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Patient Safety

Observations and Lessons Learned in Patient Safety.

Hospital-Wide Sepsis Project Reduces Mortality by Nearly 25 Percent


By Kelly Barnes, Black Belt III, Joint Commission Center for Transforming Healthcare

Five leading hospitals, including Atlantic Health System, New Jersey; Floyd Medical Center, Georgia; Kaiser Permanente, California; Northwell Health at Staten Island University Hospital (SIUH), formerly North Shore Long Island Jewish Hospital), New York; and Texas Health Resources, Texas partnered with the Center for Transforming Healthcare to reduce sepsis mortality. The Center’s sepsis project was unique in that it looked at sepsis from a hospital-wide perspective, rather than focusing only on emergency departments or intensive care units. In addition, while most other projects tend to concentrate only on severe sepsis and septic shock, this project tracked patients with:

  • sepsis
  • severe sepsis
  • septic shock 

These organizations worked with us to identify the root causes for lack of early detection and treatment for sepsis and implemented solutions that were unique to their organization’s specific root causes. The data collection tool and solutions were then tested, validated, and spread to an additional group of pilot organizations. 

Analyzing Root Causes
The five organizations on our project investigated the reasons for why they were not recognizing sepsis and why they were unable to either complete the sepsis bundle elements or complete them in a timely manner. In total, the organizations identified 40 root causes for lack of recognition and compliance with the sepsis bundle elements that contributed to their sepsis mortality. However, each organization had a different set of root causes, and no one organization had all 40. In addition, the relative impact of each root cause was different for each organization as well. For instance, one organization identified a root cause of fluids being disconnected when the patient was taken for tests as a barrier for adequate fluid resuscitation while another organization identified staff fear of fluid overload as their barrier.  

This underscores the need to drill down to the root causes at your individual organization. Once organizations identify their specific root causes, targeted solutions can be implemented to improve sepsis recognition and bundle element compliance resulting in a reduction of sepsis mortality. 

Significantly Reduced Mortality
By targeting specific solutions to their top root causes, the five original participating organizations on this project, as an aggregate, reduced sepsis mortality by nearly 25 percent. Additionally, these organizations sustained their mortality rate reduction over time. Five more pilot organizations, including Chilton Medical Center (Atlantic Health System), New Jersey; Decatur Memorial Hospital, Illinois; Helen Keller Hospital, Alabama; and Inova Alexandria Hospital, and Inova Mt. Vernon Hospital (Inova Health System), Virginia reduced their aggregated sepsis mortality rate by approximately 30 percent.  

Targeted Solutions Tool
Based on the findings and results of the participating hospitals and pilot sites, the Center for Transforming Healthcare is currently developing a Targeted Solutions Tool® (TST®) to help organizations reduce their sepsis mortality. The TST, scheduled for public release in 2019, is a unique online application that will guide organizations through a step-by-step process to address sepsis mortality in their organizations. The TST will:

  • provide an online data collection tool,
  • analyze organizations’ data,
  • identify their top root causes for sepsis mortality, and
  • link to validated solutions to address the root causes that led to sepsis mortality. 

The TST will be free for use for Joint Commission accredited organizations and is easily accessible through our Targeted Solutions Tool page. 

For any questions, or if you have any interest in serving as an early adopter/beta tester for the Reducing Sepsis Mortality TST, please contact .


Kelly Barnes is a Black Belt and Center Project Lead in the Center for Transforming Healthcare at The Joint Commission.  She is serving as the project lead for two Center projects: Reducing Sepsis Mortality, and Preventing Venous Thromboembolism (VTE).  In addition, she has served as a project co-lead on healthcare related improvement projects aimed at: Preventing Falls with Injury, and Preventing Avoidable Heart Failure Hospitalizations. Barnes joined The Joint Commission in 2006 as the Grants/Contracts Manager Prior to joining the Joint Commission, she was a project coordinator at Northwestern University and she also served as a data analyst for the University of Illinois, Chicago. In addition to her work at The Joint Commission, Barnes also owns a consulting business providing sports psychology services to athletes and teams in the Chicago area. Ms. Barnes has been an adjunct faculty member at Aurora University teaching sports psychology since 2008. She has consulted with hundreds of athletes and currently has former clients playing in the National Hockey League (NHL).