Joint Commission Center for Transforming Healthcare

The Joint Commission’s

Center for Transforming

Healthcare aims to solve

health care’s most critical

safety and quality

problems. 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. In keeping with

its objective to transform

health care into a high

reliability industry, The Joint

Commission will share

these proven effective

solutions with the more

than 18,000 health care

organizations it accredits.

Bringing the Leading Health Care Organizations

Together to Solve Challenging Health Care Problems

What is the project?

What is the customer's measure?

What, how much and by when? Who is involved?

What does demand look

like?

Are we primarily improving quality or productivity? Data analysis

potential?

Can I measure the data well?

Is my process stable?

What is the current process

capability of meeting the customer's

needs?

What are the validated

contributing factors?

Best solution / Design? RPI successful?

Are goals met and

sustainable?

Is this the right way?

Will the process continue if unstable?

All risks managed to

sustain the RPI?

Are improvements benefiting the value stream?

Have we reinforced RPI with our people and in the value

stream?

Charter Voice Of Customer, QFD

Strategic gap and scorecard

analysis

Stakeholder Analysis Takt time

RPI Roadmap of Main Street and Avenues

Measurement System Analysis (MSA)

Statistical Process

Control Chart (SPC)

Current State Capability

Validating factors (SPC, confidence intervals,

hypothesis testing)

Cause and Effect Matrix,

QFD, DOE

Pilot improvement

Capability and execution plan Standard Work

Jidoka Autonomation

Mistake - proofing

SPC, Failure Modes and

Effects Analyses,

Control Plan

Scroll and replicate

improvements

Recognition for benefits

Charter template, Customer, Sponsor & Champion

Customer, metrics Goal

Change Management. key roles, Sponsor and targets of change

Customer demand,

Operation plan

Customer, metrics

Measurement system and data

Data on inputs and outputs

Customer requirements

and process

data

Probable contributing

factors, hypotheses and data to validate

RPI ideas, process owners and members

Tests of solutions Capability study

Roles, template, maps and process owners

Process monitoring,

quality checks, empowered

workers

Process map, FMEA, Control Plan with SPC

Value Stream processes,

project management,

Champion network

Leaders, team members,

stakeholders and targets

Charter draft

Customer consensus of

issue definition

Charter signoff by Champion,

Sponsor. Finance signoff

Risk Analysis and Action Plan

Time to service customer The plan

marked on this roadmap

Measurement quality

SPC graphical scoreboard for

RPI

Baseline capability (one

or more of: Sigma level,

DPMO, SPC, Cpk, Value-

Add/Total ratio)

Validated contributing factors of

defects and wastes

Best solutionsValidated Robust

Process Improvements

Solutions validated to meet goals, Champion, Sponsor &

Process Owner approval

Correct and consistent work,

training plan

Process stops on quality

abnormality

FMEA, Process Control Plan with

signoff by Sponsor,

Champion, Process Owner, Finance and Belt

Maximized benefit

Team members reinforced for

improving continuously

Do I have all of the inputs?

What are the Key Process

Input Variables (KPIV) to focus

RPI?

What are the probable

causes for the key input variation?

Which data measure current

state and validate the contributing

factors?

What does the data show?

How can we improve the

inputs?

Is there a difference?

Significant differences?

VSMValue Stream

Map SIPOC Cause & Effect Matrix

Failure Modes

& Effects

Analysis

Data Collection

Plan

Histograms, checksheets,

pareto, scatter plots, stratification,

hypothesis tests

Experiments

Histograms, checksheets,

pareto, scatter plots,

stratification, hypothesis tests

Hypothesis Testing (Chi-

Square, ANOVA, regression, confidence intervals)

SIPOC

Supplier, Input, Process, Output,

Customer

Include all major steps and all

inputs; be sure to walk the

process

Detailed SIPOC Map

Key Process Input Variables

to focus

Probable contributing factors Patterns to the data Brainstorming Patterns to the data

SPC, confidence intervals,

hypothesis tests

SPCStatistical Process Control

SIPOC with all inputsand steps

Key Process Input Variables

to focus

Probable contributing

factors

Plan to validate current state and

capability

Narrowing of root cause RPI ideas Narrowing of RPI

ideasValidated

differences

FMEAFailure Modes

and Effects Analysis

What is the value stream

and its flows?

Areas to focus RPI waste reduction?

What is the way of working?

Where are the key areas of

focus for RPI?

What does the process flow look

like in area of focus?

Disorganized workplace?

Is process equipment

operational when needed?

Flow or batch? Flexibility among workers?

Is process fail-safe?

Process waste from set-ups?

Small batches possible?

Can we reduce lead-time to

customer and from suppliers?

Can we smooth demand or at

least production?

Replenish only on pull from customer?

Can the process flex

with demand?

Inventory wastes

present?

JIT Just-In-TimeValue Stream Map (Current

State)

Kaizen, Work Outs, 8 Wastes,

Spaghetti Diagram

Standard Work of

current state

Value Stream Maps of target

wastes

Value Stream Map (Design of Future

State), Kaizen 5S Total Productive

Maintenance Cellular Flow Multi-skilled worker Mistake-Proofing Set-up reduction 1-piece or small

lot flowLead-time reduction

Demand and production smoothing

(Mixed-Model Sequencing)

Pull replenish- ment (Just-In-

Time, Point-Of-Use, Kanban)

Quantity adapts to demand

Inventory reduction

QFDQuality

Function Deployment

SIPOC Map, takt time,

service and information flows

VSM Process operating

VSM and process owners Flows People and desire Equipment and

maintenance data

Layouts, Family Group

Technology

Training and experience Fail-safe methods Reduction

techniques All tools Suppliers and Customers Takt time, SPC

Takt time, smoothed

demand, Just-In-Time supply,

flow

Takt time, SPC of demand

profileAvenue of tools

DOE Design of Experiments

Current State VSM and wastes

found

Focused RPI areas

Current State of work

Validated wastes,

current state diagram of

flows and waste areas

Future State Map, action plans (WWW),

Kaizen Blitz plans

Organized workplace

Process equipment operating effectively Flow improved Flexible workers Mistake-proofed

process Quick set-ups 1-piece or small lot flow

Lead-time reduced

Smoothed demand

JIT replenishment

Capable service level Reduced waste

R0 - Define Phase Tollgate

with signed charter and current state

map

R1 - Measure Phase Tollgate

for Baseline Capability

R2 - Analyze Phase Tollgate for Validated Contributing

Factors

R3 - Improve Phase Tollgate for solution and

pilot validation

R4 - Control Phase Tollgate with process

control plan and trained

associates.

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How Will We Get There?

Cedars-Sinai Health System

Cleveland Clinic

Exempla Healthcare

Fairview Health Services

Froedtert Hospital

Intermountain Healthcare

The Johns Hopkins Hospital

and Health System

Kaiser Permanente

Mayo Clinic

The Miriam Hospital

Memorial Hermann Healthcare

System

Newport Hospital

New York-Presbyterian Hospital

North Shore-Long Island

Jewish Health System

Northwestern Memorial Hospital

OSF Saint Francis Medical Center

Partners HealthCare System

Rhode Island Hospital

Stanford Hospital & Clinics

Trinity Health

Virtua

Wake Forest University

Baptist Medical Center

The Roadmap

to Developing

Solutions

• Measureable Success

• Targeted Solutions

• Industry Engagement

• Sustainability

Change Management • Lean Six Sigma • High Reliability

In the United States, one in 136 hospital patients become seriously illas a result of acquiring an infection in the hospital. This is equivalent totwo million cases a year.

And the costs…..“the overall annual direct medical costs of HAI to U.S.hospitals ranges from $28.4 to $45 billion.. the benefits of preventionrange from a low of $5.7 to $6.8 billion to a high of $25.0 to $31.5 billion.”R. Douglas Scott II, Economist, Division of Healthcare QualityPromotion, CDC, March 2009

“ ”“Every day, 247 people die in the USA as aresult of a health care-associated infection."This is equivalent to a 767 aircraft crashingevery day or more than 90,000 deaths annually.”

World Health Organization

((

Why Hand Hygiene?

WHO Guidelines on Hand Hygiene in Health Care

Health Care Associated Infections (HAI) affect hundredsof millions of people worldwide and are a major globalissue for patient safety.

“Yet hand hygiene improvement is not a new concept…long lasting improvements remain difficult to sustain……”WHO, Guide to Implementation of the WHO MultimodalHand Hygiene Improvement Strategy

Hand Hygiene Project: Participating Hospitals’Characteristics and Project Details

*Implemented throughout hospital

Cedars-Sinai California Yes 950 x xHealth System

Exempla LutheranMedical Center Colorado No 400 x*

Froedtert Hospital Wisconsin Yes 486 x

The Johns Hopkins Maryland Yes 1,041 x xHospital

Memorial Hermann Texas No 252 x xThe Woodlands

Trinity Health - St. Joseph Michigan Yes 537 xMercy Hospital

Virtua - Memorial New Jersey No 270 x x x

Wake Forest North Carolina Yes 872 x xUniversity BaptistMedical Center

Hospital Location Teaching Number Medical Intensive Otherhospital of Beds Surgical Care Unit

Pilot Sites

Hand Hygiene Measures: Expectationsvs. Reality; Solutions Impact

May

March

Janu

ary '1

0

Nove

mbe

r

Septe

mbe

rJu

lyMay

March

Janu

ary

100%

90%

80%

70%

60%

50%

40%

30%

Date

Co

mp

lian

ceP

erc

en

tag

e

January October

Hand Hygiene Compliance (Aggregated)

Hand hygiene complianceimprovement in pilot sites

How The Future Must Look

Baseline Reality;Low Compliance &High Variability

Similar findings from WHO Pilots

50454035302520151051

50

45

40

35

30

25

By Day Time Series

%H

an

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yg

ien

eC

om

plia

nce

Hand Hygiene Performance at Sample Hospital Unit

WhereWe

ThoughtWe Were

SolutionsBeginning

Main Causes of Failure to Clean Hands(across all participating hospitals)

Ineffective placement of dispensers or sinks

Hand hygiene compliance data are not collected orreported accurately or frequently

Lack of accountability and just-in-time coaching

Safety culture does not stress hand hygiene at all levels

Ineffective or insufficient education

Hands full

Wearing gloves interferes with process

Perception that hand hygiene is not needed ifwearing gloves

Health care workers forget

Distractions

Note that not all of the main causes of failure appear in every hospital. The chart above representsthe validation of the root causes across hospitals. This underscores the importance ofunderstanding hospital-specific root causes so that appropriate solutions can be targeted.

A B C D E F G H

Main Causes of Failureto Clean Hands(across all participating hospitals)

Ineffective placementof dispensers or sinks

Hand hygiene compliancedata are not collected orreported accurately orfrequently

Lack of accountability andjust-in-time coaching

Safety culture does notstress hand hygieneat all levels

Ineffective or insufficient education

Hands full

Wearing gloves interfereswith process

Perception that hand hygieneis not needed if wearing gloves

Health care workers forget

Distractions

x x x x x

x x x x x

x x x x x x

x x x x x

x x x x x

x x x x x x

x x x x x

x x x x x x

x x x x

x x x x

Identifying Causes, Targeting Solutions

SolutionsHand Hygiene compliance data arenot collected or reported accuratelyor frequently

Safety culture does not stress handhygiene at all levels

Ineffective placement of dispensersor sinks

Hands full

Causes• Data provide a framework for a systematic approach forimprovement

• Utilize a sound measurement system to determine the realscore in real time

• Scrutinize and question the data• Measure the specific, high-impact causes of hand hygienefailures in your facility and target solutions to those causes

• Make washing hands a habit – as automatic as lookingboth ways when you cross the street or fastening your seatbelt when you get in your car

• Commitment of leadership to achieve hand hygienecompliance of 90+ percent

• Serve as a role model by practicing proper hand hygiene• Hold everyone accountable and responsible – doctors,nurses, food service staff, housekeepers, chaplains,technicians, therapists

• Provide easy access to hand hygiene equipment anddispensers

• Create a place for everything: for example, a health careworker with full hands needs a dedicated space wherehe or she can place items while washing hands

Habit• Always wash in and wash out upon entering/exiting a patient care area and before and afterpatient care

• Make washing hands a habit – as automatic aslooking both ways when you cross the street orfastening your seat belt when you get in your car

Active Feedback• Coach and intervene to remind staff to washhands

• Clearly state expectations about when tosanitize hands to all staff members

• Communicate frequently – provide visiblereminders and ongoing coaching to reinforceeffective hand hygiene expectations

• Engage staff – real time performance feedback• Tailor education in proper hand hygiene forspecific disciplines

• Provide just-in-time training• Use technology-based reminders and realtime feedback

• Celebrate improved hand hygiene

No One Excused• Protect the patient and theenvironment – everyone must wash in andwash out

• Make it comfortable to wash hands with soapor use waterless hand sanitizer

• Identify proper hand hygiene as anorganizational priority andperformance expectation

• Hold everyone accountable and responsible– doctors, nurses, food service staff, house-keepers, chaplains, technicians, therapists

• Apply progressive discipline from the top –managers must hold everyoneaccountable for proper hand washing

• Commitment of leadership to achievehand hygiene compliance of 90+ percent

• Serve as a role model by practicing properhand hygiene

Data Driven• Data provide a framework for a systematicapproach for improvement

• Utilize a sound measurement system todetermine the real score in real time

• Use trained, certified independent observersto monitor appropriateness of hand hygiene

• Scrutinize and question the data• Measure the specific, high-impact causesof hand hygiene failures in your facilityand target solutions to those causes

Systems• Focus on the system, not just on people• Make it easy; examine work flow ofhealth care workers to ensure ease ofwashing hands:• Provide easy access of hand hygieneequipment and dispensers

• Create a place for everything:for example, a health care workerwith full hands needs a dedicatedspace where he or she can placeitems while washing hands

• Limit entries and exits from apatient’s room – make suppliesavailable in room and eliminatefalse alarms that require staff toleave room to turn alarm off

• Identify new technologies to make it easyfor staff to remember to wash hands,i.e. radio frequency identification, automaticreminders, warning systems, real timescoring

EffectiveHygiene is inOur HANDS