High Reliability in Healthcare: Q&A With Dr. Mark Chassin of The Joint Commission
Dr. Mark R. Chassin, MD, FACP, MPP, MPH, is president of The Joint Commission and also president of the Joint Commission Center for Transforming Healthcare. Previously, Dr. Chassin was the Edmond A. Guggenheim Professor of Health Policy and founding chairman of the department of health policy at the Mount Sinai School of Medicine, New York, and executive vice president for excellence in patient care at The Mount Sinai Medical Center. Before coming to Mount Sinai, Dr. Chassin served as commissioner of the New York State Department of Health. He is a board-certified internist and practiced emergency medicine for 12 years. His background also includes service in the federal government and many years of health services and health policy research.
Q: In a recent Health Affairs article, you contend that organizational leadership must make high reliability a significant priority. Why do you think this is such a critical component to achieving high levels of safety and quality?
Dr. Mark Chassin: The first step that a healthcare organization must take if it wishes to achieve high reliability is a commitment from the leadership to this goal. No important organizational aims can be achieved without such a commitment. Further, all components of the leadership must be committed: the governing body, management, physicians, and nurses. Change of this magnitude cannot happen overnight. Everyone needs to recognize that it may take 10-15 years, but that the leadership believes in the process and is there to fully support it.
Q: What steps should leadership take to achieve these desired results?
MC: There are three imperative steps that need to be taken. The first is a strong commitment by leadership to this very high level of safety and quality. The leadership must set the goal and example for everyone in order to achieve high reliability. The second is to embed all of the principles and practice of a culture of safety throughout the organization which emphasizes trust, reporting of unsafe conditions, and highly effective improvement over time. The third step is to utilize powerful Robust Process Improvement tools like Six Sigma, Lean and change management to create near perfect processes, similar to the tools that we see in industries like commercial aviation today, and sustain very high levels of safety over long periods of time.
Q: Your article contends that organizations need to create a culture of trust, and emphasizes the importance of the reporting of unsafe conditions, but there are certainly individuals within organizations who would rather not speak up about problems in their organization because of fear of losing their job or facing scrutiny from peers. What can organizations do to help alleviate these fears?
MC: This is one of the reasons that strong leadership commitment is so important. Senior management must make sure their healthcare organization supports a healthy safety culture where reporting is essential and encouraged. Leaders must communicate — and managers must assure — that staff will not be blamed or ostracized for reporting potentially unsafe conditions. Further, management must act on those reports, fix whatever is unsafe and communicate those improvements back to the staff member who reported it. Changing the culture of any organization is one of the most difficult tasks leadership can undertake. Such change requires persistent attention.
Q: The article highlights the need to use quality improvement methods (Robust Process Improvement) to achieve beneficial results. Why do you suggest this as the direction for organizations to take to bring about improvements?
MC: Robust Process Improvement tools have been proven in industries outside of healthcare for the past 15-20 years. They are much more effective in facilitating substantial improvement in clinical quality and safety than the previous generation of tools that came from industry (e.g., continuous quality improvement or total quality management). The effectiveness of the combination of Lean, Six Sigma and formal approaches to change management lies in their systematic approach of reliably measuring the scale of a problem; identifying which specific root causes are responsible for the quality failures; finding solutions for the most important causes; proving the effectiveness of the solutions; and, lastly, deploying new programs to ensure that improvement is sustained.
Q: For organizations looking to bring about the changes you identify as necessary in the article, what should they do to get started?
MC: Healthcare organizations need to make an honest assessment of where they currently are compared to where they want to be in each of the three crucial dimensions of change required to get to high reliability: leadership commitment, safety culture and robust process improvement. They need to be able to answer the following questions:
- What is the level of current leadership commitment by the governing body, senior clinical and administrative managers? And do they have goals that measure and monitor progress?
- Is there a culture in which people feel safe reporting problems and trust that management will find a solution before patients are harmed?
- Does the organization measure progress toward full adoption of a safety culture?
- Does the organization have methods to identify and reliably measure the magnitude of their safety and quality problems, find their root causes, find solutions to those root causes and then prove the effectiveness of the solutions before they are deployed?
It is only after those questions have been fully answered that an organization can know how to properly move forward.
Q: What is The Joint Commission doing to help organizations bring about the improvements you identify?
MC: The Joint Commission has several major initiatives to help health care organizations make progress wherever they are currently on the path to high reliability, including:
- The adoption of Robust Process Improvement internally, utilizing a blend of Six Sigma, Lean and change management, which will allow us to better understand how to help guide the implementation of these tools within health care organizations.
- The creation of the Center for Transforming Healthcare, which works with healthcare organizations who have already mastered Robust Process Improvement tools, which we utilize together to create highly effective solutions to the most vexing quality and safety problems. The Joint Commission then makes those solutions readily available to healthcare organizations throughout the delivery system. The Center's solutions to improving hand hygiene performance are already available. Later this year, solutions to reducing the risk of wrong site surgery and to improving hand-off communications will become widely available.
- The development of a self-assessment tool which will allow health care organizations to analyze their own adoption of the various practices which help lead to high reliability.
- The Joint Commission standards (Leadership, National Patient Safety Goals, Quality Improvement) which emphasize where efforts should be focused for creating a culture of safety and to continuously improve performance.
- Sentinel Event Alert newsletters that give healthcare organizations information they can use to create an improved safety culture.
Learn more about The Joint Commission.
Read More Articles Featuring The Joint Commission:Joint Commission Adds Section to Website on "High Reliability"
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