Hand Hygiene Improvement Tool Linked to Significant Decrease in Health Care-Associated Infections at Memorial Hermann Health System
Article Featured in January 2016 Issue of “The Joint Commission Journal on Quality and Patient Safety”
(OAK BROOK, Illinois, January 12, 2016) Joint Commission Resources, Inc. recently released the January 2016 issue of The Joint Commission Journal on Quality and Patient Safety. The issue features an article by M. Michael Shabot, MD, Memorial Hermann Health System (MHHS), and Mark R. Chassin, MD, MPP, MPH, The Joint Commission, and their co-authors on how MHHS used the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool® (TST®) to improve hand hygiene compliance; improvements were associated with sustained reductions in health care-associated infections.

MHHS’s system-wide hand hygiene compliance improved to 95.6% in the final 12 months.  
After pilot testing the hand hygiene TST, MHHS achieved significant improvement for each of the 150 inpatient units throughout its 12 hospitals. For 31,600 observations, MHHS’s average system-wide hand hygiene compliance improved from 58.1 percent at baseline to 84.4 percent in the “improve” phase, 94.7 percent in the first 13 months of the “control” phase, and 95.6 percent in the final 12 months. During this same time period, rates of central line-associated bloodstream infections and ventilator-associated pneumonia in adult ICUs decreased by 49 percent and 45 percent, respectively.   

As described in the article, the TST is a systematic, Web-based application founded on RPI methodologies, including Lean, Six Sigma and change management. The TST guides health care organizations through a step-by-step process to accurately measure actual performance, identify barriers to excellent performance and receive direction to proven solutions customized to address particular barriers. To learn more, visit

In the issue, Editor-in-Chief David W. Baker, MD, MPH, FACP, welcomes the new Editorial Advisory Board members, who provide introductions to their current activities and interests.

The remaining articles from the January 2016 issue are:

Performance Improvement

The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation among Five Clinics
Neha A. Sathe, MD; Robert S. Nocon, MHS; Brenna Hughes, MD; Monica E. Peek, MD, MPH; Marshall H. Chin, MD, MPH; Elbert S. Huang, MD, MPH

Quality improvement collaboratives (QICs) have been cost-effective in improving the care of chronic diseases, but the cost factor may deter outpatient clinics from participating. An ongoing diabetes QIC links six clinics on Chicago’s South Side with interventions tailored to minority populations and focuses on community partnerships. Data for the first four years from five of the clinics showed that the annual cost for a diabetic patient ranged from $6 at the largest clinic to $68 at the smallest clinic, with costs peaking during the second year for four of the five clinics. This information can help administrators and policy makers predict, manage and support costs of QICs as payers seek high-value health care.

Risk Assessment and Event Analysis
A Tool for the Concise Analysis of Patient Safety Incidents
Julius Cuong Pham, MD, PhD; Carolyn Hoffman, RN, BSN, MN; Ioana Popescu, MBA; O. Mayowa Ijagbemi, MPH; Kathryn A. Carson, ScM

Given the significant resource requirements of a root cause analysis, there is a need for a more targeted and efficient method of analyzing a larger number of patient safety incidents. A Concise Incident Analysis methodology and tool were developed to facilitate analysis of no- or low-harm incidents. Staff from 11 hospitals in five countries pilot tested the tool, for a total of 52 patient safety incidents. The sites found the tool “understandable” (100 percent), “easy to use” (89 percent), and “effective” (89 percent), and 95 percent of sites planned to continue to use all or some parts of the tool.

Care Processes
Factors Associated with Inpatient Thoracentesis Procedure Quality and University Hospitals
Sarah E. Kozmic, BS; Diane B. Wayne, MD; Joe Feinglass, PhD; Samuel F. Hohmann, PhD; Jeffrey H. Barsuk, MD, MS

Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than perform them at the bedside. In an administrative database review (January 2010–September 2013), 132,472 procedures were performed on 99,509 patients at 234 hospitals. IR performed 33 percent of the procedures; medicine, 17 percent; and pulmonary, 20 percent. The incidence of iatrogenic pneumothorax was 2.8 percent for IR, 2.9 percent for medicine, and 3.1 percent for pulmonary; medicine and pulmonary were considered to have equivalent risk of iatrogenic pneumothorax as compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs and fewer hospital days than did IR admissions (each, p < 0.001). Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Tool Tutorial
Post Event Debriefs: A Commitment to Learning How to Better Care for Patients and Staff
Michele Campbell, RN, BSN, MSM, CPHQ, FABC; Kristen Miller, MSPH, DrPH; Kathleen W. McNicholas, MD, FACS, JD, LLM

Christiana Care Health System, Wilmington, Delaware, which includes two teaching hospitals, developed Post Event Debriefs as an integral component of its event management process. The primary goal of the tool, which includes process guidelines and a checklist, is to enable staff to openly discuss events in a safe and supportive learning environment. 


Joint Commission Resources, Inc.
Joint Commission Resources, Inc. (JCR), a wholly controlled, nonprofit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services, and publications and software, to assist in improving safety and quality and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Visit for more information.


The Joint Commission


Using the Targeted Solutions Tool® to Improve Hand Hygiene Compliance Is Associated with Decreased Health Care-Associated Infections


The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics

A Tool for the Concise Analysis of Patient Safety Incidents

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals

Post Event Debriefs: A Commitment to Learning How to Better Care for Patients and Staff

Journal on Quality and Patient Safety

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