentioned in the Sentinel Event Alert are the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) and the Safety Attitudes Questionnaire (SAQ). Another more recently developed tool is called SCORE, an integrated survey of safety, communication, organizational reliability, resilence/burnout, and engagement.

The HSOPS measures hospital performance on 12 dimensions of safety culture: 

  1. communication openness
  2. feedback and communication about error
  3. frequency of events reported
  4. handoffs and transitions
  5. management support for patient safety
  6. non-punitive response to error
  7. organizational learning (continuous improvement)
  8. overall perceptions of safety
  9. staffing
  10. supervisor/manager expectations and actions promoting safety
  11. teamwork across units
  12. teamwork within units.

Introduced in 2004, the HSOPS has been used by hundreds of hospitals. The most recent HSOSP database report (2016) presents safety culture data compiled from 680 U.S. hospitals comparing its safety culture results. The 2016 report also includes a chapter on trending that presents results showing changes over time for the 326 hospitals that administered the survey and submitted data more than once. Participating in the database is voluntary; therefore, more hospitals than what are included in the report may be using the survey.

The SAQ was developed by the University of Texas and was the subject of a 2006 study. The SAQ measures six culture domains: 

  1. teamwork climate
  2. safety climate
  3. perceptions of management
  4. job satisfaction
  5. working conditions
  6. stress recognition. 

The SAQ also enables users to compare themselves with other organizations.

A 2012 study compared the HSOPS and the SAQ, finding them both reliable and advising prospective users to consider survey length, content, sensitivity to change, and the ability to benchmark when selecting one of these surveys.

Introduced in 2014 by a partnership of Safe & Reliable Healthcare, LLC, and the Duke Patient Safety Center, SCORE creates detailed unit-level indicators and provides in-depth and actionable insights into organizational clinical and operational performance and risk, according to the Safe and Reliable Health care website. SCORE touts itself as an advance over its predecessors in the safety culture survey space.

Survey Fatigue
When surveying staff, hospitals sometimes struggle with “survey fatigue,” since team members may be asked to complete questionnaires on various topics in addition to safety culture. High participation rates means more reliable data, and hospitals must strike a balance between choosing a tool that gains in-depth information but is not intimidating or difficult to complete.

No matter what survey tool is used, it’s not enough only to survey, from a high reliability standpoint. Hospitals must use the information gained to make visible improvements. Otherwise, they will continue to receive subpar participation from team members on surveys. Team members will say, "I complete this survey every year, and I don't see that you've done anything with the information that I've given you.” Hospitals must view the feedback gained from team members as opportunities to make improvements all the way down to the unit level because culture varies by unit.

Goal Setting 
Drs. Mark Chassin, president of The Joint Commission and Jerod Loeb, Ph.D, late executive vice president, Division of Healthcare Quality Evaluation, wrote about this dynamic in their influential 2013 Milbank Quarterly article on high-reliability health care. “Today, many hospitals regularly use one of several available staff surveys to assess their safety culture. Few, however, analyze the meaning of the survey data, evaluate where each area of the hospital is falling short, and undertake specific, focused interventions to remedy those shortcomings. As hospitals make more progress toward high reliability, they will include safety culture metrics as part of their strategic planning programs, set goals for improving on those metrics, and report on those metrics to their boards, just as they report on metrics related to financial performance or patient satisfaction.”