The Joint Commission is launching the Center for Transforming Healthcare, designed to use new methods to find the causes of dangerous breakdowns in patient care.
The center's first initiative is tackling hand-washing failures that contribute to healthcare-associated infections that kill nearly 100,000 Americans and cost U.S. hospitals $4 billion to $29 billion each year.
"Demanding that healthcare workers try harder is not the answer," said Mark R. Chassin, MD, president of The Joint Commission. "A comprehensive approach is the only solution to preventing bad patient outcomes."
Eight hospitals and health systems have volunteered to participate in the center's first project:
- The Cedars-Sinai Health System in Los Angeles;
- Exempla Lutheran Medical Center in Wheat Ridge, Colo.;
- Froedtert Hospital in Milwaukee, Wis.;
- The Johns Hopkins Hospital and Health System in Baltimore, Md.;
- The Memorial Hermann Health Care System in Houston;
- Trinity Health in Novi, Mich.;
- Virtua in Marlton, N.J.; and
- Wake Forest University Baptist Medical Center in Winston-Salem, N.C.
Chassin praised the participating organizations for "digging deep to find out where the breakdowns take place" in hand-washing so targeted solutions for HAIs can be implemented.
The hospitals will focus on three issues related to hand-washing: Soap or alcohol-based hand rubs that are not convenient for caregivers to use, faulty data that lulls facilities into thinking hand-washing is occurring more frequently than it is, and a lack of individual accountability.
"Hand-washing in hospitals should become as automatic as looking both ways before crossing the street," said William D. Petasnick, president and CEO of Froedtert Hospital in Milwaukee, Wis. "As we achieve 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."
Random observation is not enough, Chassin said. The eight hospitals, using the center's measurement methods, have found that caregivers usually wash their hands less than 50 percent of the time.
The solutions proposed by the center now being tested include holding everyone, from doctors and nurses to food service staff, housekeepers, chaplains, technicians and therapists, accountable and responsible; using a reliable method to measure performance; communicating frequently and using real-time performance feedback; and tailoring education on proper hand hygiene for specific disciplines.
Chassin said the center intends to develop and test targeted, long-lasting patient safety solutions. He said proven and practical strategies, such as Lean Six Sigma, could help transform America's healthcare system into a high-reliability industry that ensures patients receive the safest, highest quality care they expect and deserve.
"This is an opportunity to take part in solving chronic and dangerous problems that occur in hospitals nation-wide," said Joseph Swedish, president and CEO of Novi, Mich.-based Trinity Health. "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 healthcare."
The center's next project will target breakdowns in hand-off communications. A hand-off is a transfer and acceptance of patient care responsibilities.
Hospitals and health systems participating in the hand-off project will include Fairview Health Services, Intermountain Healthcare, Kaiser Permanente, the Mayo Clinic, North Shore-Long Island Jewish Health System, Partners HealthCare System, New York-Presbyterian Hospital and Stanford Hospital & Clinics.
Chassin said future projects will focus on improving other aspects of infection control, mix-ups in patient identification and medication errors.
The Joint Commission plans to share information gleaned from the projects with the 16,000-plus healthcare organizations it accredits nationwide.