Achieving ‘Zero Harm’

A misdiagnosis leaves an Iowa man suffering after an unnecessary procedure. An Illinois woman dies after catching fire in surgery. A Tennessee hospital performs surgery on the wrong infant. A brain surgeon drills a hole in the wrong side of a patient’s head.

These errors, which unfortunately happen too frequently, highlight the need for a strong recommitment to quality in healthcare.

So association healthcare experts gathered at Association Forum’s fourth annual Winter Healthcare Collaborative, themed “The Business of Quality in Healthcare Associations,” to discuss the challenge. Held in January at the American Dental Association in Chicago, the event gave experts the opportunity to share what associations can and are obligated to do to increase patient safety — and the likelihood of desired health outcomes.

“We’re all here today because we’re all trying to solve common problems,” Paul Pomerantz, CAE, CEO of American Society of Anesthesiologists (ASA), said during his opening remarks. “We still haven’t made much movement on the quality journey … We’re here to learn who and what defines quality, what our role is as associations, what programs and services we need to provide — and how we organize and resource them.”

‘The Next Decade of Healthcare Quality’

The current state of quality in healthcare is lacking. Routine safety processes, like medical administration, patient identification and even hand hygiene, consistently fail. In fact, only 40% of the workforce in healthcare settings follow proper hand hygiene protocol, according to The Joint Commission, the nation’s leading accrediting body in healthcare.

Existing methods of quality evaluation don’t detect excellence, or how well an organization is performing above the standard. They only highlight deficiencies, said keynote speaker Mark Chassin, M.D., FACP, M.P.P., M.P.H., president and CEO of The Joint Commission.

“The current approach is not producing the results we want. It’s evaluating performance project by project … It’s very difficult to sustain a high level of performance or spread it to other areas this way.

“Thinking and acting differently about quality is the answer,” Chassin said. He challenged healthcare organizations to lead the way to “zero harm.”

“Zero harm is a commitment to zero as the ultimate goal. It will not be achieved rapidly; it’s the beginning of a journey. It’s more than eliminating patient complications — it means zero harm to caregivers, [finding] missed opportunities to provide effective care and [no] episodes of overuse.”

“[Zero harm] means understanding and tracking errors in order to avoid them propagating. That’s the next decade of healthcare quality,” Chassin added.

Striving for Zero

The Joint Commission offers a framework for its new approach to quality. It is based on 10 years of work with academics and practitioners from high-reliability organizations in nuclear power, military, commercial aviation and amusement parks along with The Joint Commission’s experiences accrediting and certifying more than 23,000 hospitals, ambulatory centers, laboratories, homecare and other organizations.

First, leadership must become committed to the goal of zero harm. “You must put aside the objections that, ‘It’s impossible,’ or ‘The boards or doctors won’t go along,’ ‘It will cost too much,’ ‘We don’t know how,’” Chassin said. “Because if not zero, how much harm is OK? If we don’t commit to this now, then when?”

A culture of safety must be embedded throughout an organization, he added. Root out exposure to intimidating behavior, and ensure safety rules are consistent across the organization for all individuals.

Robust Process Improvement (RPI) is producing the next generation of best practices, customized to key causes. The Joint Commission has fully adopted RPI — a combination of Lean Management, Six Sigma and change management — and all components of a safety culture. Lean empowers employees to identify and act on opportunities to improve processes and increase value by eliminating steps in processes that represent pure waste. Six Sigma improves outcomes of processes by identifying and targeting causes of failure.

“Together, these technical solutions are the most effective way to improve processes,” Chassin said. “It only fails when an organization does not accept or implement it.”

Change management is the rocket science of improvement, Chassin added. “It’s a systemic way to implement and sustain good solutions.”

Increasingly more hospitals and systems are using RPI tools, but they are used differently, not comprehensively, with training limited to a small group of experts. The Joint Commission’s Center for Transforming Healthcare is training hospitals and systems to adopt RPI to drive major improvements.

“A one-size-fits-all best practice is inadequate — you can’t get to zero that way,” Chassin said. “Complex problems need a more sophisticated approach to problem-solving. Each [issue] requires a different intervention. Five to six key causes explain the vast majority of failures. RPI can address your key causes … leading to safety solutions, protocols, process for high reliability healthcare.”

A handful of hospitals and healthcare systems are approaching zero harm, Chassin said. For instance, Memorial Hermann Systems achieved 71% improvement with hand hygiene — achieving 95% compliance — after implementing a solutions tool targeting hand hygiene. They discovered the causes of hand hygiene failures: dispensers were inconveniently located and often empty, providers’ hands were often full, and there was a lack of accountability. Each cause required a different intervention to be implemented, and, as a result, Memorial Hermann mastered control of the hand hygiene issue. The hospital system began to report zero harm as their most common monthly result across a spectrum of safety events — from catheter-associated urinary tract infections to mismatched blood transfusions. In fact, over a 10-year period, Memorial Hermann hospitals have performed 1.37 million blood transfusions with zero infections.

Re-Commitment to Quality

In our professional lives, we need to have a north star, a moral compass that guides us, said American College of Surgeons (ACS) executive director CEO David Hoyt, M.D. ACS offers four guiding principles toward continuous quality improvement: 1) standards, individualized by patient and backed by research; 2) the right infrastructure, e.g., staff levels, specialists, equipment and checklists; 3) rigorous data, from medical charts, post-discharge tracking and data backed by research; and 4) verification, external peer review that creates public assurance.

To drive the transformation of quality for surgical patients, ACS created a quality safety manual, THRIVE: Transforming Healthcare Resources to Increase Value & Efficiency. ACS also developed quality programs in collaboration with other organizations to provide new standards for cancer and trauma, focus on pre-operative care and other best practice recommendations.

“We all need to re-commit to quality; it’s the only way we’re going to achieve it,” Hoyt said. “Success is all ultimately about deciding what our commitment is to quality. For stakeholders, [commitment to quality] will mean cost transparency and predictability with reduced medical and administrative costs, reliable episode-specific quality metrics, efficient processes and decreased complexity, and a healthier population.”

Sherry Keramidas, Ph.D., CEO of the American Occupational Therapy Association (AOTA), provided an overview of the association’s quality initiatives. AOTA began its quality work in 2012; advanced a quality strategy in 2014; appointed a director of quality in 2016; created a set of tools called Occupational Profile — its first clinical resource to facilitate quality improvement; launched its Volume to Value program — offering a central location for payment change and quality improvement; and, in 2019, introduced its Choosing Wisely program, which outlines five areas patients and providers should question regarding quality, effective and valuable care.

“In this journey, we learned to identify practice gaps and create tools and resources for use in clinical practice and diverse practice settings, collaborate across the association for a consistent message to members, … combine education on [regulations], reimbursement, practice and quality, and keep education accessible [by offering] free, 30-minute webinars with a focus on practice areas,” Keramidas said. “Today, we’re looking at how to move forward and create partnerships.”

At ASA, quality and practice management recently became the association’s newest business unit. The unit’s mission is to enhance patient safety through access to quality management. “The unit’s objective was created to deliver value and resource that value,” Pomerantz said.

When asked whether associations should be in the business of quality, Kathleen O’Loughlin, DDS, executive director of the American Dental Association, said it’s imperative.

“If we don’t enter that space, someone else will who doesn’t understand the dual purpose of our organizations — to deliver patient care and grow the art and science of our profession,” O’Loughlin said. “If we aren’t involved, we could lose control of the real purpose of healthcare.”

Ultimately, Chassin said it’s up to everyone in healthcare to make the necessary changes.

“If we’re not happy with the results in quality and safety, we need to think and act different, adopt the goal of zero harm and adopt the process improvement tools,” Chassin said. “This needs to be the highest priority.”

Pomerantz agreed with Chassin’s approach and ambitious goal of zero harm to improve care and reduce mortality.

“Don’t strive to improve, strive for zero,” Pomerantz said. “Anything else doesn’t seem reasonable.”