Opening Keynote Monday 100 - ASCLS · 2018-07-28 · 7/28/2018 3 13 Chassin MR, Loeb JM....

7/28/2018

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July 30, 2018

Heather HurleyExecutive Director, Laboratory AccreditationThe Joint Commission

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All people always experience the safest, highest quality, best‐

value health care across all settings

One Shared Vision

© 2018 The Joint Commission. All Rights Reserved.

The Joint Commission Enterprise

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Largest accrediting

body in health care& crosses

continuum of care

Performance improvement

experts; quality and

safety resource

Creates solutions for high

reliability health care


Software Education Publications

High Reliability TrainingTools & Resources

Accreditation CertificationEducation

AccreditationCertification

Exclusive Cross-continuum Capabilities


Enterprise Comprehensive OfferingsDesigned to Support a System’s Quality / Safety Journey

High Reliability

Services

Certification

Accreditation

System

Supporting Services Education, software & publications from JCR

High Reliability Services Includes online tools, programs & training from the Center for Transforming Healthcare

Supplemented by a wide range of complimentary tools & services unique to The Joint Commission


AT THE FOREFRONT

Programs500

Surveys/Year13,000+

Organizations21,000+

Countries100+

PursuingHigh Reliability

1,000+LARGEST

Hospital Accreditor

Accreditation & Certification

Source: The Joint Commission

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Accreditation & CertificationAcross the Continuum of Care

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The Joint CommissionOur New Guiding Principle

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Zero Patient Harm is Achievable

https://vimeo.com/211533916

“The idea means to me that we will absolutely cause no harm to any patient at any time. Zero harm means identifying every patient, every specimen, collecting it appropriately from the very beginning, and then maintaining that specimen’s integrity and the quality throughout testing process. It’s what we do every day.”

“Zero harm means all of our results, whoever turns them out, would be accurate, so it would be something where we’re not turning out a falsely increased glucose, for example, where we’d have to make the patient have to come in and have a bunch of other tests done to check on it, when really it was just a bad result. So, they want everyone to be able to turn out very accurate results so that the patient can be treated correctly the first time, and not need follow up care, or something like that. It’s already what we’re striving for.”

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We Set Global Standards In

Quality & Safety

We Help Strengthen & Integrate Care Across The Continuum

We Are Uniquely Positioned To

Accelerate Progress Through

Collaboration

We Advance Patient Quality & Safety Beyond Accreditation

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Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3):459-90

LeadershipSafety

Culture

Robust Process Improvement®

Commitment to zero harm

Empowering staff to speak

up

Systematic, data-driven approach to complex problem

solving

High Reliability Model for

Health Care

14© 2018, Joint Commission Center for Transforming Healthcare

High reliability in healthcare is “maintaining consistently high levels of safety and quality over time and across all health care

services and settings” Chassin & Loeb (2013)

70%

35,000

7 to 10 Billion

Medical decisions based off of laboratory tests

Laboratories in the US performing laboratory testing

Lab tests performed in the US each year

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“We're not librarians where a book gets put in a wrong row, every sample is a life.” – Medical Technologist

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“While not all testing mistakes will injure or kill, the precise nature of the work means labs must follow regulations and treat every potential risk as an ‘avoidable risk’.”

‐Paul Epner, past president of the Clinical Laboratories Management Association.

20© 2018, The Joint Commission

What could go wrong in the laboratory? − Expired products are used and could lead to erroneous result

− Blood that is supposed to be kept cold before a transfusion isn't

− Samples are incorrectly labeled or swapped between patients

The FDA concluded that lab test errors are harming patients, and they listed many serious health consequences:

− Unnecessary medical treatment

− Diagnosis of actual condition is delayed

− Expensive treatments

− Surgery to remove healthy organs (ovaries, for example)

− Appropriate treatment is delayed

− Healthy pregnancy is aborted, or a child is born with birth defects

− Cancer treatment is inappropriate, harmful, or ineffective

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Laboratory results that can harm a patient…

For Mary Smith, the lab results seemed like good news. A routine blood screen from her 10‐week pregnancy appointment came back clear in 2006. Seven months later, her son was born critically ill with a blood disorder that could have been treated during pregnancy. The baby died three weeks later at a Louisiana hospital.

The Smiths never found out why Mary's routine blood test didn't identify the condition that killed their son. Antibodies in her blood had been attacking the baby because their blood types were incompatible. Had the condition been identified by the lab test as it should have been, it could have been treated before the baby was born.


What 99.9% in a Community

Hospital looks like:Blood Bank

− 10,906 units Blood Components Transfused

− 11 Transfusion Reactions

Pharmacy

− 3,416,600 medication doses dispensed

− 3,417 would be Improperly Dispensed

Pathology

− 43,900 Specimens processed

− 44 Wrong Diagnoses

Obstetrics

− 4,300 Babies Delivered

− 4 babies going home with the wrong parents!

Zero Harm IS Achievable

In order for the laboratory to have a positive impact on diagnostic errors, it is necessary to become part of the interdisciplinary patient-centered care team. Laboratory professionals need to view their services as contributing to patient outcomes, not just generating results.

Research on diagnostic errors and the laboratory’s role has found that failure to order appropriate diagnostic tests, including lab tests, makes up 55% of missed and delayed diagnoses in the ambulatory setting and 58% of errors in emergency departments. 5

Plebani M. Diagnostic errors and laboratory medicine – causes and strategies. EJIFCC. 2015 Jan; 26(1): 7–14

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How Safe is Healthcare?

1

1

10 100 1000 10,000 100K 1M 10M

Number of Encounters for Each Fatality

Total Lives Lost per Year

10

100

1,000

10,000

100,000

Dangerous(>1/1,000

HealthCare

(1 of ~600)

Mountaineering

BungeeJumping

Driving in US

CharteredFlights

ChemicalManufacturing

ScheduledCommercialAirlines

EuropeanRailroads

NuclearPower

Theme Parks

Ultra Safe(<1/1M)

Amalberti, et al. Ann Intern Med.2005;142:756‐764 26

Transform health care into a high-reliability

industry

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

High Reliability Industries

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Current State: Quality

Routine safety processes fail routinely:

− Hand hygiene

− Medication administration

− Patient identification

− Communication in transitions of care

Uncommon, preventable adverse events:

− Wrong surgery, retained foreign objects

− Fires in ORs

− Infant abductions, inpatient suicides 28© 2018, Joint Commission Center for Transforming Healthcare

⎻We have made some progress− Project to project work “project fatigue”

− Satisfied with modest improvement

⎻Current approach is not good enough− Improvement difficult to sustain/spread

− Getting to zero harm, staying there is very rare

High Reliability offers a different approach

Current State of Improvement


To transform health care into a high-reliability industry by developing highly effective, durable solutions to health care’s most critical safety and quality problems in collaboration with health care organizations, by disseminating the solutions widely, and by facilitating their adoption

Joint Commission Center

for Transforming Healthcare

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Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3):459-90

LeadershipSafety

Culture

Robust Process Improvement®

Commitment to zero harm

Empowering staff to speak

up

Systematic, data-driven approach to complex problem

solving

High Reliability Model for

Health Care

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Evolution of Healthcare


Swiss Cheese model of Error

Reason J. Human error: models and management. BMJ. 2000;320:768–70..


TRUST

REPORTIMPROVE

Adapted from Reason J and Hobbs A. Managing Maintenance Error: A Practical Guide. Ashgate. 2003. 34

© 2018, Joint Commission Center for Transforming Healthcare

Unsafe conditions or

daily annoyances?


Evolution of Safety Culture

− Today, we mostly react to adverse events

− Unsafe conditions are further upstream from harm than close calls

− Close calls are “free lessons” that can lead to risk reduction—if they are recognized, reported and acted upon

− Ultimately, proactive, routine assessment of safety systems to identify and repair weaknesses gets closer to high reliability


− Aim is not a “blame‐free” culture

− A true safety culture balances learning with accountability

− Must separate blameless errors (for learning) from blameworthy ones (for discipline, equitably applied)

− Assess errors and patterns uniformly

− Eliminate intimidating behaviors

Safety Culture Challenges

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What is RPI®?

− Robust Process Improvement® or RPI ® is a set of tools, methods, and training programs adopted by many organizations, including The Joint Commission, to improve business processes and results. Some health care organizations use RPI ® to improve clinical quality and safety outcomes.

− RPI ® is a blended model incorporating Lean, Six Sigma and formal Change Management methods concurrently, utilizing different parts of the tool kit to address specific improvement problems.

− RPI® is a pathway to high reliability.


The most detrimental error is failure to learn

from an error. ~James Reason

39© 2018, The Joint Commission

Through Joint Commission Laboratory Accreditation

− SAFER™ matrix

− Tracer methodology

− Employed professional surveyors

− Increased awareness and engagement with hospital leadership

− Allows organizations to speak the same language across all patient care settings

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SAFER™ Matrix

− A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys

− Provides one comprehensive visual representation of survey findings

− Helps organizations prioritize and focus corrective actions

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Survey Analysis for Evaluation Risk SAFER™ Matrix

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Unique Tracer Methodology

− “Trace” the care experiences that a patient had while at an organization

− Analyzes the organization’s system of providing treatment or services using actual patients as the framework for assessing standards compliance

− Highlights the critical connection between the lab, hospital and the patient

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Laboratory’s Impact on Patient Care

− “Laboratory medicine influences 60% to 70% of all critical decisions that affect downstream patient care.” Clin Chem, 1996;42:813‐816

− Survey readiness ensures test results are accurate

− Survey readiness is part of your journey of “Leading the Way to Zero”

Survey Readiness

Patient Readiness

Leading the way to Zero

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Survey Ready = Patient Ready

Under Laboratory Director Leadership:

− Prepare every day

− Review the standards

− Engage your staff

− Assess your risks proactively

− Promote a Culture of Safety and a Just Culture

− Promote a questioning attitude

− Use the Tracer Methodology: connect the lab with other departments

− Create a safe journey for patients

Zero Harm: An Achievable Goal


If not us, then who?

If not now, then

when?


The Joint Commission Disclaimer

⎻ This presentation is current as of July 30, 2018. The Joint Commission reserves the right to change the content of the

information, as appropriate.

⎻ This presentation is copyrighted to The Joint Commission

and cannot be reproduced or otherwise distributed without

express written permission by the speaker. Distribution of

the speaker’s presentation other than in PDF format is

expressly prohibited.

Opening Keynote Monday 100 - ASCLS · 2018-07-28 · 7/28/2018 3 13 Chassin MR, Loeb JM....

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