Accreditation watch status an evolving process
Hospitals wonder how they are chosen for review
The Joint Commission on Accreditation of Healthcare Organizations has seen "accreditation watch" status evolve in the past year as many hospitals found the former "conditional accreditation" status too negative. Yet many questions remain regarding how the agency decides to investigate hospitals in between regular surveys.
During 1995 there were a number of highly publicized, seriously adverse episodes in accredited hospitals around the United States amputating the wrong foot, operating on the wrong side of the brain, accidental overdosages. Sometimes the Joint Commission would learn of an event through the media or from a letter from a patient. Occasionally the health care organization itself brought the incident to the agency’s attention. As events surfaced, the board of commissioners and the accreditation committee struggled with how to address the situations and work with health care organizations to avoid such events in the future. The agency’s initial response was to establish a policy and procedure for dealing with that kind of event.
Surveyor asks two questions
In January 1996, the Joint Commission established the "sentinel event" policy, which states that when such an event occurs, the agency will send a surveyor to the organization. The surveyor would look at two questions:
• Did the event in fact occur?
• Could the organization have had control over the sentinel event or the events that led up to the sentinel event?
The second question was not meant to determine whether the organization did something wrong or was negligent, but whether it could have reduced the likelihood of the event happening. The focus of the survey is improvement of outcomes, not determining negligence or blame.
If the answers to the questions are "Yes," the organization surveyed would be placed on conditional accreditation and be expected to tell the Joint Commission what it intended to do to discover why the event occurred and how to prevent future occurrences. Six months down the road, the plan said, the Joint Commission would send a surveyor to assure implementation. In according the conditional status, the commission had four principles in mind:
• to improve patient care;
• to focus the attention of the organization that experienced the sentinel event on understanding the causes;
• to inform the public of the occurrence and of the fact that steps were being taken to prevent a future occurrence;
• to maintain the confidence of the public in the accreditation process.
"Unfortunately," says Paul Schyve, MD, senior vice-president of the Joint Commission, "the phrase conditional accreditation’ was perceived by some health care organizations and the public as a negative, punitive statement. That was partly because the Commission had traditionally used the term to describe an organization on the cusp of becoming accredited, but not yet there because of deficiencies. The new designation didn’t mean that. It was meant to be applied to an organization that, until the sentinel event occurred, had complied with all the commission’s standards."
It was understood sentinel events could occur even in organizations that had been accredited with commendation a year or two earlier. The designation was not meant to imply that an organization was in trouble or that it was in any way at fault. Yet the perception was that the designation was punitive.
"What we were trying to do was encourage an organization to look closely at what it was doing, determine why an event happened, and try to prevent it," Schyve says. "Instead, it placed them in a position of trying to explain away the event and come up with responses such as It wasn’t really our fault.’"
In September 1996, the commission revised its policy and began to use the phrase "accreditation watch" instead of the label perceived to be punitive. The principles were the same only the terminology changed. "Accreditation watch is meant to convey the perception that nothing untoward has been concluded about the organization," Schyve says. "A watch is in place. The sentinel event may have nothing to do with what the organization has done; it may be a matter of the environment having changed." When the commission places a facility on accreditation watch, it requires that it develop a root-cause analysis. The facility must submit the results of the analysis within 30 days.
Disasters waiting to happen
The root-cause-analysis requirement originated from a meeting held in early December 1996 when the Joint Commission co-convened at the Annenberg Center in California with the American Medical Association and the American Association for the Advancement of Science. The focus of the meeting was an investigation of errors in health care: what they are, how often they occur, and how to prevent them. The participants looked at two other industries equally concerned about errors airlines and nuclear power. The Joint Commission came to recognize that it didn’t know how often or why many health care errors occur. In addition, it acknowledged that, for the most part, the proximate cause for many errors is human. "Psychologists tell us that human errors will always occur," Schyve says. "Short-term memory and attention are fallible. When you’re dealing with health care, you’re dealing with individuals doctors, nurses, social workers and errors will occur."
Root causes generally require a series of "Whys?" Once the proximate cause is recognized a doctor prescribed a medication and the patient had an adverse interaction the analysis doesn’t stop there. The roots are analyzed and corrected. Doctors cannot be aware of every drug interaction, for example, so a system is put in place that makes the doctor aware of interactions.
Analyzing root causes involves more than questions like "What was the proximate cause?" and "Who prescribed that drug?" It considers "What can we do within the system and processes of the organization to protect against those errors?"; "How can an inevitable error be caught quickly?"; and "How can the patient be protected after he has become the victim of an error?"
The commission reviews the organization’s root cause analysis to determine its credibility. When the Joint Commission is satisfied, it removes the organization from accreditation watch and returns it to its prior status. Before the watch came into being, the organization would be removed from its prior accreditation status and placed in conditional accreditation after the investigation.
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