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The new push for reliability
Why are airlines safer than healthcare?
Perhaps one of the most startling sentences in a recent Health Affairs1 article by Joint Commission president Mark Chassin, MD, FACP, MPP, MPH, is one in which he and his co-author, commission executive vice president Jerod Loeb, state that "...we know of no health care organization that has been able to achieve a consistent state of high reliability." The authors go on to state that there are "pockets of excellence on specific measures or in particular services at individual health care facilities." They note that there are even some across-the-board measures of excellence, such as the fact that 98% of the time, heart attack patients get beta-blockers.
But Chassin is quick to point out that when you look at how many times per million beta-blockers are not provided, you are looking at thousands of patients not getting that life-extending medication. "The state of high reliability is the absence of major quality failures at a level of measurement that is well beyond what we do now," Chassin says. "It is not that we cannot achieve that as human beings they do it on an aircraft carrier flight deck all the time. But it does not exist in healthcare, partly because we have never tried and partly because we have been satisfied with 80% good when measured in the way Six Sigma measures. Commercial aviation is at maybe 5 deaths per million takeoffs and landings. Maybe lower than that." Numbers like that make him scoff at 80% compliance with processes that we know save lives.
For years, physicians and other healthcare stakeholders have responded to efforts to compare what they do to what is done in other industries, with cries that comparisons are not fair because healthcare is different. "I hear that all the time," Chassin says. "But a few years ago, no one ever thought that we could get rid of central-line infections in the ICU or get people to wash their hands. But we did. There are instances where we have achieved this level of reliability."
He again mentions the beta-blockers and heart attack patients. Although he'd love 100% compliance and to a degree really expects it there was a time when the percentage of patients who left with a beta-blocker prescription and aspirin was something around 50%.
In the Health Affairs piece, Chassin and Loeb argue that with a group mindset that understands the importance of every single step taken in healthcare, the industry can achieve high reliability like aviation and jet landings. They say it requires just three things: a commitment to leadership, a culture of safety that encourages reporting of problems, and "robust process improvement."
Demand for safer processes
What does that mean to quality professionals in hospitals? "There are increasing demands on hospitals to produce much safer processes and prevent complications," he says. "This will increase dramatically, even further than now, and there will be penalties for complications. Trying to do improvement the same way will not get us to the level of safety the way we want, will not allow us to avoid penalties, and will not protect patients. We have to do something different."
There are no healthcare organizations that are as safe as nuclear power despite the recent accident in Japan or air travel, he says. "I've said we cannot just transfer blindly from other industries, but we can learn a lot from them." And while the commission will not tell organizations exactly what to do, Chassin is happy to mention that there are tools he likes to use for robust process improvement, including GE's change acceleration process, which when combined with Lean Six Sigma has helped the commission to successfully engineer change internally.
Using a formal process to manage change like the GE model helps to ensure that the best plan for fixing a process is created. "If everyone hates it and nobody uses it, it doesn't matter if you've done it because no benefit accrues. It is not just the technical quality of the solution that matters. You also have to manage the process and get everyone to accept it and use it and be enthusiastic about maintaining improvement," he says.
Chassin says that right now, what you do next depends on where you are. The Health Affairs piece includes a table that outlines the relative maturity of organizations according to characteristics of leadership commitment, adoption of tools, and establishment of a safety culture. For instance, a minimally mature organization's leadership will focus quality improvement (QI) efforts on regulatory requirements, will not recognize the strategic importance of QI efforts, and may not have physicians who are really engaged in QI. A more mature organization will aim for and sometimes achieve zero-error rates, will show strong physician leadership, and will reward successes. Someone in the middle might not yet have a robust process improvement plan, but will be looking to adopt appropriate tools, will have begun to train staff, and will use the tools they adopt for both clinical and administrative improvements.
To start, Chassin says you should do "an honest, if not brutally honest" assessment of where you are on that chart. Are you an organization whose leadership only cares about quality as it relates to surveys or CMS payments? If you have no introspection about what you have to do to get better, no commitment to reaching zero failure rates, and the quality department has no idea it is sitting on what Chassin refers to as "a burning platform," then chances are you are in that first, least mature place. Then you need to bring it to the attention of your leadership.
This will all take time and money. But Chassin says it will pay off financially, as well as in better safety and improved outcomes. "When we got eight organizations, including Johns Hopkins and Memorial Hermann, to look at hand hygiene, it was at 48% performance levels. A little over a year later, it was at 81% after using robust process improvement methods." When he was at Mt. Sinai hospital in 1999, Chassin wanted to show the chief financial officer that using some of these tools could bring hard dollars to the bottom line and still improve safety and quality. "We did that by paying for expertise to be brought to the facility, then taking over the training of staff for them," he says. "We focused on a broad range of improvements, including billing, and ended up bringing in enough savings to pay for the program for over four years."
For more information on this story contact: Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president, Joint Commission, Oak Brook Terrace, IL. Email: email@example.com