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October 2013 Archive for High Reliability Healthcare

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

Leading the way to high reliability by communicating and connecting

Oct 23, 2013 | Comments (1) | 16361 Views

By Mark R. Chassin, M.D., F.A.C.P., M.P.P., M.P.H.
President and CEO
The Joint Commission

Mark ChassinWelcome to The Joint Commission’s new Leadership blog! I am especially excited about this newest communication vehicle for many reasons. First, it provides a new way to share current information about health care issues, and second, it helps connect our leadership team with you – our readers, customers and stakeholders. While the leadership team here at The Joint Commission can post articles, readers can also post comments. So if you have something to say, we’re listening!

Communication – especially communication from leadership – is extremely important. This has been borne out by the findings of many of the Joint Commission Center for Transforming Healthcare’s improvement projects. Leadership engagement and communication are key to improvement and help lead the way to high reliability. High reliability in health care is a goal I champion. I believe it is the future of health care, for it takes quality and safety to the next level.

High reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of health care. The Milbank Quarterly recently published an article that I wrote with the late Jerod M. Loeb, Ph.D., executive vice president of the Division of Healthcare Quality Evaluation at The Joint Commission. The article, “High-Reliability Health Care: Getting There From Here,” discusses the High-Reliability Health Care Maturity Model – a framework for improvement that is the basis for an assessment tool that The Joint Commission is developing. The tool is currently being pilot tested by the South Carolina Safe Care Commitment, a collaboration between the South Carolina Hospital Association and the Joint Commission Center for Transforming Healthcare. Look for more information from The Joint Commission and the Center about our continuing efforts to support health care organizations in their work to become high reliability organizations.

You can sign up to automatically receive news from The Joint Commission, including this new blog. By sharing information and offering a new way to connect with leaders at The Joint Commission, we hope to inspire you in your work to improve health care. I hope you enjoy reading our monthly blogs.

Preventing suicide among ED patients – a realizable goal

Oct 16, 2013 | Comments (0) | 11732 Views

By Paul M. Schyve, M.D.,
Senior Advisor
The Joint Commission

Schyve 11 10Emergency departments are busy places. Physicians and other staff can be hurried as they respond to the challenges of helping – and often saving – the patients who arrive in the ED with life-threatening or urgent conditions. Despite the physicians’ best efforts, some patients die – and the physician is sorrowful and expresses sympathy to the family.  But hardest is when a patient dies and we know we could have prevented the death. Now we feel guilt and shame, and struggle to express our apology and sympathy to the family. We are victims of the unnecessary death, just as are the patient and the family.

An immediately recognizable unnecessary death in an ED is a suicide that was initiated in the ED itself.  These suicides need not occur if suicidal patients are recognized, appropriate immediate protective interventions are put in place, and the patients are successfully transitioned to definitive treatment, whether inpatient or outpatient. When suicide occurs in the ED, it is usually the result of a failure to recognize that a patient is suicidal, to assure that the suicidal patient does not have access to a means for suicide, to communicate to other staff that the patient is suicidal, or to make an assured transition to another clinician – all of which are within the control of the physician and the other health care workers in the ED. We can and must eliminate suicides that are initiated in the ED.

Yet ED physicians and staff are often not specifically trained to recognize suicidal patients – especially for patients who may not have a psychiatric history or history of suicide attempt. Because of the frequency of these preventable deaths, The Joint Commission requires hospitals to conduct a risk assessment to identify individual characteristics and environmental features that increase or decrease the risk for suicide, to address a suicidal patient’s immediate safety needs, and to make assured transitions to appropriate care when the patient leaves the ED.

Based on the reports of inpatient and ED suicides – and of their root causes – submitted to The Joint Commission’s Sentinel Event database, and on advice from experts in suicide prevention, The Joint Commission issued a four-page Sentinel Event Alert in 2010 on preventing suicide in medical/surgical units and the emergency department. This Alert contains practical advice for physicians and for medical/surgical hospitals on reducing suicide in these settings. Like all Joint Commission Sentinel Event Alerts, this Alert is available at no cost on the Joint Commission website.

From the time of Hippocrates, our obligation has been to save lives; here is one way we can do so.



Revisiting disruptive and inappropriate behavior: Five years after standards introduced

Oct 02, 2013 | Comments (3) | 47310 Views

By Ronald M. Wyatt, M.D., M.H.A.,
Medical Director
The Joint CommissionRonald Wyatt, Medical Director, The Joint Commission

While most care providers, particularly physicians, adhere to the highest professional standards of behavior, a small number do not, and some recurrently display disruptive or intimidating behavior. In 2008, The Joint Commission became so concerned about “behaviors that undermine a culture of safety” that it issued a Sentinel Event Alert on the topic and developed a Leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors. Now there is compelling evidence that some behaviors contribute directly to medical errors. This was a prominent finding in Rosenstein and O’Daniel’s work,1 in which respondents commonly indicated a reluctance to call or interact with certain doctors to clarify or question orders for fear of provoking a hostile response.

According to the Institute of Safe Medication Practices (ISMP) survey on workplace intimidation, 17 percent of respondents had felt pressured to accept a medication order despite concerns about its safety on at least three occasions in the previous year; 13 percent had refrained from contacting a specific prescriber to clarify the safety of an order on at least 10 occasions; and 7 percent said that in the previous year they had been involved in a medication error where intimidation played a part.2

While disruptive and intimidating behavior can be displayed by nurses, pharmacists and managers, it is the behavior of doctors which most often causes problems, perhaps because medical culture has had a history of tolerance or indifference to this, or because organizations have tended to treat doctors differently from other staff.3

In its Sentinel Event Alert, The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities,” and it goes on to say that “intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation and impatience with questions.”3

All definitions recognize that disruptive and intimidating behavior occurs along a spectrum of intensity and frequency and that recurrent disruption by a small number of individuals is the most common pattern.

The 1999 Institute of Medicine (IOM) report “To Err is Human”4 – widely regarded as the document which launched the modern patient safety movement – recognized that although most efforts to improve safety should focus on reducing system failures, individual professionals’ “dangerous, reckless or impaired” behavior can also sometimes harm patients (page 169). We now accept that most errors are committed by “good, hardworking people trying to do the right thing,” and that to improve patient safety we should focus on designing systems which ensure a safe culture rather than trying to identify who is at fault.5

While the most compelling reason for addressing disruptive and intimidating behavior has been the clear demonstration that it can be harmful for patients,1,2 there are other reasons. Individuals who have a history of disruptive behavior also pose the highest litigation risk for American hospitals, and many would argue that such behavior is inconsistent with the highest professional standards.6,7,8 Such behavior also contributes to poor teamwork, difficult work environments, poor patient satisfaction, and problems recruiting and retaining nursing staff.3

Several groups have described approaches for dealing with disruptive and intimidating behavior; the ones which seem most adaptable are those from the College of Physicians and Surgeons of Ontario and the Vanderbilt group.9,10,11 These include:

  • Making expectations explicit by having a code of conduct supported by appropriate policies
  • Ensuring robust Board support for clinical leaders in implementation
  • Support and training for those dealing with disruptive and intimidating behavior
  • Screening for health and personal issues
  • Proactive surveillance systems
  • Dealing consistently and transparently with infringements
  • Dealing with lower level aberrant behavior early
  • Having a graduated set of responses (informal, formal, disciplinary, regulatory) depending on the severity of the incident
  • Making resources available to help those displaying and those affected by disruptive and intimidating behavior

1 Rosenstein AH, O’Daniel M: A survey of the impact of disruptive behavior and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety, August 2008:34(8)464-471
2 Institute for Safe Medication Practices: Intimidation: practitioners speak up about this unresolved problem (Part 1). ISMP Medical Safety Alert! March 11, 2004, http://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp (accessed September 13, 2013)
3 Joint Commission: Behaviors that undermine a culture of safety. Sentinel Event Alert, July 9, 2008:40,  http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/ (accessed September 16, 2013)
4 IOM Committee on Quality of Health Care in America: To err is human: building a safer health system. National Academy Press, Washington, D.C., 1999
5 Wachter RM, Pronovost MD: Balancing “no blame” with accountability in patient safety. New England Journal of Medicine, October 1, 2009:361(14):1401-6
6 Hickson GB, et al: Patient complaints and malpractice risk. Journal of the American Medical Association, June 12, 2002:287(22):2951-7
7 Healy GB: Competence, safety, quality. Bulletin of the American College of Surgeons, December 2007:92(12):9-12
8 Leape LL, Fromson JA: Problem doctors: is there a system-level solution? Annals of Internal Medicine, January 17, 2006:144(2):107-15
9 College of Physicians and Surgeons of Ontario: Guidebook for managing disruptive physician behavior. Toronto, 2008, http://www.cpso.on.ca/uploadedFiles/downloads/cpsodocuments/policies/positions/CPSO DPBI Guidebook(1).pdf (accessed September 16, 2013)
10 Hickson GB, et al: A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine: Journal of the Association of American Medical Colleges, November 1982:(11):1040-8 (accessed September 16, 2013)
11 Swiggart WH, et al: A plan for identification, treatment, and remediation of disruptive behaviors in physicians. Frontiers of Health Services Management, 2009:25(4):3-11