High reliability science and surgery: The Joint Commission’s Robust Process Improvement methodology

In health care, the goal is to provide safe, high-quality care to every patient, every time. The Joint Commission President Mark R. Chassin, MD, FACP, MPP, MPH, and Jerod M. Loeb, PhD, former executive vice-president of The Joint Commission’s Division of Healthcare Quality Evaluation, wrote in the Milbank Quarterly that despite our aspiration to provide high-quality care, wrong site operations and health care-associated infections have persisted.* So, the obvious question becomes how can surgeons integrate high reliability concepts into their work?

This column is the first in a series that will investigate the answers to that question. This article provides an overview of The Joint Commission’s Robust Process Improvement (RPI) methodology. Future columns will delve into practical applications of RPI for surgeons.

What is RPI?

RPI—which uses Lean Six Sigma and other change management methodologies—can be best understood as an approach that aims to create sustainable solutions for some of health care’s most critical quality and safety issues. Think of it as the scientific method, using data-driven problem-solving techniques to determine root causes of safety issues specific to a problem area and then providing a roadmap to develop and implement solutions that lead to substantial improvements.

The Joint Commission’s Center for Transforming Healthcare has been using RPI since 2008 and has focused on 11 topics, some of which have been centered on surgery, including enhancing patient safety, decreasing the likelihood of surgical site infections, improving handoff communications, and promoting hand hygiene.

Building on DMAIC

Using the DMAIC (define, measure, analyze, improve, control) approach, members of the surgical team first define the problem from the patient’s perspective. What does the patient need? From there, the project team, project goals, a high-level process map, and a project plan are developed. If we focus on “safe surgery,” for example, the team must first be very specific in defining the problem, including where the process starts and ends. From the patient’s perspective, safe surgery begins with the initial conversation in the physician’s office and the decision to proceed with the operation. Safe surgery begins long before the timeout occurs in the operating room (OR).

The measure phase quantifies the problem through a methodical approach to defining defects, metrics, and a detailed process map. This informs the development of a robust data collection plan, which is then validated.

The analyze phase allows the team to identify sources of variation and determine root causes. For example, when a patient is ready for surgery and covered in surgical drapes, the site marking should be visible. Yet when the team looks into the process, it may discover that this does not always happen; there can be variation. It may find that the mark was erased during the preoperative scrub, or the mark was made with a faulty marker, which could lead to problems, especially if it is goes unnoticed during the timeout.

In the improvement phase, the team develops potential solutions to address the root causes that are critical to quality. Using the site marking issue discussed previously, one such solution may be ensuring that the suppliers to the hospital only deliver the proper markers for site marking, so that faulty ones are not available at the institution. These solutions are tested, validated, and adjusted as necessary.

Control is the sustainability phase. Standard procedures with clear accountability and monitoring are developed based on the validated solutions. Change management tools are required throughout but are especially important in the acceptance of the solutions, which, in turn, leads to greater adherence by the team and organization. When that level of buy-in has occurred, marked improvements are possible.

The RPI toolkit

Lean tools help to take the waste out of the processes and thereby help to show respect for frontline workers. Lean tools are used at various points in the DMAIC process, depending on the problem at hand. An example in the operating room (OR) might be entering and exiting the room to get equipment, which increases the chances of infection. Lean strategies can help address that problem by figuring out ways to ensure that ORs are equipped properly prior to surgery or by minimizing the need to leave the room. Waste is defined as anything that isn’t necessary to the process or anything that is not of value to the patient.

The RPI toolkit is flexible and may be applied in many different ways. If a surgical team is having problems with health care-associated infections, ineffective timeouts, inconsistent handoffs, wrong site operations, or falls with injury, RPI can help the quality improvement team develop and implement solutions.

The RPI approach to improvement is:

  • Focused on the problem(s) specific to your area
  • Based on robust data
  • Created and sustained by the team

RPI resources are at surgeons’ fingertips, waiting to be used to create a more reliable, safe environment for patients. And the response to process improvement initiatives, specifically RPI, can be emboldened when surgeons—respected members of their health care teams—champion the cause. It is all for the goal of moving health care toward high reliability, so that every patient can receive safe, high-quality care every time. Some of these resources can be found on the Center for Transforming Healthcare’s website. In addition, articles and case studies about high reliability can be found on The Joint Commission’s website.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily represent the official views of The Joint Commission or the American College of Surgeons.

*Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Q. 2013;91(3):459-490. Available at: www.jointcommission.org/high-reliability_health_care_getting_there_from_here/. Accessed August 27, 2015.

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