Surgeons and other medical professionals want to prevent patients from being harmed during their hospital stays and to ensure that they heal without complication after they are discharged; however, accomplishing this goal can be somewhat difficult. Within the surgical continuum of care, patients may experience surgical site infections, adverse drug events, postoperative venous thromboembolism, and other adverse events that can ultimately lead to readmission.
10 core areas of focus
- Surgical site infections
- Preventable readmissions
- Adverse drug events
- Venous thromboembolism
- Catheter-associated urinary tract infections
- Central line-associated blood-stream infections
- Injuries from falls and immobility
- Obstetrical adverse events
- Pressure ulcers
- Ventilator-associated pneumonia
In the near future, up to 50 U.S. hospitals across the nation will have proven resources to help ensure patient safety and to avert post-discharge complications through their participation in the Joint Commission Resources (JCR) Hospital Engagement Network. The Centers for Medicare & Medicaid Services (CMS) selected JCR, the not-for-profit affiliate of The Joint Commission (TJC), to serve as one of its 26 Hospital Engagement Networks. These networks are part of the Partnership for Patients campaign, a nationwide public-private collaboration sponsored by the U.S. Department of Health and Human Services. Specifically, the Partnership for Patients campaign aims to reduce a set of hospital-acquired conditions by 40 percent and to reduce readmissions by 20 percent by the end of 2013. The involvement of each surgeon within his or her subspecialty will be critical to the success of the campaign.
Achieving these goals would mean approximately 1.8 million fewer injuries to patients in the hospital, saving more than 60,000 lives over three years, and would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring rehospitalization. It would also help prevent the current trend of one in every 20 patients acquiring an infection while in the hospital and an average of one in seven Medicare beneficiaries being harmed in the course of his or her hospital care. In addition, nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, translating into approximately 2.6 million seniors and people with disabilities. CMS estimates that this initiative could save Medicare $50 billion over the next 10 years.
As a Hospital Engagement Network organization, JCR will help participating hospitals identify specific risk points in their care and operational processes that create broken systems leading to human error within the surgical continuum and other areas of care. JCR will develop content, conduct learning activities, and make best practices available to partner hospitals in 10 core areas of focus (see boxed item, this page). It is important to note that hospitals do not have to limit their work to the core set of adverse events outlined in the list.
For each hospital, individual JCR patient safety consultants will be assigned to provide coaching on a weekly basis specific to the performance improvement methods used for each selected event. JCR and the other 25 Hospital Engagement Networks will also work to address additional topics related to organizational structures. These organizational topics will involve each Hospital Engagement Network working closely with surgeons, medical staff, and leadership in the hospital to produce a stronger safety culture. The reduction of preventable hospital-acquired conditions and readmissions is dependent on hospital teamwork, communication, and a collaborative work environment. To ensure quality and to promote a culture of safety, health care organizations must address any behaviors that may threaten the performance of the health care team. Healthcare Team Training, LLC, one of JCR’s subcontractors, has provided licenses for each of the JCR Hospital Engagement Network hospitals to access all of the TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) educational sessions, as well as 15-minute video vignettes addressing each of the 10 areas of focus. TeamSTEPPS is a teamwork improvement system based on more than 25 years of research and evidence on team performance developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality.
Once a participating hospital’s core areas of focus are identified, JCR, in consultation with the hospital, will select appropriate measures to track each hospital’s progress in quality improvement, and then implement evidence-based solutions focused on the prevention of future adverse events. JCR will provide education and technical support to participating hospitals so that they can provide safer patient care and achieve quality measurement goals. CMS will also closely monitor the activities of all 26 Hospital Engagement Networks to ensure that they are improving patient safety.
Under JCR’s leadership, several other organizations will support the activities of JCR’s Hospital Engagement Network project, including The Joint Commission’s Division of Healthcare Quality Evaluation; The Patient Safety Education Program housed at Northwestern University’s Feinberg School of Medicine; Healthcare Team Training, LLC; EnCompass LLC; and Social Interventions and Research, Inc.
For more information on the JCR Hospital Engagement Network: