-- 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.
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.
To view this release in a media-rich version, go to:
http://www.pwrnewmedia.com/2009/jointcommission90910nmr/index.html
Contact Information: Media Contact: Ken Powers Media Relations Manager 630-792-5175