The Joint Commission Center for
Transforming Healthcare
© Copyright, The Joint Commission
Safe Lifting Conference
November 15, 2012
Understand the components of High
Reliability.
Identify the influence of nursing and
organizational culture on patienthandling practices.
Use safety culture and change
management concepts to sustain
success in safe-handling programs.
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Objectives
No Offense but….
Why is the Joint
Commission here to talk
about Safe Lifting???????
a high reliability industry and to ensure
patients receive the safest, highest quality
care they expect and deserve
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Our Mission: Transform health care into
Helping organizations improve
healthcare and achieve high
reliability
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Donise Musheno, RN, MS, CPHQ
Center Project Lead, Black Belt
Introduction to CTH-Vision
One Vision
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All people always
experience the safest,
highest quality, best-value
health care across all
settings.
Current State of Quality
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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 infections
– Medication errors that cause harm
– Failed communication in
transitions of care
 More than 400,000 harmful,
preventable, bad outcomes occur in
hospitals every year.
Chassin, M.R. & Loeb,
J.M. (2011) The ongoing
quality improvement
journey: next stop, high
reliability. Health Affairs,
30 (4) 559-568.
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High Reliability Organizations
Three Crucial Elements of High
Reliability
• Responsibility to make high reliability a priority
Leadership
RPI™
• Must be created in organization
• Robust Process Improvement™
• Lean, Six Sigma and change management tools
to systematically improve processes
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Safety
Culture
Robust Process Improvement™(RPI) – A
New Way in Delivering Results
New Generation of Best Practices:
“One-size-fits-all” works well only in
Complex processes require RPI to
very limited circumstances:
produce solutions – customized to an
•Process varies little from place to place
•Causes of failure are few and common organization’s most important causes
Usual Approaches:
Many
causes of
the same
problem
Protocol
s
Toolkits or
“Bundles”
Each cause
requires a
different
strategy
RPI
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Checklist
s
Key causes
different
from place
to place
Some Important Causes of
Hand Hygiene Failures
 Each requires a very different
strategy to eliminate
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1. Faulty data on performance
2. Inconvenient location of sinks or hand gel
dispensers
3. Hands full
4. Ineffective education of caregivers
5. Lack of accountability
Causes Differ by Hospital
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Each letter = one hospital
Atlantic Health
Barnes-Jewish
Baylor
Cedars-Sinai
Cleveland Clinic
Exempla
Fairview
Floyd Medical Center
Froedtert
Intermountain
Johns Hopkins
Kaiser-Permanente
Mayo Clinic
Memorial Hermann
Nebraska Medical Center
NY-Presbyterian
North Shore-LIJ
Northwestern
OSF
Partners HealthCare
Sharp Healthcare
Stanford Hospital
Texas Health Resources
Trinity Health
Virtua
Wake Forest Baptist
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Wentworth-Douglass
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Develop Solutions with Leading Hospitals
Center Operating Model
Determine Topic
Create Solutions, Pilot Test, Build
Spread
Solve with Participating
Organizations
Pilot Test 1
Pilot Test 2:
Integrate Solutions
into TST
(Beta-Testing)
Launch TST
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Project
Selection
SPREAD
MECHANISM
• Educational, no jargon, no special
training and no knowledge of RPI
methodology needed
• Guides users to customized solutions.
Data analysis conducted by the tool, not
the user. Tool walks user through
process of:
 Measuring current state
 Determining root causes
 Selecting targeted solutions
 Control of process after
implementation
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Confidential ● Easy to Use ● No Extra Cost
Separate from Accreditation
 Project 1 – Hand Hygiene Compliance
 Project 2 – Wrong Site Surgery
 Project 3 – Hand Off Communication
 Project 4 – Surgical Site Infections
– With American College of Surgeons
 Project 5 – Preventing Avoidable Heart Failure
Hospitalizations
– With American College of Physicians
 Project 6 – Safety Culture
 Project 7 – Preventing Falls with Injury
 Project 8 – Reducing Sepsis Mortality
 Project 9 – Medication Safety
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Introduction to CTH-Projects
Leadership commitment to zero
MH Woodlands Hospital was among the 8
Center hospitals that carried out the hand
hygiene project and got impressive results
2010: MH committed to use TST to improve
hand hygiene system-wide (12 hospitals)
Baseline (150 inpatient units) = 44%
– Range (12 hospitals ): from 21% to 65%
– Aim: to exceed 90%
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Memorial Hermann’s Story:
Getting to Zero
NICU Central Line Associated
Blood Stream Infections (CLABSI)
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Memorial Hermann Healthcare System
NICU Central Line Associated Blood Stream Infections
UCL = 19.19
18
14
12
Mean = 11.96
10
UCL = 8.62
8
Mean = 1.85
6
LCL = 4.74
UCL = 4.44
4
Mean = 3.45
2
Mean = 1.62
Q
tr
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1
0
2006
2007
Generated: 7/14/2012 9:43:21 AM
Source file date: 7/14/2012
2008
2009
2010
Mean =
1.07
2012
2011
Reporting Months
produced by S ystem Quality and P atient S afety
© Copyright, The Joint Commission
CLABSI Rate per 1K Line Days
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Ventilator Associated
Pneumonias (VAP)
System Adult VAP
Do No Harm
Ventilator Associated Pneumonia
UCL = 4.30
4.00
UCL = 3.12
UCL = 2.47
Mean = 0.95
Mean = 2.19
2.00
Mean = 1.37
Mean = 0.72
2008
3
Q
tr
Q 4
tr
1
tr
2
1
tr
tr
4
Q
Q
Mean
= 0.5
2011
2012
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2010
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3
2009
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2007
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Generated: 4/2/2012 8:08:13 AM
Source file date: 3/23/2012
Q
tr
2
Q
tr
1
Q
tr
Q
2006
3
LCL = 0.07
0.00
Reporting Months
produce d by Sys te m Qua lity a nd Pa tie nt Sa fe ty
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VAPs Rate per 1K Vent Days
6.00
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Woodlands: Zero Hospital Central
Line Blood Stream Infections
Hand-off communication failed to include
adequate information 41% of the time
Interventions reduced this rate to 17%
One hospital focused on the transition
from its inpatient units to a nursing home
Baseline Improve
Inadequate hand-offs
29%
<1%
30-day readmissions
21%
10%
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Improving Transitions
Safety Culture and Safe Lifting
© Copyright, The Joint Commission
Coleen Smith, RN, MBA, CPHQ
Center Project Lead, Black Belt
Leadership
High
Reliability
Trust
Improve
Report
Health
Care
Safety Culture
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RPI
Why is culture important?
“Culture is what people do when no one
is looking.”
Herb Kelleher, Chairman
Southwest Airlines
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Lack of an optimal safety culture allows
unsafe behaviors/conditions to be
present, but not always identified or
acted upon, before they cause harm [to
patients].
What is the impact?
The price of avoidable harm1:
– $17.1 billion in 2008
– On average, the cost per medical error was
$11,366.
– Direct and indirect costs associated with
only back injuries:
 Estimated to be $20 billion annually2
1Van
Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1
Billion Problem: The Annual Cost of Measurable Medical Errors. Health Affairs 30 (4):
596-603, April 2011
2United
States Dept. Of Labor Statistics
http://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html
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 The price of unsafe patient handling:
What is the impact?
– 27,020 cases--which equates to an
incidence rate (IR) of 249 per 10,000
workers
– More than seven times the average for all
industries.
3United
States Dept. Of Labor Statistics
http://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html
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In 2010, nursing aides, orderlies, and
attendants had the highest rates of
MSDs3:
The myth:
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For decades, we were persuaded that
we could avoid back injuries simply by
using “ergonomic” manual lifting
techniques and performing abdominal
strengthening exercises.
We now know better, but….
The Safety Culture Project
Take Action
or resolve
report
Report unsafe
condition
or behaviors
ID unsafe
Conditions or
Behaviors
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Triage
report
Feedback or
Communication
to involved
parties
Project Goals
Increase recognition
– And reporting, triage, action and
communication
Increase the quality and effectiveness
of the communication
Increase the effectiveness of the
actions
– Is this going to prevent a recurrence?
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– What happened to our report?
1
Anonymous. The nurse’s load (editorial). Lancet 1965; II:422-3.
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“The adult human form is an
awkward burden to lift or carry.
[I]t has no handles, it is not
rigid, and is susceptible to severe
damage if mishandled or
dropped.”1
How does culture relate to safe
lifting?
– Barriers to use
– Policy adherence
– Learn from close calls
Change in focus to prevention
– Errors will never be completely eliminated
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Acceptance and buy-in of the
technological and procedural
Recognition of errors, close calls and
disregard of procedures
“High reliability organizations” manage
very serious hazards extremely well
– Commercial aviation, nuclear power
What do they all have in common?
– Highly effective process improvement
– Fully functional safety culture
Discover and fix unsafe conditions early
“Collective mindfulness”
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How Have Others Done It?
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Swiss Cheese theory of causation
Success in Safe Handling
Follow solid, well-understood policies
BUT—education and training are not
enough
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Partial or optional buy-in will not lead to
success
Leaders establish a safety-oriented culture
that supports caregivers to perform safe
handling.
– Peer safety leaders/Lift champions
 Ability to report injuries/errors/near misses
without fear of being blamed.
– Learning Culture
– Leadership then follows up and
communicates
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Success in Safe Handling
And don’t forget…
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Change management techniques are
crucial.
Change Management
Dawn Allbee
Director of Corporate Robust Process Improvement
Master Change Agent
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Application for Safety: Yours and Others
“Change is good.
You go first.”
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— Dilbert
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Robust Process Improvement
(RPI)
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Six Sigma
Lean
Change Management
To Get Effective Results
– How will people accept the change?
–What if they don’t?
– How will people be accountable for the
change?
–What if they aren’t?
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Consider the solution and the human
side of change:
Change Management Challenges
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Lack of team engagement
Lack of key stakeholder support
Resistance
Lack of buy-in
How do we sustain the gains?
Why do we need to change?
 Why is the change important?
 Demonstrate the need to change
– What does the data show?
– Who or what is driving the initiative?
– What are the threats if we do nothing?
 Create a sense of alignment
– Do we all see the same problem?
– Do we all share the same goals?
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– What are the opportunities with success?
Demonstrate the Need
Six Sigma Performance
99.99966% Good (6 Sigma)
 Unsafe drinking water for almost
15 minutes each day
 Unsafe drinking water for one
minute every seven months
 52 incorrect site surgeries for
every 5,000 surgeries
 1.7 incorrect site surgeries every
500,000 surgeries
 Two short or long landings at a
major airport each day
 One short or long landing every
five years at a major airport
 10,000 wrong drug prescriptions
per 1 million filled each year
 3.4 wrong prescriptions per
1 million filled each year
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99% Good (3.8 Sigma)
What will the future state look
like?
 If you had a crystal ball and could go into the future,
what would you see?
– What behaviors would we see more of?
– What behaviors would we see less of?
 Create a vision for the direction you want to move
 Develop key words and phrases for the team to use
when describing the vision
– To motivate and energize
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– A picture paints 1,000 words
Engaging Key Stakeholders
 Identify key stakeholders and gauge their support
 Utilize early adopters to build additional support
 Identify resistance early and have a plan of action to
address
– Where is resistance coming from?
– Understand stakeholder concerns and identify wins
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– Why is there resistance?
Identifying Resistance
Know who your key
stakeholders are
and what’s important
to them!
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What Resistance Do You Hear/See?
Sustain the Gains
If You Don’t Actively Make the Change Last, It Won’t
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What will happen here if someone lets
go?
Keys to Sustaining the Gains
Energize your key stakeholders
Know where resistance may be hiding
Align management practices with the
change
Ensure continued leadership support
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Actively make change last
Can we operationalize the
change?
It looks good on paper, but do we have
the structure in place to support the
change?
– Right people and skill sets
– Right message and medium to communicate
– Right technologies
– Right organization structure
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– Right incentives
Leadership Commitment and
Support
 Ever hear the phrase “Follow the Leader”?
– Leadership commitment and support is crucial to any
change initiative
– Leadership support is maintained throughout the
project
 People focus their time, passion, and energy on things
that are important to them
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 Leadership’s involvement in change initiatives
– Shows importance of change
– Helps others move through change initiatives
– Helps reduce resistance
Celebrate Success!
The First Step in Sustaining the Gains
Remember where you started
Relive the journey
Capture the lessons learned along the
way
Celebrate success!
Don’t be afraid to ask, “So now what…?”
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Compare the “before” and “after”
To Get Effective Results
– How will people accept the change?
–What if they don’t?
– How will people be accountable for the
change?
–What if they aren’t?
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Consider the solution and the human
side of change:
Introducing a new concept focused on
Personal Accountability
Discussing the concept and how it
applies in your daily work
Focusing on what you can do (selfmanagement)
Ownership, Solving Problems and
Taking Action !!
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This is about...
This is NOT ...
About banishing the words “Why?”
“When?” and “Who?” from our
vocabulary (its about knowing when to
use them).
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An interpersonal skill intervention!!
Overview of QBQ concepts
Personal Accountability is about each
of us holding ourselves accountable for
our own thinking and behaviors and the
results they produce.
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QBQ Definition:
QBQ Concepts
Lack of personal accountability results in:
– an epidemic of blame
– complaining
– procrastination
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No organization or individual can achieve
goals, compete in the marketplace, fulfill a
vision, or develop people and teams
without personal accountability.
QBQ – Question Behind the
Question
Source: QBQ – The Question Behind the Question by John G. Miller
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Ask “what” or “how” not “why” or “when”
Use the word “I”
Include some action
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Not QBQ...
QBQ Examples...
 When is somebody going to train me?
 What can I do to develop myself?
 Why do we have to go through all of this change?
 How can I adapt to the changing environment and
world so that I am successful?
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 When is that department going to do its job right?
 What can I do to better support my team and
organization?
Call to Action
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Learning is really about translating
knowing what to do into doing what we
know....its about changing so....
Call to Action
What is the single most important idea
for me in this session?
What rewards will come from my
efforts?
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What will I start doing, stop doing or do
differently to bring this idea to life?
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