Joint Commission Takes Aim at HAIs


Teaming up with top hospitals and health systems across the country to use new methods to find the causes of and put a stop to dangerous and potentially deadly breakdowns in patient care, the Joint Commission is launching the Center for Transforming Healthcare. The Center’s first initiative is tackling handwashing failures that contribute to healthcare-associated infections (HAIs) that kill nearly 100,000 Americans each year and cost U.S. hospitals $4 billion to $29 billion annually to combat.

Eight leading hospitals and health systems volunteered to address hand washing failures as a critical patient safety problem–one that requires fixes far more complex than just putting up signs urging caregivers to wash their hands. Participants in the Center’s first project to make care safer by being more reliable are:

•Cedars-Sinai Health System, Los Angeles, Calif.

•Exempla Lutheran Medical Center, Wheat Ridge, Colo.

•Froedtert Hospital, Milwaukee, Wis.

•The Johns Hopkins Hospital and Health System, Baltimore, Md.

•Memorial Hermann Health Care System, Houston, Texas

•Trinity Health, Novi, Mich.

•Virtua, Marlton, N.J.

•Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina

“Demanding that healthcare workers try harder is not the answer,” says Mark R. Chassin, MD, MPP, MPH, president of the Joint Commission.”These healthcare organizations have the courage to step forward to tackle the problem of handwashing by digging deep to find out where the breakdowns take place so we can create targeted solutions that will work now and keep working in the future. A comprehensive approach is the only solution to preventing bad patient outcomes.”

Recognizing that there is no quick fix, the participating hospitals set out to solve the problems—soap or alcohol-based handrubs that are not convenient for caregivers to use, faulty data that lull facilities into thinking hand washing is occurring more frequently than it is, and lack of individual accountability—by using Robust Process Improvement™ tools. The front-line work of the hospitals shows that random observation is not enough. In fact, the eight hospitals, using the Center’s measurement methods consistently, found on average that caregivers washed their hands less than 50 percent of the time. The targeted solutions from the Center now being tested include holding everyone accountable and responsible – doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists; using a reliable method to measure performance; communicate frequently and use real time performance feedback; and tailor education in proper hand hygiene for specific disciplines.

The Center’s work to identify and measure poor quality and unsafe healthcare will lead to the development and testing of targeted, long-lasting patient safety solutions. These proven and practical strategies, based on methods such as Lean Six Sigma long used by other industries, can help transform American health care into a high-reliability industry that ensures patients receive the safest, highest quality care they expect and deserve.

Handwashing is the Center’s first patient safety challenge. The next project with safety experts and leading hospitals—Fairview Health Services, Intermountain Healthcare, Kaiser Permanente, Mayo Clinic, North Shore-Long Island Jewish Health System, Partners HealthCare System, New York-Presbyterian Hospital and Stanford Hospital & Clinics—will target breakdowns in hand-off communications. A hand-off is a transfer and acceptance of patient care responsibilities achieved through effective communication. Future projects will focus on improving other aspects of infection control, mix-ups in patient identification and medication errors. The Joint Commission will share information about the proven solutions with its more than 16,000 accredited healthcare organizations nationwide to prevent bad outcomes that touch thousands of Americans each year.

For more information about the Joint Commission Center for Transforming Healthcare, visit  


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