High Reliability Healthcare:
What’s Holding Us Back?
Mark R. Chassin, MD, FACP, MPP, MPH
President, The Joint Commission
5th International High Reliability
Organizing Workshop
Oakbrook Terrace, IL
May 21, 2012
Current State of Quality
Routine safety processes fail routinely
• Hand hygiene
• Medication administration
• Patient identification
• Communication in transitions of care
Uncommon, preventable adverse events
• Surgery on wrong patient or body part
• Fires in ORs, retained foreign objects
• Infant abductions, inpatient suicides
“Joan Morris”
“Joan Morris” is a 67 year old woman,
admitted to telemetry unit for angiography
and possible Rx of cerebral aneurysms
Unexplained fall led to MRI, which showed
two cerebral aneurysms
She is a fluent English speaker and a high
school graduate
Her daughter is a physician
Hospital Stay
Cerebral angiography confirmed 2
aneurysms; one treated successfully
Plan to discharge the next day
After angio, she was “boarded” on oncology
The next day, instead of being discharged,
she was taken to the cardiac EP lab and an
invasive procedure was performed
More than two hours into the procedure, the
team discovered they had the wrong patient
Ann Int Med 2002;136:826
Wrong Patient: The Sequel
www.webmm.ahrq.gov
The “Right” Patient
“Jane Morrison” had been transferred
from an outside hospital (also to the
telemetry unit) for an EP study.
Ms. Morrison’s procedure had been
delayed and was scheduled as the
first case of the morning of Joan
Morris’ discharge.
Events in detail: 6:15-6:30am
EP nurse (RN1) reviews EP schedule,
calls telemetry, asks for “Morrison,” told
(in error) that the patient was moved to
the oncology floor
RN1 calls oncology and is told (in
error) that patient is there
Joan Morris’ nurse (RN2), unaware of
plan for procedure, checks with charge
nurse, agrees to bring her to EP lab
Events in detail: 6:30-6:45am
Ms. Morris objects--says she is
unaware of plan for procedure.
RN2 says she can refuse when she
gets to the EP lab
RN2 brings patient down to EP lab
with her chart
Patient repeats reluctance to undergo
procedure, says she is nauseated
Events in detail: 6:45-7:00am
RN1 pages EP attending MD; patient
tells attending on phone that she does
not want procedure and is nauseated
EP attending had met the “right
patient” the night before but does not
recognize difference in voices
Attending tells RN1 patients agrees to
proceed and to give drug for nausea
Events in detail: 7:00-7:15am
RN1 reviews chart, notices no consent
form, pages EP fellow (the physician
who will perform the procedure)
EP fellow reviews chart, is surprised
at lack of pertinent information
He discusses procedure with patient
She signs the consent form
To What Did Ms. Morris
Consent?
Cardiac electrophysiology study
AND possible surgery for...
Cardiac defibrillator implant
Pacemaker implant
“Informed” Consent
Properly conducted, it should protect
patients from errors like this
In practice, the process often fails to
achieve its theoretical benefits
In 2 different studies, 60+% of patients
agreed that: “Consent forms are
designed to protect physicians’ rights”
Events in detail: 7:15-7:30am
Neurosurgery resident had gone to
see Ms. Morris prior to discharge,
found her room empty
He goes down to EP lab, demands to
know why “his patient” is there
RN1 says patient had been bumped
from schedule previously
He leaves, assuming his attending
ordered the study without telling him
Events in detail: 7:30-8:00am
RN3 administers IV sedation
EP attending MD and RN4 arrive
Fellow begins procedure, inserts large
tube into femoral artery, threads EP
catheter up the aorta into the heart
EP attending MD, who had met Ms.
Morrison the previous evening, takes
his position at computer outside room
Events in detail: 8:30-8:45am
Jane Morrison’s nurse (RN5) calls EP
lab, asks why no one has called for her
RN3 consults with nurse scrubbed in
on the case (RN4), advises RN5 to
send Ms. Morrison down at 10am
EP charge nurse notices stickers she
made for Joan Morris do not match
any of the names on the EP schedule
Events in detail: 8:30-8:45
EP charge nurse comes into lab,
questions fellow about the names
Fellow says: “This is our patient!”
Charge nurse leaves
She assumes Ms. Morris (the
wrong patient) was a late addition
to the printed schedule
Events in detail: 9:00-9:15am
Radiology attending MD comes to see
Joan Morris, finds her room empty, and
is told she was sent to EP lab
Calls EP lab to ask why she is there
EP attending speaks to Radiology
attending, who asks about Joan Morris.
EP attending tells nurse that the call
concerns patient named Morris, while
Jane Morrison is on the table
Events in detail: 9:15-9:30am
The EP charge nurse says that
Joan Morris is on the table
EP attending asks to see the chart
and recognizes the error
The study is halted. Ms. Morris
returns to her room.
Both physicians explain error to the
patient and her physician daughter
Summary
Many people made many errors
Most (but not all) errors were small
No single error caused the event
Many chances to avoid this event
• How many failed to speak up?
• How many failed to recognize the
unsafe conditions and practices?
These conditions are very common
Defenses That Failed
Communication (at multiple levels)
Protocols for patient identification
Teamwork within services
Coordination between services
Supervision of trainees
Informed consent process
Safety culture that assures staff recognize
unsafe conditions and speak up
The Swiss Cheese Model
Defenses with Weaknesses
The Swiss Cheese Model
Errors
Defenses with Weaknesses
Harm
High Reliability Science
Research has defined how HROs
produce sustained excellence over time
No health care organizations function
at this high level of sustained safety
No guidance on how to transform
organizations from low to high reliability
How do we create blueprints for health
care to build high reliability?
Leadership
High
Reliability
Trust
RPI
Improve
Report
Health
Care
Safety Culture
From Health Affairs
Health Affairs 2011;30:559-68
High Reliability Self-Assessment
Leadership
• Board, CEO, physicians
• Quality strategy, quality measures, IT
Safety culture
• Trust and accountability
• Identifying unsafe conditions or practices
• Strengthening systems, measurement
Robust process improvement
• Methods, training, spread
Stages of Maturity
High Reliability Self Assessment Tool (HRST)
• Series of questions, branching logic
• All 14 components are assessed
Four stages of maturity for each component
• Beginning
• Developing
• Advancing
• Approaching
Robust Process Improvement
Systematic approach to problem solving:
(RPI = lean, six sigma, change management)
The Joint Commission is adopting RPI
• Improve processes and transform culture
• Focus on our customers, increase value
The Joint Commission is adopting all
components of safety culture
We measure RPI and safety culture and
report on strategic metrics to Board
Center for Transforming Healthcare
www.centerfortransforminghealthcare.org
Center for Transforming Healthcare
Customers asking us for solutions
Delivering products at no added cost
• TJC: $20M; 9 other major donors
• AHA, BCBSA, BD, Cardinal Health
Ecolab, GE, GSK, J&J, Medline
2009: hand hygiene, wrong site surgery
and hand-off communications
2010: colorectal surgery SSIs
2011: safety culture, preventable HF
hospitalizations, and falls with injury
Participating Hospitals
Atlantic Health
Barnes-Jewish
Baylor
Cedars-Sinai
Cleveland Clinic
Exempla
Fairview
Froedtert
Intermountain
Johns Hopkins
Kaiser-Permanente
Mayo Clinic
Memorial Hermann
NY-Presbyterian
North Shore-LIJ
Northwestern
OSF
Partners HealthCare
Stanford Hospital
Trinity Health
Virtua
Wake Forest Baptist
Wentworth-Douglass
Current State of Quality
Routine safety processes fail routinely
• Hand hygiene
• Medication administration
• Patient identification
• Communication in transitions of care
Uncommon, preventable adverse events
• Surgery on wrong patient or body part
• Fires in ORs, retained foreign objects
• Infant abductions, inpatient suicides
Current State of Improvement
Usual approaches: best practices, toolkits,
protocols, checklists, “bundles”
• Describe a specific set of process steps
that must be followed to solve a problem
• ICU central line protocol, VAP bundle
They produce consistent results only in
limited circumstances
• Process varies little from place to place
• Causes of failure are few and common
A New Approach is Promising
Best practices often fail to achieve
consistently excellent results, because:
• Complex processes require more
sophisticated problem solving methods
• Many causes for the same problem
• Each cause requires a different strategy
• Key causes differ from place to place
Next generation of best practices will use
RPI to produce solutions---customized to
an organization’s most important causes
Wrong Site Surgery
Best estimate = 40 per week in US
Joint Commission Universal Protocol
has not solved the problem
High rates of risks introduced in 3 areas:
• Scheduling: 39% of cases had risks
• Pre-op area: 52% of cases had risks;
25% with multiple risks
• OR: 59% of cases had risks;
32% with multiple risks
Risks of Wrong Site Surgery
Scheduling: incomplete data, verbal
requests, lack of standardization
Pre-op area: missing documents,
inadequate patient ID, time pressures lead
to rushing, non-surgeon marks site, marking
inconsistent, use of non-approved markers
OR: mark covered by drapes, distractions,
time out performed without full participation,
staff are not empowered to speak up,
verification omitted with multiple procedures
The Swiss Cheese Model
Defenses with Weaknesses
Reducing the Risks
Hospitals and ASCs targeted specific
interventions to the risks they uncovered

Relative Risk Reduction
Scheduling:
46%
Pre-op:
63%
multiple risk cases 72%
OR:
51%
multiple risk cases 75%
1.
2.
3.
4.
5.
Some Important Causes of
Hand Hygiene Failures
Faulty data on performance
Inconvenient location of sinks or
hand gel dispensers
Hands full
Ineffective education of caregivers
Lack of accountability
 Each requires a very different
strategy to eliminate
Causes Differ by Hospital
Each letter = one hospital
Results are Consistent
More sophisticated improvement methods
(RPI) required for complex problems
• Measure and discover specific causes
• Identify how causes vary among
different organizations and settings
• Target interventions to specific causes
to maximize effectiveness
• Avoid wasting resources by targeting
This is the Center’s unique capability
Targeted Solutions Tool (TST)
Uses secure, established extranet channels
• No added cost, voluntary, confidential
• Can assess performance across system
Educational, no jargon, no special training
Guides users to customized, proven solutions
Targeting only your causes means you don’t
use resources where they aren’t needed
Hand hygiene and WSS available now; will
add hand-off communication later this year
Results Through April 2012
666 projects are using interventions
• Baseline = 52.4% (n = 75,451)*
• Improve = 75.5% (n = 204,982)*
Results Through April 2012
666 projects are using interventions
• Baseline = 52.4% (n = 75,451)* *p<0.0001
• Improve = 75.5% (n = 204,982)*
Results Through April 2012
666 projects are using interventions
• Baseline = 52.4% (n = 75,451)* *p<0.0001
• Improve = 75.5% (n = 204,982)*

Unit
Baseline Improve
• Adult critical care
52%
71%
• Emergency dept.
46%
74%
• Adult med-surg
46%
75%
• Pediatric critical care
62%
81%
• Long term care
55%
73%
C. Difficile Rate Declines as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
1.3
1.2
90
1.1
80
1
HH
0.9
C diff
0.8
70
60
0.7
0.6
50
0.5
40
0.4
2007
2008
2009
2010
2011
C. difficile Cases (per 1000 patient days)
100
MRSA Rate Decreases as
Hand Hygiene Improves
Hand Hygiene Compliance (%)
2.5
90
2.0
80
HH
1.5
70
MRSA
60
1.0
50
0.5
40
0.0
30
2008
2009
2010
MRSA Cases (per 1000 patient days)
100
The Joint Commission and
High Reliability
Consistent excellence is the vision
Leadership + safety culture + RPI
All Joint Commission programs and activities
are aligning around this aim:
• Accreditation, performance measurement
• JCR education, publication, consulting
• Center-developed improvement solutions
Help customers improve no matter where
they are on the journey to high reliability