The Joint Commission's newly created Center for Transforming Healthcare is teaming up with eight hospitals to identify and reduce deadly breakdowns in patient care. The center's first initiative is tackling hand-washing failures that contribute to healthcare-associated infections, which kill about 100,000 people each year and cost hospitals between $4 billion and $29 billion annually.
The Joint Commission President Mark K. Chassin, MD, credits the eight health systems that volunteered for the study with understanding that simply posting more signs or demanding that healthcare workers try harder isn't enough.
"A comprehensive approach is the only solution to preventing bad patient outcomes. These healthcare 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," he says.
The eight hospitals and health systems in the center's first project to make care safer by being more reliable are:
- Cedars-Sinai Health System, Los Angeles
- Exempla Lutheran Medical Center, Wheat Ridge, CO
- Froedtert Hospital, Milwaukee
- The Johns Hopkins Hospital and Health System, Baltimore
- Memorial Hermann Health Care System, Houston
- Trinity Health, Novi, MI
- Virtua, Marlton, NJ
- Wake Forest University Baptist Medical Center, Winston-Salem, NC
The center will examine front-line problems that could hinder hand washing, such as a lack of individual accountability, or whether or not soap or alcohol-based hand rubs are convenient for caregivers to use. The center has already determined that many hospitals have been lulled by faulty data into thinking that hand washing is occurring more than is actually the case. In fact, using The Joint Commission-developed enhanced measuring standards, the eight hospitals in the study found that their caregivers washed their hands less than 50% of the time.
To improve compliance, new strategies being tested include: Holding everyone accountable—doctors, nurses, food service staff, housekeepers, chaplains, technicians, and 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.
"Hand washing in hospitals should become as automatic as looking both ways before crossing the street," says William D. Petasnick, president/CEO of Froedtert. "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."
The next center project will target breakdowns in hand-off communications. The hospitals involved in that project are: 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. Future projects will focus on improving infection control, mix-ups in patient identification, and medication errors.