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The HAI tipping point has been reached

February 08, 2017
Infection Control
From the January 2017 issue of HealthCare Business News magazine

Reversing the tipping point requires change developed from mistakes.
For example, investigations following a series of airplane crashes concluded that the most frequent immediate cause was failure of the cockpit crew to act as a team. The response was to create an entirely new training program — Crew Resource Management — that was designed to foster more effective communications among crew members. It focused on improving performance by improving the rate of error detection, reporting and appropriate and timely action within the structure of the cockpit team. All airlines now use this method of improving teamwork.

Health care organizations, even with equally or even more complex teams of professionals charged with caring for critically ill patients, must adapt to the method for successful teamwork. To be effective in moving health care to a pinnacle of excellence, a health care organization must also analyze effective management styles used in business and then apply the process that best fits the organization’s ability.

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Two successful processes are Total Quality Management (TQM) and Six Sigma. TQM, developed by mathematician and management guru W. Edwards Deming focused on precise manufacturing for improved customer satisfaction. The simplified lesson applied to health care is zeroing in on each aspect of patient care, not just silos of delivery. Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects, driving toward six standard deviations between the mean and the nearest specification limit, in any process.

Both TQM and Six Sigma are focused on eliminating mistakes at every level of the process. Some health care leaders may say that they already put in place systems in the OR for eliminating identification mistakes such as verifying the patient’s name, review of the procedure to be performed, the exact appendage location, etc. This is an initial step, but not a complete process. It is imperative to review the route the patient took to the OR, the environmental conditions in the operating room, the process for sterilizing the instruments and more.Too often, the surgical team communicates with the attending team, the SPD only communicates with their department, the facilities team relies on the equipment and their response to complaints, whereas no one has brought everyone together and explained the large-picture goal. Each department only realizes their individual goals.

About the author: Thom Wellington is the CEO of Infection Control University.

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