Who’s doing truly great work when it comes to safety, efficiency, culture, and cost in health care? NEJM Catalyst’s Tom Lee sat down with Dr. Mark Chassin, President and Chief Executive Officer of The Joint Commission and asked, “Who’s making me jealous?”
Chassin discusses a few organizations, big and small, that are changing the game and cites some of the common denominators when it comes to their success. “It’s this characteristic of leaders being personally involved in these initiatives, not delegating it to somebody else, [that] is one of the hallmarks of organizations that are making the most progress,” Chassin says.
These institutions are worthy of praise because they’re doing things that the rest of us can do, adds Lee. Read or listen to the interview below.
Tom Lee: This is Tom Lee for NEJM Catalyst. I’m speaking today with Dr. Mark Chassin, President and CEO of the Joint Commission, to learn about some terrific practices going on around the country.
Mark, no one gets around the country and looks under the hood more thoroughly and at more hospitals than you and your colleagues at the Joint Commission. What I’d like to hear about are things that will make me feel jealous. You know, organizations that are making leaps, culturally or otherwise, in quality, in safety, efficiency. I know we all have things to learn from some institutions that are not famous, as well as the ones we hear about all the time. Can you pick out a place that’s doing some great stuff and tell us about it?
Dr. Mark Chassin: I sure can. Thanks, Tom, it’s great to be with you, and you’re right. We see quite a spectrum of health care organizations. We accredit or certify 21 thousand in the United States alone, but we’ve learned I think the most about hospitals and systems with truly outstanding efforts in quality from our high-reliability programs, where we’re working with hospitals and systems that are literally aiming to achieve zero harm for patients and for health care workers, and they’re using a very systematic and structured set of priorities, and some of them are really starting to achieve remarkable results.
I would first pick out Memorial Hermann Health System. It’s a 12 hospital system that’s headquartered in Houston, Texas, and we tend to look at progress in these organizations in three major domains. The first is how committed are their leadership — and that means the board, management, physicians, nurse leaders — and at Memorial Hermann they’ve been committed to this zero harm goal for almost 10 years. Their board is highly engaged. Quality is the first topic at every board meeting. They report all of their serious harm events system wide to their board.
So the first domain is leadership commitment, and the second is what you mentioned about changing the culture of health care organizations so that safety is everybody’s job. And everybody feels obligated, from the newest hire in every part of the organization to the more senior folks. Everybody’s obligated to find unsafe conditions, report them, [and] speak up if they see anything that’s unsafe, whether it’s behavior patterns. And Memorial Hermann started down this road by training all 20 thousand of their employees, taking them offsite for a very specific safety culture training and specific behaviors about how to make sure they’re speaking up, how to identify unsafe conditions. So, that’s the second big area.
The third is using much more effective process improvement tools. We refer to these tools. We’ve adopted them at the Joint Commission as Robust Process Improvement (RPI). Lean, Six Sigma, Change Management — three separate but very complementary tools that produce enormous improvements just by applying them systematically to the most resistant problems. Like hand hygiene compliance. You wouldn’t think that was a resistant problem, but anybody that’s close to health care, especially hospitals, knows that it is.
Memorial Hermann, using some tools that we created at the Joint Commission, these process improvement techniques, increased system wide — all 12 hospitals — their hand hygiene compliance from 58 to over 96 percent, sustained now for over three years. And they’ve seen remarkable declines in health care–associated infection.
Hospitals began to report zero HAIs for entire calendar months. Part of their process is to celebrate when one of their hospitals goes 12 months or more with zero on a specific adverse event. In the last five years they’ve awarded 190 certified zero awards of at least 12 months at zero on a particular HAI, and they’ve even had hospitals go 24 months with no serious safety events. So, this commitment to zero is starting to move organizations toward much greater levels of improvement and allowing them to sustain over long periods of time. Truly remarkable work.
Lee: Boy, that sounds like Memorial Hermann’s one of the safest places in the world to be for health care. And just to take all your employees and take them away from work for hours, I can imagine what the CFO must have thought, but it reflects real commitment. So, who else? That makes me feel jealous. Who else can make me feel jealous?
Chassin: Well, let me comment on that last point because it’s critical in this idea that the entire leadership needs to be committed, that every important stakeholder group be onboard. So, the CFO is a crucial ally and their CFO would tell you that this commitment to safety — as the CEO of Memorial Hermann expresses it: “safety is our core value, and it’s our only core value.” By focusing on safety and quality all the other outcomes that they want to achieve, whether it’s financial performance, market share, patient satisfaction, staff turnover reductions, all of those have followed from Memorial Hermann. So, it’s a critical point that the CFO is part of the leadership commitment.
Another organization that is marching down this road, and for more than 10 years, is Cincinnati Children’s. They also have an incredibly high degree of board engagement. They have also pioneered a number of the organization-wide safety measures, like safety huddles, their daily observation briefs. One of the most interesting characteristics of that organization is another characteristic that we see in these organizations making progress, and that’s transparency about their rates of adverse events.
Cincinnati Children’s — you can go on their website and you can see that they publish their rates of adverse drug events. They also publish their rates of employee injury. For them, the emphasis on staff safety is just as important as patient safety. So, you’ll see their surgical site infection rates. You’ll see catheter-associated blood stream infection rates, and probably most remarkably, you can sign up to call in and listen in to their daily operations briefs where the leadership of the organization, together with the staff managers, discuss what issues they have with respect to safety on a daily basis, what they’re paying attention to, their daily safety huddles. That kind of transparency is really an important characteristic of organizations that are making the most progress here.
And I guess I would add one more thing to that observation. It’s the places like Cincinnati Children’s and Memorial Hermann that have literally committed — and Cincinnati Children’s has done this, you can see it on their website — committed to eliminate all serious harm. Those are the organizations that will tell you that they know how far away they are from getting to this state of high reliability where zero harm is a byproduct of the way they do their work every day, like commercial aviation. So, that transparency is another terrific characteristic of these organizations.
Lee: Well, I didn’t realize that about the University of Cincinnati and that’s extraordinary. Are there other places out there doing that?
Chassin: There are a couple. I think that that’s the only one that I know of. This is the Cincinnati Children’s Hospital, not the university. They’re the only ones that I know of where you can actually dial in to their huddle or their daily operations brief by registering in advance. You can see it on their website, but it’s part of their commitment to sharing the knowledge that they’ve accumulated over the last 10 years. And like I said, other organizations publish a lot about their adverse events and their learning, but from an operational standpoint, this is the only one that I know that takes that step.
Lee: Are there other people out there who are going to make me feel jealous?
Chassin: Yes. So, there are other organizations that are a little bit earlier on in the journey. I’ll mention one: Citrus Valley Health Partners. Because it’s a small system — three hospitals and a hospice in Southern California — they adopted high reliability as their goal about three years ago. We have trained trainers for them in Robust Process Improvement.
And what’s remarkable about that organization is in demonstrating that this leadership commitment requires constant attention. The CEO of that organization is the biggest champion and cheerleader. They, through his actions, have engaged the board effectively. The CFO is a complete convert champion for quality and for the adoption of these Robust Process Improvement tools, and the CEO himself is enrolling in Green Belt training in the next wave. So, it’s this characteristic of leaders being personally involved in these initiatives, not delegating it to somebody else, [that] is one of the hallmarks of organizations that are making the most progress.
Lee: I think we have time for maybe one more.
Chassin: Let me give you another one. You know, the adoption of these tools, of RPI tools Lean, Six Sigma, [and] Change Management — Mayo has published a very nice article where they document a five-to-one financial return on their adoption and deployment of these tools, conservatively scored by the CFO. That’s one of the usual suspects, but you don’t have to be Mayo. Wentworth-Douglass is a hospital that we work with, a small hospital, 120 beds, on the Seacoast of New Hampshire, not part of a big system. They have an extraordinarily effective RPI program with a three-to-one return on investment.
One of my favorite stories from that hospital and their program: their CEO, again, is the champion and the leader. They built a new ambulatory building with 100 thousand additional square feet, and he challenged the housekeeping department to use these tools of Lean, Six Sigma, and Change Management to fold this extra 100 thousand square feet of space into their cleaning without any diminution in quality, without any additional staff, or any additional expense, and they met that goal by using these tools and thereby avoided $450 thousand in cost.
So, you don’t have to be a Mayo in order to have one of these programs that will generate a financial return while you’re using them simultaneously like Memorial Hermann did to tackle some of the most resistant quality and safety problems.
Lee: Well, Mark, this is really encouraging. I know you’re a hard-headed, clear-thinking guy and you wouldn’t be praising these institutions if they weren’t doing stuff that was both worthy of praise, but also something that the rest of us can do. I want to thank you today for taking the time to talk with us, and for the very good work that you and the Joint Commission does, and I look forward to getting you involved more in sharing best practices from around the country with NEJM Catalyst. Thanks again.
Chassin: You’re welcome. It’s a pleasure to be with you.