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High Reliability Healthcare

Data Driven Insights and Aha Moments in the Pursuit of Zero Harm and High Reliability Healthcare.

Targeting Sepsis to Achieve High Reliability in Health Care


A patient in a hospital gown is laying on a bed with 2 people around in safety equipment with one in conversation with person in bed.

Sepsis is a persistent problem within health care and has been for years. Every year, at least 1.7 million Americans develop sepsis, and nearly 270,000 of those patients die, the Centers for Disease Control and Prevention reports. In addition, sepsis is a preventable problem that costs the healthcare system approximately $41 billion annually.

The harm and deaths from sepsis are magnified by the current pandemic. The Global Sepsis Alliance has confirmed that COVID-19 can cause sepsis, and that signs of multi-organ injury typical in sepsis cases occur in approximately 2-5% of COVID-19 cases. Although it is still early in the pandemic and data is continuously being collected and analyzed, some studies indicate sepsis may be the second leading cause of death among COVID-19 patients.

Disasters expose and exacerbate pre-existing system weaknesses. And this is true of the COVID-19 pandemic’s effect on the American health care system. Healthcare workers and organizations have risen to the pandemic’s challenge and have performed heroically to save and treat patients in the face of many unknowns and at great danger to themselves. It has also become apparent that many healthcare organizations were challenged by lack of resources and poor systems long before the pandemic compromising their ability to provide care that was consistently excellent and safe. The high sepsis mortality rates are an example of safety challenges in health care prior to the pandemic. When we get through the pandemic—and we will get through it—will we go back to the same set of harm events and unsafe conditions that plagued health care and the patients before the pandemic?

These are tough times, so I am encouraged and proud to share news about the Reducing Sepsis Mortality Targeted Solutions Tool (TST) from the Joint Commission Center for Transforming Healthcare. This resource, which we are launching during Sepsis Awareness Month, is now available to help organizations target and reduce sepsis – even during this global crisis.

The Reducing Sepsis Mortality TST is a web-based application developed following an improvement project with a national cohort of five leading hospitals, including Atlantic Health System, Floyd Medical Center, Kaiser Permanente, Northwell Health at Staten Island University Hospital and Texas Health Resources. This cohort was successful in reducing sepsis mortality by nearly 25%. A subsequent cohort –with five additional hospitals, including Chilton Medical Center, Decatur Memorial Hospital, Hellen Keller Hospital, Inova Alexandria Hospital and Inova Mt. Vernon Hospital – succeeded in reducing sepsis from nearly 20% to 50%. This TST is showing strong outcomes in reducing sepsis mortality. In addition, its implementation will result in a decrease in patient harm, lead to sustainable improvements and cost savings.

This tool cannot work as intended without purposeful leadership. As one of the three domains of high reliability health care, leadership commitment is key. Leaders should ensure that their organization is equipped with the resources, expertise and culture necessary to succeed. In a high reliability culture, issues like sepsis aren’t seen as unavoidable – but as something that can be prevented with early detection and initiation of treatment. By identifying causes that contribute to sepsis and taking the steps to eliminate the causes they identify, organizations can make zero harm a reality.

We are pleased to make this tool widely accessible to help healthcare organizations implement sustainable improvements that lead to better outcomes. If you are interested in this solution, learn more here.

Anne Marie Benedicto is Vice President at the Joint Commission Center for Transforming Healthcare