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Staff-Led Facilitation Work Yields IMEC Silver Award for Joint Commission and CTH


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By Mark Pelletier, MS, RN, chief operating officer and chief nursing officer

In recent weeks, the news was official: The Joint Commission and the Joint Commission Center for Transforming Healthcare have received the Illinois Manufacturing Excellence Center (IMEC) Silver Award for Excellence. 

The Silver Award is the second highest level of recognition awarded by IMEC. It is presented to organizations that demonstrate effective, systematic well-deployed approaches that are aligned with organizational needs – leading to sound and notable continuous improvement toward excellence. Additionally, recipients must provide data that demonstrate improvement trends and/or good performance in areas necessary to accomplish an organization’s mission. 

The IMEC Recognition Program is the Baldridge-based program serving Illinois. The Baldridge Excellence Framework has empowered organizations to accomplish their missions, improve results and become more competitive for more than 30 years. Since 1995, IMEC has awarded 14 Gold Awards, 58 Silver Awards and 120 Bronze Awards.

We’re honored to be among such distinguished company. This couldn’t have been accomplished without the dedication of our staff as the application process was a year in the making.

Staff-Led Initiatives
One of the key aspects of our application and selection was The Joint Commission and the Center’s adoption of Robust Process Improvement (RPI), an evidence-based blend of Lean Six Sigma and change management tools and methods. This will be one of the enduring legacies of our President and CEO Mark R. Chassin, MD, FACP, MPP, MPH, who is leaving The Joint Commission at the end of this year. When he initially came onboard in 2008, Dr. Chassin launched a new department to guide and support the enterprise’s RPI journey through staff training, education and strategic project facilitation. This was a high priority of his and the intended goal was for staff to develop potential strategic projects that would permit the organization to achieve its desired performance.

Creating this department was an investment that paid off. Currently 99% of staff who have been with The Joint Commission and the Center for more than a year are formally trained in some form of RPI. This training and subsequent project facilitation has:

  •  transformed our culture
  • increased our capacity for problem solving
  • encouraged organizational learning and innovation
  • improved quality and safety
  • exceeded customer expectations 

The Center for Transforming Healthcare brings the same tools and training to partner organizations, who have reported excellent results to long-standing problems. 

Rigorous Application Process
Nearly every one of The Joint Commission’s 1,069 employees was involved in fine-tuning the processes outlining in our 67-page IMEC application. Joint Commission leadership is amazed at the dedication of our staff in showcasing their best practices throughout the site visits and application process. Staying focused on this task amid a global pandemic when all of our workflows changed is doubly impressive.

As anyone who has been through the Baldridge or Magnet process already knows, the bigger lift is actually still to come when it’s time to prove to IMEC that we’ve sustained these improvements during the next application cycle. Today, however, is the time to celebrate. Speaking for the entire executive officers’ group, we are proud of each and every one of our colleagues! 

Mark G. Pelletier, RN, MS is the Chief Operating Officer, Accreditation and Certification Operations, and Chief Nursing Executive for The Joint Commission. Prior to his current position, Pelletier served as the Executive Director for the Hospital Accreditation Program and was also responsible for business development in the Hospital, Critical Access Hospital and Laboratory accreditation programs. Mr. Pelletier has more than 30 years of experience in hospital operations, performance and quality improvement, process redesign, and program development.