Joint Commission Center for Transforming Healthcare Takes Aim at Patient Safety Failures
Top U.S. hospitals identify causes, develop targeted solutions to save lives.
Washington, DC, September 10, 2009—Teaming up with top hospitals and health systems across the country to use new methods to find the causes of and put a stop to dangerous and potentially deadly breakdowns in patient care, The Joint Commission is launching the Center for Transforming Healthcare. The Center’s first initiative is tackling hand-washing failures that contribute to health care-associated infections that kill nearly 100,000 Americans each year and cost U.S. hospitals $4 billion to $29 billion annually to combat.
Eight leading hospitals and health systems volunteered to address hand-washing failures as a critical patient safety problem–one that requires fixes far more complex than just putting up signs urging caregivers to wash their hands. Participants in the Center’s first project to make care safer by being more reliable are:
- Cedars-Sinai Health System, Los Angeles, California
- Exempla Lutheran Medical Center, Wheat Ridge, Colorado
- Froedtert Hospital, Milwaukee, Wisconsin
- The Johns Hopkins Hospital and Health System, Baltimore, Maryland
- Memorial Hermann Health Care System, Houston, Texas
- Trinity Health, Novi, Michigan
- Virtua, Marlton, New Jersey
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
“Demanding that health care workers try harder is not the answer. These health care organizations have the courage to step forward to tackle the problem of hand washing by digging deep to find out where the breakdowns take place so we can create targeted solutions that will work now and keep working in the future,” says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “A comprehensive approach is the only solution to preventing bad patient outcomes.”
Recognizing that there is no quick fix, the participating hospitals set out to solve the problems — soap or alcohol-based hand rubs that are not convenient for caregivers to use, faulty data that lull facilities into thinking hand washing is occurring more frequently than it is, and lack of individual accountability — by using Robust Process Improvement™ tools. The front-line work of the hospitals shows that random observation is not enough. In fact, the eight hospitals, using the Center’s measurement methods consistently, found on average that caregivers washed their hands less than 50 percent of the time. The targeted solutions from the Center now being tested include holding everyone accountable and responsible – doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists; using a reliable method to measure performance; communicate frequently and use real time performance feedback; and tailor education in proper hand hygiene for specific disciplines.
The Center’s work to identify and measure poor quality and unsafe health care will lead to the development and testing of targeted, long-lasting patient safety solutions. These proven and practical strategies, based on methods such as Lean Six Sigma long used by other industries, can help transform American health care into a high-reliability industry that ensures patients receive the safest, highest quality care they expect and deserve.
Hand washing is the Center’s first patient safety challenge. The next project with safety experts and leading hospitals — Fairview Health Services, Intermountain Healthcare, Kaiser Permanente, Mayo Clinic, North Shore-Long Island Jewish Health System, Partners HealthCare System, New York-Presbyterian Hospital and Stanford Hospital & Clinics — will target breakdowns in hand-off communications. A hand-off is a transfer and acceptance of patient care responsibilities achieved through effective communication. Future projects will focus on improving other aspects of infection control, mix-ups in patient identification and medication errors. The Joint Commission will share information about the proven solutions with its more than 16,000 accredited health care organizations nationwide to prevent bad outcomes that touch thousands of Americans each year.
Statements from the Center’s Participating Hospitals
“The Center for Transforming Healthcare has already assisted in the acceleration of new technology monitoring alternatives. The options for all hospitals focused on resolving the hand hygiene issue will expand as the Center moves forward in its effort to transform healthcare in this – and other – arenas.”
Thomas M. Priselac, president and CEO, Cedars-Sinai Health System
“Exempla Lutheran Medical Center staff and physicians were excited to participate in the inaugural work of the Joint Commission Center for Transforming Healthcare. It provided us an opportunity to collaborate with other renowned hospitals from across the nation and apply our expertise in using Lean to achieve consistently high levels of hand hygiene performance and patient safety.”
Robert Malte, president and CEO, Exempla Lutheran Medical Center
“Hand washing in hospitals should become as automatic as looking both ways before crossing the street. As we achieve successful and sustainable progress in improving this long-standing issue, I’m confident hospitals can apply the same collaborative techniques and process improvement tools to other complex patient safety issues.”
William D. Petasnick, FACHE, president and CEO, Froedtert Hospital
“Our involvement with the project has led to a better understanding of the factors leading to lapses in hand hygiene, and in turn, to interventions that have brought lasting improvements across all eight participating hospitals. The identification of common causal factors among the participants is an encouraging sign that the interventions have the potential to improve hand hygiene at hospitals everywhere.”
Ronald R. Peterson, president, The Johns Hopkins Hospital and Health System
“When Memorial Hermann The Woodlands Hospital was invited to collaborate with The Joint Commission’s Center for Transforming Healthcare, we viewed it as an opportunity to address and potentially resolve a quality issue that is critical to each and every hospital in our country. Our participation in this project has already resulted in accurate measurement and increased awareness regarding hand hygiene.”
Steve Sanders, CEO, Memorial Hermann The Woodlands Hospital
“This is an opportunity to take part in solving chronic and dangerous problems that occur in hospitals nation-wide. The Center for Transforming Healthcare is poised to engage in a number of breakthrough process improvement projects, which will make a transformational improvement in the quality and safety of health care.”
Joseph Swedish, president and CEO, Trinity Health
“I applaud The Joint Commission for bringing together eight organizations for the Center for Transforming Healthcare’s inaugural project. As the Center moves forward with new efforts, the results will serve to expand our body of knowledge across all disciplines and continue to make healthcare reliable and safe for patients and providers.”
Richard P. Miller, president and CEO, Virtua
“Hand hygiene compliance is not a simple problem to fix. It requires systematic process improvements to identify and overcome barriers. We look forward to sharing our findings and working with other hospitals to meet this important health care quality challenge. Wake Forest Baptist is honored to participate in this powerful collaborative with The Joint Commission to improve quality and patient safety.”
Donny Lambeth, president and COO, North Carolina Baptist Hospital, part of Wake Forest University Baptist Medical Center
The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Ecolab, GE Healthcare and Johnson & Johnson, as well as the support of the Federation of American Hospitals and Hospira.
For more information about the Joint Commission Center for Transforming Healthcare, visit www.centerfortransforminghealthcare.org.
About the Joint Commission Center for Transforming Healthcare
The Joint Commission Center for Transforming Healthcare is a 501(c)3 not-for-profit affiliate of The Joint Commission. The Center aims to solve poor quality and unsafe health care and transform health care into a high reliability industry. The Center’s participants – the nation’s leading hospitals and health systems – use a proven systematic approach to analyze specific breakdowns in patient care and discover their underlying causes to develop targeted solutions that solve these complex problems. For more information about the Center, please visit www.centerfortransforminghealthcare.org.