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Targeted Solutions Tool(TM) for Wrong Site Surgery Debuts

Joint Commission Center for Transforming Healthcare Application Aims to Reduce the Risk of Wrong Site Surgery

A new weapon in the critical fight to reduce the incidence of wrong site surgery becomes available today. The Targeted Solutions Tool™ (TST), developed by the Joint Commission Center for Transforming Healthcare, guides health care organizations through a step-by-step process to identify, measure and reduce risks in key processes that can contribute to a wrong site surgery.

Although reporting is not mandatory in most states, some estimates put the national incidence rate, which includes wrong patient, wrong procedure, wrong site, and wrong side surgeries, as high as 40 per week.

"Wrong site surgery is a rare event for individual surgeons or health care organizations. But when it does happen it is a devastating event that is often life altering for the patient who experiences it. We know wrong site surgery should never happen, but the problem persists," says Dr. Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president, The Joint Commission. "Reducing the risk of wrong site, wrong procedure and wrong patient surgery is critical to patient safety and the reputation of any health care organization that performs invasive procedures. The Targeted Solutions Tool offers organizations a straightforward approach to identifying and eliminating risks of wrong site surgery in all phases of the process of surgery, from scheduling to the operating room."

The TST helps organizations evaluate risks across their surgical system, including scheduling, pre-operative and operating room areas. Because wrong site surgery incidents are rare, the TST helps an organization monitor its surgical cases for weaknesses that might result in a wrong site surgery.

The wrong site surgery project began in July 2009. Eight U.S. hospitals and ambulatory surgical centers teamed up with the Center to address the problem and develop the solutions. The organizations that participated in the Center's project used Robust Process Improvement™ (RPI) methods. RPI is a fact-based, systematic and data-driven problem-solving methodology. It incorporates tools, concepts and methods from Lean Six Sigma and change management methodologies to discover the causes of and put a stop to these preventable breakdowns in patient care. The participants identified 29 main causes of wrong site surgeries that occurred during scheduling, pre-op/holding or in the operating room, or which stemmed from the organizational culture. The TST was then pilot tested by six hospitals and ambulatory surgical centers.

Over the course of the project, the original eight project organizations were able to reduce the number of surgical cases with risks by 46 percent in the scheduling area, by 63 percent in pre-op and by 51 percent in the operating room. The hospitals and ambulatory surgical centers that pilot tested the TST experienced the same gains as the original participants.

Although invasive surgical procedures occur in many settings, the scope of this project included all procedures performed in the operating room and regional blocks performed by anesthesia either in the preoperative area or the operating room. Within the project scope, the timeframe begins at the time a procedure is scheduled for surgery and ends with incision.

The Joint Commission has been at the forefront of the wrong site surgery issue for many years, issuing Sentinel Event Alert newsletters in 1998 and 2001 on wrong site surgery. The Joint Commission later convened a Wrong Site Surgery Summit that led to the development of the Universal Protocol, a standardized approach to eliminating wrong site surgery. Use of the Universal Protocol, which includes a pre-procedure verification, site marking and a Time Out, is an accreditation requirement for Joint Commission-accredited hospitals, ambulatory care and office-based surgery facilities. The solutions in the wrong site surgery TST further the effectiveness of the Universal Protocol.

All Joint Commission-accredited health care organizations have access to the TST via their secure Joint Commission Connect extranet. The first set of targeted solutions, created by eight of the country's leading hospitals and health care systems working in collaboration with the Center, focuses on improving hand hygiene. Solutions for hand-off communications, another Center project, are expected to be added to the TST in summer 2012. In addition to wrong site surgery, the Center is working to reduce surgical site infections following colorectal surgery through a project launched in August 2010 in collaboration with the American College of Surgeons. The solutions for this project are expected to be published later this year. Other projects include Preventing Avoidable Heart Failure Hospitalizations, Preventing Falls with Injury and Safety Culture.

Statements from the project organizations

"We were honored to be selected by the Joint Commission Center for Transforming Healthcare and National Surgical Hospitals to participate in the pilot testing of the Targeted Solutions Tool for the Wrong Site Surgery Prevention Project. As a physician owned surgical hospital, we strive to provide quality, safe patient care every day for every patient. This project has allowed us to perform an overview of our processes with our staff and physicians. It has been a tremendous experience, allowing for input from our staff and physicians on implementing evidence-based solutions for improved safety and quality care. Going forward, we will share the knowledge gained through the Wrong Site Surgery Project with other facilities within National Surgical Hospitals."
Buffy Domingue, CEO, Lafayette Surgical Specialty Hospital

United Surgical Partners International's mission is to provide first-class surgical services for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families therefore it was a great honor to be asked by the Joint Commission Center for Transforming Healthcare to be included in the Wrong Site Surgery Project. We live by our motto of "Every Day Giving Excellence" at Memorial Hermann Surgery Center Northwest. Involvement in this project enhanced our focus on the processes we had in place in regards to the prevention of wrong site surgery.
Vanessa Saenz Smith, M.H.A., regional vice president, United Surgical Partners International

The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Blue Cross and Blue Shield Association, Cardinal Health, Ecolab, GE Healthcare, GlaxoSmithKline (GSK), Johnson & Johnson and Medline Industries, as well as the support of The ARAMARK Charitable Fund, Federation of American Hospitals and GOJO Industries. For more information about the Joint Commission Center for Transforming Healthcare, visit www.centerfortransforminghealthcare.org.

Established in 2009, the Joint Commission Center for Transforming Healthcare aims to transform American health care into a high-reliability industry that ensures patients receive the safest, highest quality care they expect and deserve. The Center's collaborators -- the nation's leading hospitals and health systems -- use a proven, systematic approach to analyze specific breakdowns in care and discover their underlying causes to develop targeted solutions for health care's most critical safety and quality problems. The Center is a not-for-profit affiliate of The Joint Commission, which shares the Center's proven effective solutions with its more than 19,000 accredited health care organizations. Learn more about the Center at www.centerfortransforminghealthcare.org.

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