Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm.

INTRODUCTION: Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm. METHODS: Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives. RESULTS: Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations. CONCLUSIONS: Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

Using the Targeted Solutions Tool® to Improve Emergency Department Handoffs in a Community Hospital.

BACKGROUND: There is little evidence for solutions to improve the handoff process between units, particularly from the emergency department (ED) to the inpatient unit. A systematic approach was used to improve the handoff communication process between the ED and the four private physician groups serving Juneau, Alaska, that admit and deliver care to patients of a 73-bed, Level 4 trauma center community hospital. METHODS: Data were collected in using the Joint Commission Center for Transforming Healthcare's Targeted Solutions Tool (®)(TST(®)) to determine the rate of defective handoff communications and the factors that contributed to those defective handoff communications. Targeted solutions were then implemented to specifically address the identified contributing factors. RESULTS: A random sample of 107 handoff opportunities was collected during the baseline phase (November 4, 2011- January 12, 2012) to measure performance and identify the contributing factors that led to defective handoffs. The baseline handoff communications defective rate was 29.9% (32 defective handoffs/107 handoff opportunities). The top four contributing factors, together accounting for 69.8% of all the causes of defective handoffs, were inaccurate/incomplete information, method ineffective, no standardized procedures for an effective handoff, and the person initiating the handoff, known as the "sender," lacks knowledge about the patient. After implementation of targeted solutions to the identified contributing factors, the handoff communications defective rate for the "improve" phase (April 1, 2012-July 29, 2012) was reduced from baseline by 58.2% to 12.5% (13 defective handoffs/104 handoff opportunities), p = 0.002; 2-proportions test. The number of adverse events related to hand-off communications declined as the handoff communications defective rate improved. CONCLUSION: Use of the TST was associated with improvement in the ED handoff communication process.

Beyond the collaborative: spreading effective improvement in hand hygiene compliance.

BACKGROUND: Data assessing the effectiveness of quality improvement (QI) collaboratives are mixed; spreading improvement beyond the original collaborative group has proved difficult. Little is known about whether organizations that did not participate in the collaborative are able to effectively employ interventions developed or implemented by those organizations that did participate. METHODS: The Joint Commission Center for Transforming Healthcare conducted a collaborative QI project with eight hospitals, using Lean, Six Sigma, and change management methods to improve hand hygiene compliance. Participating hospitals achieved a 70.5% relative improvement (47.5% to 81.0%; p < .001). Following this project, working with an additional 19 hospitals, the Center created Web-based tools to enable health care organizations to use the same methods employed by the original eight hospitals without needing any knowledge or experience with Lean, Six Sigma, or change management. This Targeted Solutions Tool® (TST)® allowed organizations to discover the most important, specific causes of hand hygiene noncompliance in their facilities and to target interventions at those causes. RESULTS: In the first three years, 289 health care organizations used the TST to initiate 1,495 projects to improve hand hygiene compliance. Of the 769 projects at 174 organizations for which baseline and improvement data were available, average compliance improved from 57.9% to 83.5% (p < .0001). Similar improvement was observed in many clinical care settings, including ambulatory, long term care, inpatient pediatrics, critical care, and adult medical/surgical units. CONCLUSION: Hospitals and other health care organizations using the TST achieved levels of hand hygiene compliance comparable to those experienced by the participants in the original collaborative.

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.

BACKGROUND: Hospitals and infection prevention specialists have attempted to achieve high levels of compliance with hand hygiene protocols for many decades. Despite these efforts, measured performance is disappointingly low. METHODS: The Joint Commission Center for Transforming Healthcare convened teams of experts in performance improvement and infectious disease from eight hospitals for its hand hygiene quality improvement project, which was conducted from December 2008 through September 2010. Together, they used Lean, Six Sigma, and change management methods to measure the magnitude of hand hygiene noncompliance, assess specific causes of hand hygiene failures, develop and test interventions targeted to specific causes, and sustain improved levels of performance. RESULTS: At baseline, hand hygiene compliance averaged 47.5% across all eight hospitals. Initial data revealed 41 different causes of hand hygiene noncompliance, which were condensed into 24 groups of causes. Key causes varied greatly among the hospitals. Each hospital developed and implemented specific interventions targeted to its most important causes of hand hygiene noncompliance. The improvements were associated with a 70.5% increase in compliance across the eight hospitals from 47.5% to 81.0% ( p < .001), a level of performance that was sustained for 11 months through the end of the project period. CONCLUSION: Lean, Six Sigma, and change management tools were used to identify specific causes of hand hygiene noncompliance at individual hospitals and target specific interventions to remedy the most important causes. This approach allowed each hospital to customize its improvement efforts by focusing on the causes most prevalent at its own facility. Such a targeted approach may be more effective, efficient, and sustainable than "one-size-fits-all" strategies.