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2012 5th International High Reliability Organizing Conference:
Seeking Reliability through Operations, Attitudes,
and Measuring Success
Dr. Mark R. Chassin
Keynote Address
May 21, 2012
Part III
Robust process improvement and the Center for Transforming Healthcare
So what we mean by RPI (Robust Process Improvement) are the three different tool chests that we
believe need to come together to support the creation of nearly perfect processes — Lean, Six Sigma and
change management, three tool chests inside the RPI tool shed, if you will. I know it's a cumbersome
metaphor, but it's the only one I can come up with so far. Each of these tool chests has specific tools and
methods and strategies for making health care processes, and any process, more effective.
We are in the middle of a very aggressive program inside The Joint Commission to adopt all of these
tools and train all thousand of our workforce in them at levels that are appropriate for their jobs. It helps
us with our own business processes. It helps us focus on our customers, as those of you that are expert
in these tools know. And we are also adopting all of the components of a safety culture. We measure
both of these, and we report them to our board as part of our strategic plan and our strategic metric so
that our board can see how well we're doing in achieving the goals of adopting safety culture and RPI.
Now, we are doing this to improve our business, and it's already had a dramatic impact, including with a
positive ROI, although that wasn't our primary purpose. But we also did this because we wanted to apply
these tools with healthcare organizations that had also mastered them in order to tackle some of the most
resistant quality and safety problems that we have. And we created a new part of The Joint Commission
called the Center for Transforming Healthcare in order to do that. And you probably can't read that little
tagline under the Center's name which says "Creating solutions for high reliability health care."
So this is the RPI component of getting to high reliability. How do we create these processes with
defenses that have minuscule holes in them? How do we create safety protocols that work not 40 or 50
percent of the time but 90, 95 percent of the time, at least? And we are not very good at doing that today
in health care.
The Center was created not only because we thought these tools would work but because our customers
were asking us for solutions to the same safety and quality problems that The Joint Commission has
been talking about for years. The Joint Commission discovered wrong-site surgery in 1995 — not solved.
We are committed to delivering the products of the Center. Now, three years later, we're still committed,
at no added cost to our accredited customers. As part of accreditation, we've raised now about $33
million from — both from The Joint Commission but from other major donors. Each of these farsighted
organizations — from the American Hospital Association to Medline, Cardinal Health, the Blue Cross Blue
2012 5th International HRO Conference, Chicago, Illinois The Joint Commission
Dr. Mark R. Chassin: Keynote Address, May 21, 2012 Page 1

Shield Association — has contributed $1 million or more to the Center. And we are continuing down this
road.
We've tackled a large number of problems using these tools. This year we will launch a project on sepsis
and a medication safety project and a third one before the end of the year. And this is the list of hospitals
and systems that has joined with us to tackle these problems. Some have been involved in three or four
projects. And we are recruiting more all the time. We'll probably add another three or four this year.
These organizations have been recruited because they know how to use Lean, Six Sigma and change
management. And we can do these projects essentially on business time frames — well, close to
business time frames. Most of us are not-for-profits, so we're not used to for-profit business time frames.
But these are not training exercises, is my point. We apply the tools and we generate generalizable
knowledge.
Now, I said these problems have been with us for a long time. And they've been with us despite at least a
decade in which health care has focused a lot of effort and energy to solving. Why haven't they been
solved? Well, I think one of the questions we have to ask is, what improvement model have we been
throwing at these problems over this decade? And pretty much it's been a single note or slight variations
on a single note. We find somebody that says they've solved a problem, and we say, "Oh, that's a best
practice. Let's make a toolkit, a checklist, a protocol out of that. We'll call it a bundle. Everybody should do
it the same way, and the problem will be solved everywhere." Right? How is that working out?
Well, I know it wasn't working out very well when I was on the hospital side trying this five, six years ago.
And we thought there's probably a better way. And, in fact, when you look carefully at this approach, it
does work in certain very narrowly circumscribed situations. It's worked to get rid of — almost get rid of
ICU infections from central lines. It's worked to drastically reduce ventilator-associated pneumonia. But
they produce these results only when the process you're trying to fix doesn't vary very much from one
place to another and when the causes of failure are few and easily identified.
Now, none of the problems on the previous slide have any of those characteristics. They are much more
complicated, and they require more sophisticated problem-solving approaches, ones that use RPI.
Complicated processes are not solved with simple solutions. It turns out there are many causes of failure
for these processes, not just four or five, but 15, 18, 20, 25, when you look carefully. Each cause typically
requires a very different strategy to get rid of. And another critical finding of this work is that when you
look at one place and find the four or five critical causes that explain half of the failures and you look at
place number two, you don't find the same critical few causes, you find different ones, which is a big
reason why the same best practice, even if it really did a good job over here, is not going to work in the
second place.
So we believe that the next generation of best practices, using these very effective process improvement
tools, will produce solutions that are customized to an organization's specific and important causes of the
problem, which will vary from one place to another.
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