Transformers: Joint Commission's center debuts with infection prevention project

Collaborative approach could lead to new standards

Infection prevention is a top priority of an ambitious new quality improvement effort that could lead to new accreditation standards for the nation's hospitals, says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.

Taking on the longstanding hand hygiene problem as its first project, the Joint Commission recently launched the Center for Transforming Healthcare. Eight hospitals and health systems volunteered to address hand washing failures as a critical patient safety problem — one that requires fixes far more complex than just putting up signs urging caregivers to wash their hands.

"There are a ton of potential topics in infection prevention and control, but we picked hand hygiene after doing a poll of the participating hospitals," Chassin says. "We wanted them to be working on a project that was of paramount importance for them to solve."

The Joint Commission hopes the Center's work to identify and measure poor quality and unsafe health care will lead to the development and testing of targeted, long-lasting patient safety solutions. The idea is to establish proven and practical strategies based on methods such as Lean Six Sigma long used by other industries.

"Our aim is to transform health care into a high-reliability industry with rates of preventable adverse events that are equal to or better than the best high-reliability industries in the world, just as low as commercial jet travel and nuclear power," Chassin says.

The collaborative drive toward best practices and quality innovations could ultimately translate the new center's work into new Joint Commission standards in infection prevention and other areas, he adds.

"The problem that got the most high-priority votes was hand hygiene, but there were a lot of other infection prevention projects in that poll," Chassin says. "[Those] include barrier precautions violations, control of multidrug-resistant organisms, prevention of surgical-site infections, prophylactic antibiotic [administration], urinary catheter and central lines. There are many topics; and as we expand the reach of the center, we will certainly include other infection and prevention control problems."

How serious is the Joint Commission about enacting real change? In addition to taking on arguably the most difficult daily problem in infection prevention as its premiere project, Chassin made it clear the center wants to move beyond the longstanding slogans and stock campaigns — including the Joint Commission's own "Speak Up" program. Empowering patients to remind workers to wash hands sounds good in theory, but speaks volumes to the lack of a true safety culture in health care settings, he says.

"It's quite a comment on how far we have left to go if we are relying on patients and their families to solve the hand hygiene problem," he says. "If you don't have the safety culture — in which employees respond by saying, 'Sure, thanks for reminding me' — then it's not going to help much."

The project began last December, as the hospitals assessed baseline compliance with hand hygiene. An immediate conclusion was that random observations were an unreliable measure of compliance, which may be much lower than typically assessed. In aggregate, the eight hospitals identified that staff wash their hands less than 50% of the time, which is about the rate found in hand hygiene studies historically.

"It seems like, what could be simpler? Just wash your hands," Chassin says. "Everybody expects it to happen and can't understand why it doesn't. But even a seemingly simple problem turns out to be complicated. In some places, soap and alcohol gel dispensers were not placed in convenient locations for caregivers; some caregivers were approaching patients' rooms with their hands full, didn't have any place to put down what they were carrying so that they could wash their hands before entering the room; some places found a lack of individual accountability."

'The center of the strike zone'

After establishing the humbling baseline, the hospital-specific underlying causes of hand hygiene failure were identified and analyzed.

The targeted solutions from the Center now being tested include holding everyone accountable and responsible — doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists; using reliable methods to measure performance; communicating frequently and using real time performance feedback; and tailoring education on proper hand hygiene for specific disciplines. By January 2010, The Joint Commission hopes to have the data to demonstrate whether the solutions can achieve and sustain a 90%-plus compliance rate.

"As the solutions are proven, The Joint Commission will spread the use of these tools and interventions to improve the safety and quality of the care provided at the more than 16,000 health care organizations that we accredit in the United States," Chassin says. "That's what's different about this Center — the systematic approach to solving a problem is coupled with the reach of The Joint Commission."

Indeed, Chassin sees the Center for Transforming Healthcare as The Joint Commission's key foray into national health care reform, which must include a quality component — including preventing health care-associated infections (HAIs) — if it is to become an effective and affordable reality, he notes.

"We have been very vocal about the need for health care reform to amplify efforts like this that will save money and improve quality at the same time," he says. "Without the sort of 'wishing and hoping' aspect of investing in prevention and health care information technology, and chronic disease management [in which] maybe someday down the road some savings will occur. We know that for every HAI that is prevented, we will save money and we save the patient that suffering. This is absolutely part of the appeal of the center's work. It's right in the center of the strike zone for health care reform."

Institutions collaborating in the center's hand hygiene project include Cedars-Sinai Health System, Los Angeles; Exempla Lutheran Medical Center, Wheat Ridge, CO; Froedtert Hospital, Milwaukee; 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. For more information about The Joint Commission Center for Transforming Healthcare, visit