RPI can be used to improve surgical care

Last month’s column focused on the idea of surgeons using The Joint Commission’s Robust Process Improvement (RPI) toolkit—which encompasses Lean Six Sigma and other change management strategies—to bring about substantial, lasting change to health care. But how can these tools be applied in practice to achieve high-reliability for patients?

The Joint Commission Center for Transforming Healthcare has focused on a number of complex, chronic patient safety issues, which has led to the development of the Targeted Solutions Tool (TST), an online application that guides a project leader through an RPI project. The TST is available for safe surgery, hand hygiene, hand-off communications, and prevention of falls.

The project leader and team that use the TST do not need to be experts in RPI methodology and change management; RPI is a “learn while you do it” tool. The goal is to understand the key factors that contribute to a specific practice environment and to implement proven solutions to any problem factors that may inhibit the provision of optimal care.

Protecting patients

The TST application helps health care institutions safeguard patients from preventable harm, including wrong site surgery, across the continuum of surgical care. For example, the safe surgery TST provides guidelines for the project leader to evaluate the organization’s surgical care system from scheduling all the way through the completion of the operation. Through this systematic, data-driven approach, practices are standardized across the perioperative phase of care, which includes all activities aimed at optimal preparation of the patients for surgical procedures.

The Joint Commission Center for Transforming Healthcare collaborated with health care organizations, including hospital systems and other health care providers, across the U.S. to address wrong site surgery, identifying 29 main causes of these surgical errors. They ranged from scheduling and preoperative errors to operating room (OR) and organizational culture errors.

In scheduling procedures, situations that may lead to wrong site surgeries include:

  • Schedulers accepting verbal requests, instead of written documents, for surgical bookings
  • Unapproved abbreviations or illegible handwriting used on booking forms
  • Preoperative factors include:
  • An unapproved marker identifying the surgical site or use of stickers to identify a surgical site
  • Inadequate patient verification by the team
  • Sources in the OR include:
  • Distractions occurring during a scheduled timeout
  • Portions of the team being absent from or not participating in the timeout
  • Organizational culture factors include:
  • Staff not being empowered to speak up
  • Inadequate education provided to the staff regarding the changes

RPI at work

Applying RPI methodology in another practical scenario, Julia Berian, MD, a Clinical Scholar in Residence at the American College of Surgeons, used the RPI toolkit to improve an aspect of the vacation scheduling process (flexible time) for the general surgery residency program at the University of Chicago, IL. The previous process was not centralized, leading to a haphazard, and often strained, scheduling process with a number of last-minute time-off requests that left some residents overburdened.

Dr. Berian was able to define the key players in the process and create a system that alleviated scheduling problems by selecting a lab administrative resident who is responsible for organizing the flexible vacation time. All requests now go through this individual, eliminating part of the frustrating administrative issues that some surgeons face on a daily basis.

RPI techniques can effect change in a variety of ways, such as reducing the chance of patient injury and creating a more efficient process for scheduling physicians. In next month’s column, we will continue to highlight notable aspects of this innovative methodology.

For more information on RPI and the TSTs, go to the Joint Commission Center for Transforming Healthcare website.


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

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