Joint Commission report shows quality gains
Compliance lags in surgical time-outs
A new report from The Joint Commission, of Oakbrook Terrace, IL, indicates that hospitals in the United States have achieved significant improvements in quality of care in the past four years for patients suffering from three conditions: Heart attack, heart failure, and pneumonia. However, the report, entitled "Improving America's Hospitals: A Report on Quality and Safety" also showed room for improvement in areas such as surgical time-outs.
According to The Joint Commission, this report will now be issued annually. The current report covers 2002 through 2005 and details the performance of accredited hospitals against standardized national performance measures and the Joint Commission's National Patient Safety Goals. (To view hospital-specific performance on the measures, go to the individual hospital's Quality Report on Quality Check at www.qualitycheck.org.)
During a March 20, 2007, press conference unveiling the report, Dennis S. O'Leary, MD, president of The Joint Commission, said, "The magnitude of improvement in the safety and quality of care provided ranged from 1.1% to 42.8% over the four-year period between 2002 and 2005, with performance improving the fastest on measures where the initial performance level was lowest."
The biggest improvement was in providing patients admitted to the hospital with pneumonia with smoking cessation advice. The national rate of sharing this type of information rose from 37% in 2002 to 80% by 2005. Another area of improvement was the overall use of specific care interventions for patients admitted with heart attacks and the in-patient mortality rates.
"Room for improvement exists for most of the quality measures," O'Leary said. "For example, hospitals are currently achieving 90% performance or higher for about half of the measures tracked since 2002. Hospitals are performing at less than 65% for two of these measures — providing pneumococcol vaccination to patients admitted with pneumonia, and providing discharge instructions to patients admitted with heart failure."
Change varied by states. For examples, O'Leary said, "the statewide averages for providing discharge instructions to patients admitted with heart failure range from 33.5% to 89%. On the measure of providing pneumococcol vaccination to patients admitted with pneumonia, performance ranges from 48% to 84% across the states."
Results showed some hospitals performed better than others in treating specific conditions and more than 90% of hospitals showed 90% performance on only one measure.
Where was compliance lowest? For National Patient Safety Goal requirements that surgical teams take a time-out before surgery to confirm the patient's identity, that the procedure is the correct one, and that potentially confusing abbreviations are not used in ordering the necessary medications.
"Although National Patient Safety Goal compliance is trended over time for the various requirements," O'Leary said, "the report urges caution in interpreting these trends because Joint Commission surveyors have become increasingly sophisticated in assessing compliance with some of the requirements."
Good news, bad news
This hard data, O'Leary continued, "moves us ever closer to creating truly informed health care consumers. The good news is that we have made significant progress in improving quality of care for these conditions. However, the data also indicate there are significant opportunities for improvement."
The progress that has been made, he continued, "is quite real — but so are the opportunities to improve safety and quality of care."
"This report is a very important addition to the total body of information, and is the product of valid, reliable, evidence-based measures that have a broad consensus of support in the field," adds Carolyn M. Clancy, MD, director, Agency for Healthcare Research and Quality (AHRQ). "It tracks very closely the findings of our own agency's National Healthcare Quality Report, which we present every year to Congress."
Even the "bad" news, adds Richard J. Umbdenstock, FACHE, president of the American Hospital Association, is "good news for us in that it points out where we can and should focus our improvement efforts."
What's behind the improvement? "Much of it is due to public reporting and the availability of information on hospitals," Clancy asserts.
"This is not a time to be complacent," she adds. "The health care system continues to have significant gaps in quality that need to be addressed; for example, except for vaccinations, the improvement rate for preventive services was less than 2%. We've read what hospitals have done in smoking cessation; we can do the same elsewhere in health care."
Issues such as broad disparities in care by race and ethnicity also must be addressed, she points out.
Improving time-outs
Indeed, a good portion of the conference was devoted to potential solutions to nagging problems, such as low compliance with time-out standards. In response to a question from HBQI, O'Leary admitted to "some significant frustration" over what the data showed.
"[Time-outs are] the embodiment of trying to prevent wrongs, and we did issue a universal protocol two years ago that was endorsed by some 50 medical societies and nursing groups," he said.
Whatever the level of non-compliance is, O'Leary asserted, "It is too much." Part of the problem, he added, lies in the very nature of surgeons. "No surgeon has ever had a wrong-site surgery," he noted sarcastically. "My surgical colleagues tend to be strong-minded in their beliefs about things and some are less inclined to take [time-outs] seriously."
O'Leary said The Joint Commission convened a summit on wrong-site surgeries a couple of years ago and not only reaffirmed the universal protocol, "But it was suggested we become even more prescriptive. That process is moving forward, and there is a good chance we will be tightening [the requirements]."
There are two key issues at the heart of the problem, O'Leary added. "One is care process design. This can be solved in part by integrating the usual steps in the OR," he said. "The other is attitude and behavior, which will require increased attention to peer pressure and leadership."
Looking ahead
In response to other queries from the media, O'Leary indicated where The Joint Commission was headed in terms of performance measures. "We will see the measure set on surgical infections," he predicted. "We will also bring in line pediatric asthma. In the pipeline are critical care and ICU measures. Further back are issues like the nursing-sensitive measures set, which is in final field testing."
When asked at what point The Joint Commission will start measuring outcomes, O'Leary responded: "I know a lot of people believe that outcomes measures are the Holy Grail, but there are a number of process measures that have been scientifically established to be good proxies for eventual outcomes. I'm not saying we should not have outcomes measures, but a good profile includes both."
Another media question addressed the issue of multiple reports being issued by different bodies. Might a single report eventually be produced?
"The major achievement we've reached is a national collaborative to focus on emerging numbers through a common process, so that at least we are talking about the same sets of measures and providers are able to focus on those that are deemed ready to be used and documented," Umbdenstock says. "You will continue to see a variety of organizations take that data and work to make it available — maybe in different formats and through different perspectives."
"For those who get 'down in the weeds,' there are some subtle differences," added O'Leary.
For more information contact:
Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 2000, Rockville, MD 20850. Phone: (301) 427-1364.
Dennis S. O'Leary, MD, President, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.
Richard J. Umbdenstock, FACHE, President, American Hospital Association, One North Franklin, Chicago, IL 60606. Phone: (312) 422-3000.
A new report from The Joint Commission, of Oakbrook Terrace, IL, indicates that hospitals in the United States have achieved significant improvements in quality of care in the past four years for patients suffering from three conditions: Heart attack, heart failure, and pneumonia.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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