Category Type:  Quality of Care/Patient Safety

This project was initiated in July 2009 by two Rhode Island hospitals affiliated with the Lifespan system:  Rhode Island Hospital and Newport Hospital. The hospitals wanted to collaborate with The Joint Commission on a project to improve the safeguards to prevent patients from wrong site, wrong side and wrong patient surgical procedures. The Miriam Hospital, also in Rhode Island, joined the project in November.
 

Like many hospitals throughout the United States, these hospitals recognize that, while wrong site surgery is a rare problem, when it occurs, its impact can be devastating. Simply stated, wrong site surgery should never happen; yet by some estimates, wrong site, wrong side and wrong patient procedures occur more than 40 times every week in the United States.
 

This project is addressing this problem of wrong site surgery using Robust Process Improvement™ (RPI) methods. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates specific tools and methods from Lean Six Sigma and change management methodologies. Using RPI, the project teams will discover specific risk points and contributing factors and will implement interventions and controls to foster the elimination of wrong site, wrong side, and wrong patient surgical procedures.

The project team includes hospital leadership, surgeons, operating room directors and staff, and an obstetric and gynecologic surgeon who is experienced with both RPI and the change management process. The scope of the project includes all procedures performed in an operating room. Within the project scope, the timeframe begins at the time of scheduling a surgical procedure and ends with confirmation that the intended operation was performed.
 

Through this collaboration with the Rhode Island hospitals, the Center for Transforming Healthcare aims to benefit patients by sharing the proven and effective solutions emanating from this project with all of the thousands of health care organizations it accredits in which surgery is performed. The Joint Commission has been at the forefront of the wrong site surgery issue for many years. Its Sentinel Event program first identified wrong site surgery as a common type of sentinel event. The Joint Commission has issued two Sentinel Event Alert newsletters on the subject of wrong site surgery; the first published in 1998 and the follow-up in 2001. In 2003, The Joint Commission held the first Wrong Site Surgery Summit and in 2004, it launched the Universal Protocol, which expanded and integrated the 2003 and 2004 National Patient Safety Goals. The Joint Commission continues to press the urgency of this issue, so it was only natural that the Joint Commission Center for Transforming Healthcare would tackle this problem as one of its first initiatives. 
 

The solutions for this project are targeted for publication in early 2011, following pilot testing.