Moving Toward Culturally Competent Quality Improvement

Improvement from Front Office to Front Line October 2010 Volume 36 Number 10 Moving Toward Culturally Competent Quality Improvement Culturally competent QI interventions are designed to improve care for everyone but with particular attention to disparity groups. This involves specifically tailoring QI interventions to emphasize cultural and linguistic competence and access for disparity groups, while not excluding majority patients. Green et al. (p. 438) Features Performance Improvement Leveraging Quality Improvement to Achieve Equity in Health Care Human Factors Engineering Mobile In Situ Obstetric Emergency Simulation and Teamwork Training to Improve Maternal-Fetal Safety in Hospitals Health Professions Education Teaching Quality Improvement in a Primary Care Residency Risk and Event Assessment A Proactive Risk Avoidance System Using Failure Modes and Effects Analysis for Same-Name Physician Orders Departments Forum Improving the Quality of Quality Improvement Projects Interview An Interview with Mark Chassin www.jcrinc.com

Interview An Interview with Mark Chassin Interviewed by Steven Berman Mark R. Chassin, M.D., M.P.P., M.P.H., has been president of The Joint Commission since January 1, 2008. In this role, he oversees the activities of the nation s predominant standardssetting and accrediting body in health care. Joint Commission accreditation and certification is recognized worldwide as a symbol of quality that reflects an organization s commitment to quality improvement and to meeting state-of-the-art performance standards. Among the initiatives instituted during Dr. Chassin s tenure at The Joint Commission is the Center for Transforming Healthcare. Established in 2009, the Center is working with a cadre of leading hospitals and health systems in the United States to develop and implement consistent safety solutions that address quality and safety challenges facing health care organizations. These challenges such as health care associated infections and medication and surgical errors threaten lives and increase costs. The Center uses Lean Six Sigma and change management tools and methods to identify the most pressing safety problems, measure their impact, discover their causes, develop specific solutions that are targeted to each important cause, and thoroughly test the solutions in real-life situations. In September 2010, The Joint Commission, through the Targeted Solutions Tool TM (TST), shared an initial set of proven effective solutions for improving hand hygiene compliance in hospitals, the first project of the Center, with the more than 18,000 health care organizations and programs it accredits and certifies. The TST allows each hospital to customize its improvement solutions to address the most important causes in its own organization. As new solutions are developed, they will be added to the TST. For more information about the Center, visit http://www.centerfortransforminghealthcare.org/. What is the goal of the Center for Transforming Healthcare? The Joint Commission created the Center to add to its available tools and methods for quality improvement, a completely new activity. The aim of the Center is to go beyond accreditation and use the most sophisticated and up-to-date process improvement tools and methods to help health care organizations develop much more effective ways to solve the most difficult and pressing quality problems that we have in health care today. The Joint Commission has always been about best practices. Joint Commission surveyors suggest best practices to organizations for issues or problems that emerge during the survey. Joint Commission Resources [JCR] provides publications, educational conferences, long-distance learning, and consulting to disseminate best practices, but those have always been best practices developed elsewhere. The Center s goal is to work with hospitals and systems that have mastered these new process improvement tools and methods to create a new generation of best practices. What s unique about the Center? What s unique about the Center is the use of systematic approaches and tools to solve problems in combination with the reach of The Joint Commission to disseminate the solutions. Those two factors really address, in my view, two of the most important failings of the way we do quality improvement today in health care. One of them has to do with the way in which these systematic approaches to problem solving work. It s not enough just to define a problem and measure how big it is. If you re really going to solve these problems, such as hand hygiene compliance, that have resisted our efforts so far, you have to understand what the specific causes of the failures are, and that s what these tools are so good at. They help us figure out exactly why the process isn t working, and when you do that, you also find that the causes of the same problem differ from one place to another. So in the old mode of best practices, when you read about, learn about, or hear about a best practice and you try it in your own organization, you very frequently don t get the same stellar result that the organization that developed the best practice reported. Now sometimes that s because the developers were overhyping what they did. Yet, the most fundamental reason that best practices don t work the same way everywhere is that they were developed to work on a different set of causes than the ones you have at your own organization. 475

If you don t ask the question, What are my causes? targeting solutions is impossible, as we re finding with all the Center s projects. So the first important innovation is to discard the notion of a one-size-fits-all best practice and instead to develop a portfolio of interventions that are targeted to the specific causes of the problem in different locations. Working with a group of orga - nizations enables us to identify a large portfolio of causes and then develop solutions targeted to each of those causes. The second innovation concerns the ability of The Joint Commission to spread this knowledge about best practices well beyond the Center s participating hospitals, which, as many of the hospital CEOs have actually told me, was one of the most important reasons that they were interested in joining us in this effort. We in health care do not generally do a good job of spreading innovation. For example, when you participate in a multiinstitution quality improvement effort, you may benefit, but the neighboring organization across the river or down the road that was not a participant doesn t benefit at all. What we re constructing with the Center is this systemic approach to solving a problem and then marrying that with the reach of The Joint Commission so that all 18,000 of our accredited organizations and programs can benefit. After developing solutions in the Center, we push them out to all our organizations. We require them to have a good hand hygiene program, so they re motivated to consider these solutions and learn from them. We believe that secondary spread becomes much more effective when we employ this model. Well, this model has been persuasive for the hospitals that agreed to participate in the Center. We recruited 16 of the leading hospitals and systems in 2008, one CEO at a time. As Tom Priselac, president and CEO of Cedars-Sinai Medical Center said, Getting a call from the president of The Joint Commission usually provokes a particular kind of reaction, but once the subject of this call was clear, the CEOs recognized that The Joint Commission was engaged in a new initiative. The prospect of working together with their peers and using these effective tools that they ve already made the investment in mastering was a very attractive notion. The fact that we were convening the group in this way, completely unique for The Joint Commission, was also another important ingredient in the initial enthusiasm. This year so far, we ve expanded the Center from 16 to 19 participants. As word has gotten out since the Center s public launch in September 2009, many other hospitals have wanted to be involved. But what we ve found is, just as we had discovered in 2008, that there actually is only a relatively small, very small single-digit percentage of hospitals and systems that have mastered tools such as Lean Six Sigma and change management sufficiently to enable them to really participate in these projects on business time frames. These are not training projects. We want experts to come together and apply the tools as effectively and rapidly as possible on the basis of a common language and a common understanding of which tools are deployed in which circumstances. How is the Center funded? To enable us to provide as much learning publicly and to accredited organizations as part of accreditation at no added cost, we have been raising outside funding to support the Center s research and development work. We re also training our surveyors and JCR consultants, so that when they see a problem, such as in hand hygiene, they will be able to refer the organization to the Center s resources. The Joint Commission made the initial investment in the Center. We have now seven major donors, and of course it s now the worst time in years to raise money. But we have many prospects. Can you provide some examples from the hand hygiene project to reflect the variation in the kinds of causes that the Center has identified? The Center s Web site now has the initial results, which shows the top 10 causes, which vary tremendously across the eight participating hospitals. 1 So, for example, for one of the causes ( hands full ), which was a surprise for many of the participants, caregivers approach a patient s room with their hands full for example, a nurse is carrying materials to do a dressing change and there s no place to put the materials down. The hand-gel dispenser is right there, on the wall, but there s no place to put the materials down, so what do you do? You frequently miss the opportunity to wash your hands. So that cause requires a targeted intervention or solution. Another common cause is accountability failures, as seen when people who think that they are above the law and they don t really have to abide by the policy go past the sink or the hand-gel dispenser, and there s no accountability culture that allows somebody else that s witnessing that to say, Wait a second, doc, you need to wash your hands before you go in there. So you need to think about how you would solve that problem compared with the hands-full problem. The Center s Web site shows how the Center hospitals used the specific causes to develop targeted interventions. 476

How will the Center spread learnings to hospitals at large? Through the Targeted Solutions Tool TM (TST), we are providing learnings from the Center projects that any accredited hospital whether a 50-bed rural hospital or an academic teaching center, for example can use (See Sidebar 1, right). And while the health care organizations that are working with the Center use RPI [Robust Process Improvement TM ] tools to develop targeted solutions, an organization is not required to use Lean Six Sigma concepts to implement the solutions. So it s a way to customize best practices from a portfolio that will work on the specific causes that you have. How do you know that the solutions, as available through the TST, will work at hospitals that don t have expertise in Lean or Six Sigma? We pilot tested the solutions that were developed at the 8 participating Center hospitals at those hospitals, as well as 29 additional hospitals small, medium, and large and rural and urban across the United States. We found that all pilot hospitals, the vast majority of which do not have Lean or Six Sigma capability, were able to successfully implement the solutions and realize the same gains found in the 8 Center hospitals. We are also piloting the solutions in ambulatory and long term care organizations to expand their applicability to those settings. Are the tools intuitive enough to help organizations find solutions with no further explanation? We expect that many organizations will be able to make great progress from just that amount of information. There are little help cues built into the Center s Web site, which are rather innovative. For example, the methodology for hand hygiene is to train observers who are unknown to the staff to observe hand hygiene compliance. They re like hand hygiene marshals or secret shoppers, who are part of the staff. So what happens when the observers are found out? The Center s Web site provides tips on how to deal with that in the most effective way. Now, we recognize that this type of measurement of hand hygiene compliance is not going to be sufficient in some orga - nizations, so JCR will make a variety of solutions available in a number of forms and media. We ll provide tools and programs on the Center s Web site and in trade publications and journals. The American Hospital Association, one of the Center s major sponsors, is going to be a partner in disseminating this learning as well. JCR will provide articles and books and hold educational conferences, and we ve trained JCR consultants to help Sidebar 1. Targeted Solutions Tool TM For the first time ever, Joint Commission accredited organizations have access to an application that simplifies the process for solving some of the most persistent health care quality and safety problems that exist in the health care system today. The Targeted Solutions Tool TM (TST) scheduled for release mid-september 2010 encapsulates the work of The Joint Commission Center for Transforming Healthcare to deliver solutions for difficult and pressing safety and quality problems....the TST application guides health care teams through a step-by-step process to measure their organization s actual performance, identify barriers to excellent performance, and identify proven, tested, and targeted solutions. The advanced process improvement methods used by organizations participating in the Center projects have been simplified via the TST and are now available to all Joint Commission accredited organizations. Organizations do not need statistical data analysis capability or specialized performance improvement expertise to use the TST; the Center designed the self-paced tool to be clearly understood and used by an organization s staff so that no new resources are required to utilize it. The easy-to-use TST is not just a checklist; it provides instantaneous data analysis saving the organization time and resources. The TST is accessible via an accredited organization s Joint Commission Connect extranet site at no additional cost. The entire process is confidential. Excerpted from: Center for Transforming Healthcare releases first targeted solutions. Jt Comm Perspect 30:1, 10, Sep. 2010. disseminate specific tools at an additional cost that will amplify the impact of the Center s work. How will the Center evaluate the effectiveness of the solutions for the hand hygiene project and current and future projects? We are collecting data from all Center hospitals. We are continuing to do so even for the eight hospitals that participated in the hand hygiene project, past its formal closure. In April 2009 at the beginning of the project performance was collectively at 48% and has now stabilized at around 82%. It s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%. So getting reliable measures was understandably a big issue at the start of the project. The Center hospitals set a goal of about a 50% increase in their hand hygiene compliance, which they ve now met, but they re not resting on those laurels. We re looking to industry to address one of the more difficult parts of sustaining and getting past 80%, namely, replacing this very labor-intensive measurement system with devices, software solutions, and applications that are relatively inexpensive but will provide real-time feedback on performance. 477

How is the Center working with industry? Each project identifies critical parts of these processes, which are very complicated and require a lot of help. You can t just solve the problems by telling people to try harder. For example, when you have demonstrated effective improvement, you still need to maintain it for the long run, which is often harder than achieving the original improvement. We have found that you frequently have to learn from other industries that have sustained improvements longer and better than health care has. You need help in implementing measurement systems to monitor performance, as I ve just mentioned, as well as automated computer decision support, to keep the process going at a very high level of performance. In the hand hygiene project, early on we recognized that while the trained-observer measurement system was the best way to first get a handle on performance, the results are not scalable to, say, a 1,000-bed hospital and are not sustainable over long periods of time. So the Center staff created a request for proposal [RFP] that defines specifications for what a sustainable solution would look like. We sent the RFP to a couple dozen companies and asked them if they would be interested in submitting proposals for products that they would make available free to the Center s participating hospitals. The hospitals would then test the products and figure out whether they work for them or not. We now have four or five really good ideas that the Center hospitals chose from some months ago and are now assessing in the beta-testing phase. Can you provide an example? One of these industry solutions marries proximity sensors on hand-gel dispensers with radio frequency identification [RFID] tags on ID badges, so a little buzzer goes off if you pass by but don t activate the hand-gel dispenser. The resulting data are fed into a database that actually measures and gives you realtime feedback on performance. The point of collaborating with industry of course is not to help sell giant computer systems or MRI scanners but to develop focused solutions that are integrated into the process improvement identified through the Center s RPI methodology. Staying with hand hygiene are you looking at the downstream impact on infection rates? Absolutely, all the Center hospitals are collecting those data. Tom Priselac from Cedars-Sinai, which was one of the hospitals participating in the hand hygiene project, and I did a joint presentation at the American College of Healthcare Executives in Chicago in March. It was one of their hot-topics sessions, and 1,100 hospital executives showed up at 7 A.M. I talked in general about the Center, and Tom talked about the experience at Cedars. He presented some data for the three pilot units that showed that their hand hygiene compliance was at 80 or 85, maybe 90%, and that their MDRO HAIs [multidrug-resistant organism health care associated infections] went away, which has been sustained for at least six months. So the hospitals are collecting those data. We certainly want to be able to associate improved hand hygiene with reduction in infection. I think one of the reasons that hasn t been done as much as one would like is that a lot of data on hand hygiene compliance are really unreliable, as the Center hospitals found out and as I mentioned earlier. How did the Center identify the projects to work on? The way we started off in identifying topics is basically this: We did a poll among the participating hospitals in late 2008, and repeated it last year, of the 30 or 40 or so most challenging safety and quality problems that we have. Each of those problems were drawn basically from the National Patient Safety Goals current and past. So The Joint Commission had already identified most of these really difficult safety and quality problems and has developed specific requirements that hospitals need to address, whether the problems involve medication safety issues, infection prevention, identifying patients appropriately for surgery, and so on. The problem that received the most number-one votes was hand hygiene, and handoff communications received the second-most votes, so those are the topics of the first two projects. Wrong-site surgery is the third, surgical site infection will be the fourth, and preventable hospitalizations, with a focus on patients with congestive heart failure [CHF], will most likely be the fifth. Did you choose preventable hospitalizations because of the CMS interest in re-admissions? Yes and no. There is certainly more attention to reducing readmissions. I happen to think that that problem is mischaracterized as a re-admissions problem because that implies that there was something wrong with the first hospital admission which led to another admission. The real problem is admission for patients with chronic illness, and the solution is to prevent hospitalization, and we actually know how to do that. The reason that preventable hospitalizations came up in this context is that they represent a variation of handoff communication. The Center s handoff communications project focuses more on internal handoffs, such as from the ED to an inpatient floor. However, in the course of the handoff communication project, some of the 10 participating hospitals have also chosen to 478

address handoff from a referring hospital to a receiving hospital. There are three or four variations on that theme. What we can learn from that could be applied to the handoff from hospital to community source of care, which is of great interest to one of our corporate members, the American College of Physicians, just as the American College of Surgeons, another corporate member, is collaborating on our surgical site infection project. What does the Center add to Joint Commission accreditation? This relates to the overarching dimension to the Center s work: Even though we ve identified all these problems and require through standards or National Patient Safety Goals that organizations pay attention to them, we have never told orga - nizations how to solve the problems. That s the message I ve gotten loud and clear over the last couple of years from customers: Stop telling us only about the problems and start telling us how to fix them not just what to do, but how to do it. Moreover, experience with the learnings from the Center will help us determine what everybody should be doing to provide safe and effective care of the highest quality and value, and we can use that as a feedback loop to improve the standards. So you see the standards as becoming more evidence based? More evidence based and more how to, based on real-world experience. We will have already provided some of that in terms of specific-assist devices, software solutions, and applications, to our organizations, as I ve mentioned with reference to hand hygiene compliance, so they don t have to guess how to do it, they re already there. Then we ll bake solutions into the accreditation standards so that everybody starts using them. What does the Center s experience so far suggest about any lessons learned? There are all kinds of obstacles and difficulties. There are no magic bullets. These are problems that we have been struggling with for a long time. I often cite the hand hygiene data from Ignaz Semmelweis in the 1840s. This is not a knowledge problem, but it s not a simple problem to fix, as some outside observers would conclude just wash your hands. There are many, many different interacting forces, and it s very difficult to get complicated organizations like hospitals to pay attention to 45 different problem areas. So what I think we are looking at over the long run is really a transformation which is why the Center has that name of health care to an industry that will be adopting many more of the high-reliability principles that come out of industries that are much, much safer than health care. These principles allow organizations to maintain many processes at a very highly safe level of performance over a long period of time. So this is going to be very hard work for orga - nizations. The point, then, is that it is a matter of addressing the systemic and cultural issues, not just a list of solutions. Is that where Lean Six Sigma and RPI come back in? Exactly right. The Joint Commission itself is in the middle of a widespread adoption of all these tools, and we re using them not just to have a better way to improve our processes but as a way to transform our culture. This systematic approach and systematic attention to quality must become the way we work every day, serving as a model for health care. As the title of a magazine article from last year says, we are not just talking the talk, we are walking the walk. 2 I think that the prescription for health care to get to high reliability is the rigorous adoption and mastery of these tools to perfect our processes and the full establishment of a safety culture that wraps around those improvement processes so they keep producing at very high levels over long periods of time. But we will not require health care organizations to adopt Lean Six Sigma or RPI. I am hopeful, though, that many of them will see, based on our experience and that of others, that these are really effective tools that can solve some business problems along the way you can increase your financial productivity. Now, we do already have a requirement that hospitals have to adopt a safety culture, but I believe very strongly that it s the combination of such a culture with really effective improvement that makes for a highly reliable organization. J References 1. Joint Commission Center for Transforming Healthcare: Facts About the Hand Hygiene Project. http://www.centerfortransforminghealthcare.org/ projects/about_hand_hygiene_project.aspx (last accessed Aug. 19, 2010). 2. Adrian N.: Don t just talk the talk: The Joint Commission tackles its own processes with lean and Six Sigma. Quality Progress 42:30 33, Jul. 2009. 479