Joint Commission president outlines top strategic priorities to aid QI efforts
Patient safety, value of accreditation head the list
It’s probably no surprise that patient safety tops the list of strategic priorities at the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO). "If you asked most of the people on our board their top priorities, the top five would be patient safety," says Dennis O’Leary, MD, president of JCAHO. In light of the media exposure of sentinel events, many hospital quality assurance programs have already moved into the area of safety, including needle sticks, patient falls, or medication errors.
"Quality professionals have become patient advocates for safety," says Marie Pears, RHIA, CPHQ, quality coordinator at Meadville (PA) Medical Center. Pears says the Joint Commission is moving in the right direction in the area of patient safety, and adds that a reliable comparative database would also be helpful. But she says JCAHO should heed its own advice and create quality teams focused on specific problem areas using people from JCAHO-accredited hospitals.
The Joint Commission faces numerous challenges beyond patient safety, O’Leary says, and one issue is the value of accreditation. According to O’Leary, an underlying problem is that only about 15% of the 150,000 health care entities currently eligible for accreditation are actually accredited. Roughly two-thirds of those are JCAHO- accredited, he adds. He contends that when it comes to performance comparisons, accreditation should be seen as a plus, but that decision is driven in part by the environment of comparative information. He says it is troubling that some current purveyors of this information rely solely on secondary databases and don’t employ any health professionals.
O’Leary says JCAHO plans to address "the impact of accreditation" through a scholarly paper developed by internal and external resources. That document might be released this fall. "This I think may become a fairly powerful paper," he says.
Another priority facing the Joint Commission is information dissemination, O’Leary says. Specifically, that means commercially packaging some of the information that is already publicly available. "The difficult issue that we are trying to face is whether we are going to become a source of comparative information," he reports. O’Leary says some of JCAHO’s earlier ventures in this area led merely to comparing accredited organizations with one another. "In reality, that is probably an exercise in futility," he says.
Yet another challenge facing JCAHO is the lack of physician engagement. Currently, JCAHO is not even engaged with the average practitioner, he says. "We are collectively trying to move forward [on] some very difficult issues, and of the five issues that the board has identified, this is clearly the most wanting."
Looking ahead, O’Leary says protective legislation now pending in Congress is a top priority. He says JCAHO has been vetting a series of principles to guide lawmakers for the last five years and now has key congressional support as well as 100 organizations signed on to the effort.
According to O’Leary, the issue amounts to a "fork-in-the-road decision-making process." Organizations interested in improving patient safety can create a reporting model, but those reports must be protected, he says. "You need to have reporting to accountable entities, whether they are in the public or private sector, and you have to depend on that entity to do the things the public expects to be done without hanging everybody out to dry." He says this type of model is now gaining clear favor.
O’Leary says the other issue is what the public will be informed about. JCAHO has been discussing patient safety for about a year and is moving forward a proposal that would build into the organization performance report a patient safety profile, which would provide five to seven subsets of standards that are understandable in lay terms, he says.
According to O’Leary, that record would include medication safety, environmental safety, as well as items such as sentinel events. "We are probably not going to include Leapfrog, but Leapfrog is another player out there that plans to report all sorts of things," he says. The National Committee on Quality Assurance also is prepared to start releasing patient safety-related information on hospitals, he adds.
Standards review project planned
"There are a lot of trains moving down this track, and in all candor, I think most people are looking to us to take the lead on this," says O’Leary. "It is likely that we will, and that will probably begin by the end of this year or the beginning of next year."
According to Pears, most patients have no idea what it means for a hospital to be accredited by the Joint Commission. The question facing hospitals is how to bring this information to the average patient and when that is appropriate, she says. "Sick patients are concerned about receiving the appropriate care. They assume that they are being treated by competent staff in a safe environment."
O’Leary notes that JCAHO is starting to move its patient safety standards across its other programs. "The existence of patient safety problems across all the centers of care is real." But the problems are not the same, and the standards issues are probably not going to be exactly the same, he says. "Those we expect to have in place pretty close to the end of the year as well."
JCAHO has an assortment of other targets on its radar screen as well, O’Leary reports. Very shortly, he says, the Joint Commission will launch a major standards review project that looks at both the standards and the survey process. "Some of the standards that were put in place back with the agenda for changes are a little bit rusty around the edges," he explains.
"Those standards are about six or seven years old and most of them can go," O’Leary says. There also are ways JCAHO can change the survey process requirements to diminish the documentation, he says. "But even if we became totally pristine, we will not totally eliminate documentation issues." Many of those documentation issues, particularly in large metropolitan areas, are driven by large Medicare contracts, O’Leary explains. "This is an important problem, and it may even merit an extensive study to document some of this."
Pears adds that JCAHO needs to change the focus of the survey process from documentation to real problems hospitals encounter, such as lack of competent staff, lack of finances, and staffing problems. "Hospitals spend an enormous amount of time making sure they adhere to the documentation standards." The focus of the survey needs to change, she says, because JCAHO is viewed as very prescriptive.
Patrice Spath, president of Brown-Spath Associates in Forest Grove, OR, says the Joint Commission appears to be working closely with regulatory and special interest groups to help reduce the data collection overlap and redundant regulatory requirements. "If people at the grass-roots level speak out more about the importance of collaboration among the movers and shakers in health care, perhaps some of the redundancy can be eliminated," she asserts.
Encouraging collaborative efforts
To help JCAHO improve working relationships with other groups, it behooves quality managers to encourage such collaborations, Spath says. For example, when state health departments demand performance data that are not part of the Joint Commission core measures, managers should explain what the core measures are and how they can be used to evaluate performance, especially in lieu of the ones chosen by the health department, she adds.
In particular, JCAHO is actively looking at ways to weave ISO 9000 requirements into its standards, O’Leary reports. "We do that with some great trepidation because ISO 9000 is kind of accreditation a la 1982. You have not seen documentation until you have seen ISO 9000."
JCAHO is talking to U.S. Pharmacopia about a reporting system, O’Leary says. These discussions are still in their early stages but far enough along enough to lend confidence in a final agreement, he adds. This system presents an attractive opportunity because it is not confidential, but it is anonymous, O’Leary says. "They know who is enrolled but they don’t know who is making the report. However, if you want to, you can dialogue with whomever the reporter is. It is a very cleverly designed system, and over time if this works itself out, this will probably become our database."
According to O’Leary, JCAHO is also looking at a project that would involve co-training physicians, nurses, physician assistants, nurse practitioners, and others in academic health centers at the student-training and residency levels. The goal would be to teach them about errors, systems analyses, teamwork, and other issues. "Sooner or later, we are going to have to start educating our health professionals on how you do this early on [instead of] trying to retrain them later on," he says.
Finally, he says, JCAHO will likely hold a national seminar about a year from now on how to make "the business case" for patient safety. "This is how you are going to make it through tomorrow. The fact that I believe this does not persuade you at this stage, but we have been harvesting that information in a variety of ways to make it available out in the field."
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