Joint Commission targets safety failures

September 18, 2009

The Joint Commission is targeting patient safety failures with a new program that will directly affect pharmacy operations.

The Joint Commission is targeting patient safety failures with a new program that will directly affect pharmacy operations. In the short term, look for increased emphasis on hand hygiene in direct patient care and in every step of medication preparation and administration.

Changes in patient hand-off and transfer between settings, including medication reconciliation, are next. Expect new survey standards that will assess health systems on how effectively they have increased patient safety. New standards will also grade systems on how effectively they have instituted specific safety processes.

“Our aim is to transform healthcare into a high-reliability industry,” Joint Commission president Mark Chassin, MD, MPP, MPH, said at a press conference announcing the Commission’s new Center for Transforming Healthcare. “The Joint Commission has not been involved in preemptory interventions until now. We will look at interventions that work and build them into the accreditation framework.”

The Center for Transforming Healthcare is designed to apply to healthcare the kind of process improvement that has made air travel one of the safest modes of transportation. That means identifying unsafe conditions, quantifying the activities that make care less safe, applying mandatory changes to increase safety, and starting all over again.

The initial target is healthcare-acquired infections (HAIs), Chassin said, noting that HAIs rank in the top 10 causes of death in the United States. “There is a reason airliners don’t fall out of the sky every day or that nuclear reactors don’t routinely leak radiation,” Chassin said. “Those industries and others have created cultures designed to foster safety and instituted mandatory measures that constantly make operations safer. Healthcare has not gone that direction and we are all paying the price.”

One of the chief culprits behind HAIs is handwashing. Repeated studies show that less than half of healthcare workers wash their hands before or after providing direct patient care. That failure comes despite decades of educational programs and countless generations of mothers chiding their children to wash their hands. Eight hospitals and health systems around the country have volunteered to measure, test, and refine targeted interventions that work, Chassin said.

The Center will share the most effective interventions with the 16,000 organizations it accredits. The Joint Commission will add selected interventions to proscriptive survey standards to ensure that health systems actually change the way they operate.

Participating systems include Cedars-Sinai Health System, Los Angeles; Exempla Lutheran Medical Center, Wheat Ridge, Colo.; Froedtert Hospital, Milwaukee, Wis.; The Johns Hopkins Hospital and Health System, Baltimore; Memorial Hermann Health Care System, Houston; Trinity Health, Novi, Mich.; Virtua Health, Marlton, N.J.; and Wake Forest University Baptist Medical Center, Winston-Salem, N.C. “Hand hygiene is low-tech but incredibly effective at reducing infections,” Chassin said. “But only if you do it all the time, every time.

“These eight institutions have committed to dig deep to understand why they have failed to create viable solutions to hand-hygiene failures. That systematic approach to safety coupled with the reach of the Joint Commission is what makes this program different. We need effective, durable improvements, not another slogan that is widely ignored.”

The biggest immediate change for pharmacy will be having handwashing measured, recorded, and reported, said pharmacist Paul Conlon, senior vice president for clinical quality and patient safety at Trinity Health. Hygiene is already a priority in IV admixing and other areas of medication preparation, he said, but pharmacists are no better than other healthcare workers when it come to handwashing in direct patient care.

“Our intention at Trinity is that any person and every person who enters that patient room or immediate patient-care area washes hands upon entering and again upon leaving,” Conlon said. “That applies absolutely to pharmacists whether they are taking a patient history, reviewing medications, rounding, giving discharge education, or doing anything else.

“Those behavioral changes are going to be much more important than the effects we see on formularies, antibiotic selection, or drug inventory resulting from the drop in hospital-acquired infections we will see from improved hand hygiene.”

Changing hygiene practices will affect more than patient-care areas, Conlon said. He predicted that handwashing will become as routine when care providers sit down at a computer or other duty station as it is when they enter and leave a clean room environment for IV admixing or sterile compounding.