JCAHO drafts error reduction standards
Nonpunitive approach emphasized
Patient safety has been a hot topic since the Institute of Medicine released its startling report on medical errors, To Err Is Human, in 1999. The Joint Commission on Accreditation of Healthcare Organizations continues to address the issue of medical errors in health care with a draft of its "revisions in support of patient safety programs in accredited organizations." The draft revisions are currently undergoing field review, and the Joint Commission is aiming for January implementation.
The revised requirements emphasize leadership, improving organizational performance, nonpunitive approaches to error reporting, and learning and sharing methods that improve patient safety.
In February, the Quality Interagency Coordin-ation Task Force, established by President Clinton, recommended that the Health Care Financing Administration establish a new condition of participation requiring hospitals to develop patient safety programs. The task force recommended the establishment of patient safety programs with executive responsibility to:
1. create nonpunitive systems that encourage reporting and analysis of medical errors;
2. incorporate well-understood safety principles;
3. provide for interdisciplinary team education and training.
In a letter advising hospital administrators of the draft standards, Dennis O’Leary, MD, president of the Joint Commission, emphasized the following points:
• the importance of an integrated, organizationwide safety program that encourages organizational learning and fosters communication;
• a need to clearly articulate the definition of what constitutes a "safety program," including designation of individuals who manage it, the scope of the program, procedures for immediate response to medical/health care errors, and expectations for internal and external reporting;
• the importance of forming a partnership between the provider and the patient and/or family in the health care process, while making it clear that accountability for safety remains a provider responsibility;
• the importance of addressing not just medical/health care errors leading to sentinel events but also "near misses."
O’Leary notes that "a recent analysis of current standards has found that 43% are directly related to patient safety and an additional 35% are indirectly related. . . . Nevertheless, the Joint Commission’s intensive five-year experience in reviewing sentinel events . . . makes clear that a more intensive focus on patient safety in health care organizations is needed."
The draft standard outlines reporting procedures for sentinel events in specific terms and specifies that "the leaders are responsible for establishing processes for the identification, reporting, analysis, and prevention of sentinel events." This would include developing a definition of a sentinel event and making sure it is communicated throughout the organization.
Take proactive approach
The standard also addresses the issue of proactive identification and management of potential risks to patient safety. It calls for leaders to prioritize processes that are identified as high-risk with respect to patient safety. The Joint Commission suggests that at least annually, the hospital select one high-risk process for proactive risk assessment, assess the implementation of the process to identify potential risks, identify the effect on patients, redesign the process, test the redesigned process, then implement it.
"Hospitals cannot rely only on investigating yesterday’s mishaps in order to improve the safety of patient care," says Patrice Spath, RHIT, of Brown-Spath Associates in Forest Grove, OR. "Like other high-risk industries, we must learn how to identify the weaknesses in our processes so that those weaknesses can be eliminated before patients are harmed.
"The new Joint Commission standards are just what the health care industry needs . . . less emphasis on retrospective sentinel event investigation and more emphasis on preventing accidents from occurring in the first place." Spath is also the author of Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, published by Jossey-Bass Publishers and AHA Press.
Health care administrators have gone to private industries where risk is a major factor, such as aviation and space travel, and asked for quality direction. The advice from some of the world’s top risk takers is for hospitals to look at processes before they are implemented and to ask themselves where the potential lies for errors or sentinel events.
The National Aeronautics and Space Admini-stration (NASA) wouldn’t launch a space ship before considering the "what ifs." What if the power system fails? What if the oxygen system closes down? What if the astronauts become disoriented? Aircraft manufacturers wouldn’t deliver a new airliner without questioning all the mechanical aspects from computer systems to food preparation.
"Sometimes, things are built in such a way that it’s amazing people don’t make more errors," says Paul Schyve, MD, senior vice president of the Joint Commission, "and sometimes the systems are so good you can’t see what to change." As Schyve points out, "NASA can’t [sit around and] wait for bad things to happen. It needs to know from the outset what could go wrong and then work to prevent it."
Health care obviously needs to look at new processes, as well as old, in the same way: before the process is implemented. What if the surgeon opens the hip replacement patient on the wrong side? What if the bottle the pharmacist sends to the unit has a lethal dosage and the nurse doesn’t realize it must be administered in increments? What if the new diagnostic machine won’t work correctly without specific lighting components?
Outside industry shows that when designers and administrators ask questions first, the end product is safer and better. "We in health care need to do likewise," says Schyve. "We need to ask ourselves, What are the potential bad outcomes?’"
The draft standard also concerns the planning process and calls for it to show how hospitals adjust priorities in response to unusual or urgent events. Priority consideration is expected for processes that affect a large percentage of patients — those that place patients at risk if not performed well and processes that have the potential for problems.
Communication is also important to the Joint Commission. The standard states that "the leaders develop a culture that emphasizes cooperation and communication." It requires leaders to "develop methods for promoting communication among services, individual staff members, and less formal structures such as quality action teams, performance-improvement teams, or members of standing committees."
"The organization’s leaders must support a patient-safe environment," says Spath, "and this includes educating physicians and staff in how to redesign processes so that errors can be eliminated, or if not eliminated, caught before patient safety is jeopardized."
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