Dr. Erin DuPree
Patients can be placed into two broad categories. Some need help with an event: set a broken arm, and that patient’s problem is resolved. Others need help with a process: they must manage high blood pressure, or diabetes, or another chronic condition. No quick fix solves these problems, but by approaching them systematically, consistently, and attentively, chronic conditions can be controlled and patients’ lives made much, much better.
When it comes to healthcare quality, many facilities treat issues as events rather than processes. When a solution is implemented, the problem is treated as if it’s been cured. Unfortunately, unless they receive systematic and attentive treatment, quality problems in healthcare are likely to persist and worsen—just like a chronic condition.
That’s why the Joint Commission Center for Transforming Healthcare helps hospitals and health systems adopt new ways to improve patient safety and quality. The center’s Robust Process Improvement® methodology encourages a different approach to solving healthcare problems, incorporating Lean, Six Sigma and change management principles.
“We have the potential to significantly improve healthcare safety through the spread of Robust Process Improvement,” says Dr. Erin DuPree, the center’s chief medical officer and vice president. “Not only does it improve and save lives, but it also improves the culture of the organization.”
DuPree is particularly proud of gains made in hand hygiene. The center collaborated with eight hospitals and health care systems to develop hand hygiene solutions, and introduced an online “Targeted Solutions Tool®” for hand hygiene in September 2010.
The Hand Hygiene TST® guides teams through a Robust Process Improvement project to improve hand hygiene compliance rates. At the same time, it helps familiarize team members with data-driven quality methods. The use of the tool and the methodology has proven to be tremendously effective, improving average hand hygiene compliance rates from 57.9 percent to 83.5 percent.
We asked DuPree to share her perspective on Robust Process Improvement and changing perspectives about quality among healthcare professionals.
Why are healthcare organizations considering new approaches to quality improvement?
When organizations approach a problem, they often gather a group in a room. They try to see what the best practices are and then see if those work in the organization. That's largely the current approach to process improvement in healthcare, and we're finding that doesn’t really result in the kind of improvement we need to see.
Healthcare organizations have a growing interest in learning improvement science and methodology, because they're reaching plateaus and not seeing a dramatic improvement—or they thought they fixed the problem, but initial improvements haven’t been sustained. That's where healthcare is at right now, and that's why there is a growing interest in learning and applying process improvement methodology. It’s a big cultural shift for a lot of organizations.
How does Robust Process Improvement address challenges in health care?
The solution is actually in the methodology. When you use Robust Process Improvement as intended, you start to approach problems from the perspective of the patient or, in other industries, from the customer perspective. When you approach problems from that perspective, the definitions change and silos start to come down. Different teams start to form in order to solve problems across your organization, which starts to improve the culture of the organization. This can lead to dramatic improvements.
How important is data analysis in Robust Process Improvement?
Data is an integral aspect of improving quality. Without data, we’re not able to measure the impact of a problem, or determine how well our solutions are actually working. It’s really at the heart of the center's work. It helps us define, measure, analyze, and improve processes to save lives.
Hand hygiene seems like something everyone in a medical facility would do automatically. Why is it a problem?
Healthcare organizations have been working to improve hand hygiene since the 1800s, with limited success. But hand hygiene is one of the biggest contributors to healthcare-associated infections, so reliability in hand hygiene is critical to saving lives.
Studies show healthcare workers wash their hands 40% of the time that they're supposed to. We know that there are many, many root causes as to why healthcare workers do not wash their hands. Culture, accountability, and setting up the work environment so that it's easy for a healthcare worker to do the right thing are all root causes.
A best practice does not address local variation. Because of the complexity of contributing factors, hospital A is going to require a different solution set than hospital B.
The center’s approach has led sustained improvements in hand hygiene at organizations using the
Targeted Solutions Tool®.
How does the TST apply the DMAIC (Define-Measure-Analyze-Improve-Control) methodology to hand hygiene in healthcare facilities?
The TST guides the project team through the Define phase to ensure the organization has leadership commitment, engaged the relevant stakeholders, and set up solid operational definitions for hand washing. Believe it or not, that's a change for many organizations. The team then goes into the Measure phase. What they often discover is they haven’t been measuring hand hygiene compliance accurately. The tool has training for data collectors to ensure that an accurate measurement system is in place. When hand hygiene is measured accurately, the rates of compliance are typically much lower than they expected.
In the Analyze phase, the contributing factor data that has been entered into the TST is analyzed by the project teams. They discover the top reasons why people don't wash their hands in the project area. That leads to the Improve phase, with organizations implementing specific targeted solutions for their top contributing factors. Every organization is loading different contributing factor data, so every organization is going to have a different solution set based on their unique contributing factors. And once improvements have been made, the TST helps a team sustain them by monitoring data in the Control phase.
It sounds like using the TST helps teams learn some principles about data analysis that could be applied to other challenges.
Absolutely. It's an educational tool, because a lot of this is very new for healthcare workers and healthcare organizations. It guides them through how to gather data, how to make sure the data is reliable, how to interpret the analysis of the data, and finally how to use that data to actually improve something. In that way, it’s very much an educational tool— it’s like giving them training wheels. Ultimately, taking it to the next level would typically require more skills and training.
There are a number of tools within the TST that teams could certainly use in other contexts—other projects or meetings that they're involved in. We would hope for that kind of spread.
How can more healthcare practitioners get involved in process improvement activities?
A way to get started is to identify a problem that they want to solve, then ensure they have the knowledge and skills to work on that problem, either by partnering with an expert in their organization, using the TST, or getting training themselves.
Any final thoughts you can share with us?
It’s important to commit to learning about how to improve—improvement science. Everybody in healthcare needs to become an expert in that. It has to become the way we work every day in healthcare.
For more information about the Joint Commission Center for Transforming Healthcare, visit
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