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December 2017 Archive for High Reliability Healthcare

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

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.