The Joint Commission Center for Transforming Healthcare

The Joint Commiss Center for Transforming Healthcare Hand-off Communicats Targeted Soluts Tool April 2013 Teena Wilson, Center Outreach Director Klaus Nether, Master Black Belt and Project Lead Copyright, Th he Joint Commiss

Overview Introduct to the Joint Commiss Center for Transforming Healthcare (CTH) Overview of the problem solving framework: Robust Process Improvement (RPI) Hand-off Communicats Project History Outcomes Hand-off Communicats Targeted Soluts Tool Demo 2 Copyright, Th he Joint Commiss

Current State of Quality Source: Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15:174-178. We have focused intensely for more than a decade on improving quality and safety Yet, quality problems still surround us Health care associated infects Medicat errors that cause harm Failed communicat in transits of care Uncommon, preventable adverse events that are inexplicable to patients and families Wrong site surgery, OR fires 3 Copyright, Th he Joint Commiss

Introduct to CTH-Vis One Vis All people always experience the safest, highest quality, best-value health care across all settings. 4 Copyright, Th he Joint Commiss

Introduct to CTH-Miss Leadership The responsibility of leadership to make high reliability the priority Safety Culture The importance of creating a culture of safety within an organizat RPI The use of proven quality methods Lean Six Sigma & change management (known together as robust process improvement ) to systematically improve processes and avoid common, crucial failures Our Miss: Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve 5 Copyright, Th he Joint Commiss

Robust Process Improvement (RPI) A New Way in Delivering Results Usual Approaches: One-size-fits-all all works well only in very limited circumstances: Process varies little from place to place Causes of failure are few and common Protocols Checklists Toolkits or Bundles New Generat of Best Practices: Complex processes require RPI to produce soluts customized to an organizat s most important causes Many causes of the same problem Key causes different from place to place RPI Each cause requires a different strategy 6 Copyright, Th he Joint Commiss

Project 1: Improving Hand Hygiene Compliance Each letter = one hospital Wake Forest Cedars- Sinai Exempla Virtua Joint Commiss CTH Black Belt & Master Change Agent Froedtert Trinity Health Memorial Hermann Johns Hopkins 7 Copyright, Th he Joint Commiss

Develop Soluts with Leading Hospitals Atlantic Health Barnes-Jewish Baylor Cedars-Sinai Cleveland Clinic Exemplal Fairview Floyd Medical Center Froedtert Intermountain Johns Hopkins Kaiser-Permanente Mayo Clinici Memorial Hermann NY-Presbyterian North Shore-LIJ Northwestern OSF Partners HealthCare Sharp Healthcare Stanford Hospital Texas Health Resources Trinity Health VA Palo Alto HCS Virtua Wake Forest Baptist Wentworth-Douglass 8 Copyright, Th he Joint Commiss

Center for Transforming Healthcare 2009: hand hygiene, wrong site surgery and hand-off communicats 2010: colorectal l surgery SSIs 2011: safety culture, preventable HF hospitalizats, and falls with injury 2012: sepsis mortality, insulin safety 9 Copyright, Th he Joint Commiss

Center Operating Model Project Create Soluts, Pilot Test, Build Spread Select RPI Expertise Solve with Participating Determine Topic Organizats No RPI Expertise Pilot Test 1 Pilot Test 2: Integrate t Soluts Launch TST into TST (Beta-Testing) 10 Copyright, Th he Joint Commiss

Confidential Easy to Use No Extra Cost Separate from Accreditat Educatal, no jargon, no special training and no knowledge of RPI methodology needed Guides users to customized soluts. Data analysis conducted by the tool, not the user. Tool walks user through process of: Measuring current state Determining i root causes Selecting targeted soluts Control of process after implementat 11 Copyright, Th he Joint Commiss

Introduct to CTH-Projects Project 1 Hand Hygiene Compliance Project 2 Wrong Site Surgery Project 3 Hand Off Communicat Project 4 Surgical Site Infects With American College of Surgeons Pilot Testing Project 5 Preventing Avoidable Heart Failure Hospitalizats With American College of Physicians Project 6 Safety Culture Project 7 Preventing Falls with Injury Project 8 Reducing Sepsis Mortality Project 9 Medicat Safety: Safe Use of Insulin Web: www.centerfortransforminghealthcare.com com Solve 12 Copyright, Th he Joint Commiss

Why Tackle Hand-off Communicats? Health care organizats have long struggled with the process of passing necessary and critical informat about a patient from one caregiver to the next, or from one team of caregivers to another An estimated 80 percent of serious medical errors involve miscommunicat during the hand-off between medical providers 14 Copyright, Th he Joint Commiss

Why Tackle Hand-off Communicats? A hand-off is the transfer and acceptance of patient care responsibilities achieved ed through effective communicat The hand-off process involves senders the caregivers transmitting patient informat and releasing the care of the patient to the next clinician, and receivers the caregivers who accept patient informat and care of the patient 15 Copyright, Th he Joint Commiss

What was Measured? Defective Hand-offs A defective hand-off occurs when the hand-off did not meet the needs of either the sender or the receiver 16 he Joint Commiss Copyright, Th

Hand-Off Communicats (HOC) In 2011, targeted soluts for hand-off communicats were pilot tested in hospitals and ambulatory care settings to prove their effectiveness in demographically diverse hospitals and other care settings Both hospital and ambulatory pilot settings experienced a decrease in defects 18 Copyright, Th he Joint Commiss

54% Reduct Copyright, The Joint Commiss

Experience of HOC Projects The universal experience was the differing expectats of the senders and receivers. Organizats aligned expectats of the hand-off developed a process for a successful hand-off fostered better relatships and communicat among staff 20 Copyright, Th he Joint Commiss

Improving Transits: Hand-off Communicats One hospital focused on the transit from its inpatient units to a nursing home Baseline Improve Inadequate hand-offs 29% <1% 30-day readmisss 21% 10% he Joint Commiss Copyright, Th 21

Did improved HOCs impact anything else? Other Outcome Metrics Reduct in bounce backs Reduct in LOS in ED Improved Patient Satisfact Improved Family Satisfact Improved Staff Satisfact he Joint Commiss Copyright, Th 22

TST Step 1 Getting Started Tips from Experts Copyright, The Joint Commiss 24

TST Step 1 Getting Started Copyright, The Joint Commiss 25

TST Step 2 Training Observers Copyright, The Joint Commiss 26

TST Step 2 Training Observers Downloadable training materials/ videos & competency exam 27 Copyright, Th he Joint Commiss

TST- Step 3 Measuring Compliance Copyright, The Joint Commiss 29

TST- Step 4 Determining Factors Copyright, The Joint Commiss 30

TST Step 5: Implementing Soluts Targeted Soluts to Root Cause 33 he Joint Commiss Copyright, Th

TST Step 6: Sustaining the Gains Copyright, The Joint Commiss 34

Concluss Persistent safety issues are complex and multi-factorial. Unless you understand the true reasons why something isn t working, you will constantly struggle to improve it. CTH s approach: data-driven methodology that seeks to uncover the true root causes of failure leading to customized soluts. 35 Copyright, Th he Joint Commiss

Center for Transforming Healthcare www.centerfortransforminghealthcare.org g 36 Copyright, Th he Joint Commiss

How an Organizat s Extranet Security Administrator can Grant Access to Users of the TST he Joint Commiss Copyright, Th

Getting Access to the TST The Targeted Soluts Tool (TST) is a secure, password protected, web based applicat. To access the TST, you must have a valid login ID and password. Access to the TST is administered by the designated Extranet Security Administrator at each Joint Commiss accredited healthcare organizat. Usually, this individual is responsible for the organizat s accreditat related activities. If you do not know who your organizat s Extranet Security Administrator is send an email message, with your name, your organizat s name and locat to: - Mr. Tony Cabell joseph.t.cabell.civ@mail.mil or - Lt. Cindy Renaker cindy.s.renaker.mil@mail.mil If you are a designated Extranet Security Administrator and you are looking to learn how to grant access to a TST user, please follow the instructs in this video tutorial http://tjc.s3.amazonaws.com/tst/tsthelp.html. 38 Copyright, Th he Joint Commiss