The New Joint Commission: Much Improved, With Room for More

Until about 8 years ago, inspections by the Joint Commission (TJC) were predictable and fairly silly. Hospitals were given a couple of years’ notice of the week that “The Joint” would be visiting. Everybody scurried around preparing – waxing the floors, locking up all the medications, that sort of thing. (It always struck me as the most dangerous day to be in the hospital, since nobody could find any of the medications, and the floors were slippery as hell). After arriving, the inspectors spent most of their time sealed in a conference room, pouring through policy manuals (we dusted them off before the visit) and meeting with administrators, exposed to whatever reality the hospital wanted them to see. It was an ineffectual kabuki dance.

Last week, the Joint Commission visited UCSF Medical Center. Luckily, our director of regulatory affairs, Jolene Carnagey, is tasked with checking the TJC website every Monday at 7:30 am to see what hospitals they’ll visit that week. Because of this, we had advance notice of our inspection – by about 15 minutes! Once Jolene spotted UCSF on the TJC schedule, she sent stat alerts to our key people, like a parental phone tree on a school snow day.

By 7:45 am, there were half-a-dozen TJC accreditors in our hospital lobby.

As important as the unannounced visits (which are, of course, what you’d want if you were a patient), TJC has made other major improvements over the past decade. The inspectors spend far more time walking around on clinical units – talking to docs, nurses, hospital administrators, and patients – and less time wading through policies and procedures. Their agenda is a bit less focused on the nitpicky “Standards” and more on a series of National Patient Safety Goals that TJC began issuing in 2003 – things like the pre-operative time out and developing methods to analyze errors and use the results to improve safety. The important stuff.

In my 2004 review of the state of the patient safety field, these changes led me to laud the Joint Commission as the most important driver of safety in American hospitals. I recognize that praising a regulator or accreditor seems frankly un-American – we cherish our individualism and (at least until we learned about toxic assets) generally put our faith in the wisdom of the market. But in the world of patient safety, I believed then, and now, that we needed a central authority to force us to implement certain safety practices.

In my recent reassessment of the safety field, however, my appraisal of accreditation was a bit less charitable, for several reasons. First, accreditation and regulation are, in policy-speak, blunt tools – great for compelling adherence with limited sets of processes, but less useful for other types of complex activities. Just compare TJC Safety Goals circa 2003-4 (avoiding high risk abbreviations, “sign your site”) with more recent ones (improving handoff communications, better leadership, dealing with disruptive providers). Although TJC can message the importance of addressing these nuanced, socio-cultural problems, it is awfully hard for them to be prescriptive about solutions.

Second, in a well-meaning effort to drive the safety agenda forward, TJC outran the evidence or failed to anticipate negative consequences on several occasions. Two prime examples: TJC’s medication reconciliation mandate was issued before there was any evidence about how to do reconciliation effectively (or even whether it worked). Not surprisingly, the “med rec” requirement was followed by several years of Brownian motion. And the 4-hour “door-to-antibiotic” pneumonia rule was a disaster, leading to the administration of thousands of doses of unnecessary antibiotics by ED docs who felt pressured to promptly treat patients who “might have pneumonia,” but actually didn’t.

Finally, a grim “we’re the safety police” posture squanders a tremendous opportunity. TJC personnel have a unique, bird’s-eye view of American healthcare, since they peek under the hood of thousands of provider organizations each year. Their accumulated wisdom could be used to not only evaluate accredited organizations, but to help them improve. This, of course, would take a major change in culture at TJC.

The odds of such a culture change went up when my friend Mark Chassin became TJC’s president in 2008 – partly because Mark is a do-er, partly because Mark is religious about QI, and partly because Mark’s previous job was to lead quality and safety at a large medical center (Mt. Sinai), so he knows the issues from the provider point of view. Soon after starting his new job, Mark set out to transform TJC. Last week’s visit demonstrated that his efforts are bearing fruit.

Last year, Mark launched TJC’s Center for Transforming Healthcare to help discover and disseminate best practices in safety and quality. The Center partnered with a dozen or so healthcare organizations to tackle key challenges, starting with hand hygiene, surgical safety, and hand-off communication. Although the accreditation side of the house is separated from the Center by a firewall, one has to believe that an in-house innovations/best practices engine will ultimately influence the nature of the inspections and the ability of TJC accreditors to recommend evidence-based, well vetted practice changes to the institutions they visit.

Perhaps more importantly, TJC’s mission statement has changed. As Ann Blouin, TJC’s new director of accreditation (a former healthcare consultant and practicing nurse), recently described when we spoke at a conference together, “you’ll notice that the word accreditation doesn’t appear in our mission anymore.” Rather, it reads:

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 

Inspire? The Joint Commission? Yes, that’s what it says. But lots of organizations have lofty mission statements that don’t quite extend to their front line personnel; I was interested to see how it would play out during last week’s inspection.

And sure enough, at a closing session with our senior leadership, the TJC team leader, Jerry Dykman, began by describing TJC’s mission statement – including the “inspire” part, and added, “and we hope we’ve done that this week.” He then ran a terrific session, prompting an open dialogue about the things UCSF was doing well, along with our areas for improvement.

Then Mr. Dykman asked us whether there were things that TJC could do better. What’s even more remarkable, all of us felt that he was truly seeking honest feedback. So we gave it. Here’s mine:

First, I commended the visitors on the openness of this session and the positive tone of the visit.

Second, I recommended that they build in more time at the end of a visit (after summarizing the evaluation) for an informed and collaborative discussion regarding ways the hospital can improve.

Finally, while I understand that TJC needs to make sure that hospitals are crossing their t’s, the continued focus on the small stuff is annoying and distracting. There is no evidence, for example, that the absence of a signed verbal order is a significant public health hazard (in fact, the only study that ever addressed this issue found that verbal orders were associated with improved outcomes). I’m not arguing that verbal orders should go unsigned, but the emphasis on documentation feels awfully bureaucratic, and risks losing the forest for the saplings.

Instead of playing small-ball, TJC should shift its focus to initiatives that could save hundreds, if not thousands, of lives. Here are two of them:

First, they should require that hospitals deliver more than 90 percent of their discharge summaries to the follow-up provider within 24 hours of hospital discharge. We know that rates of readmissions are stunningly high; one reason is that more than two-thirds of follow-up providers lack a discharge summary when they see patients for first time after discharge. That’s crazy, and it’s unacceptable. TJC could fix it tomorrow.

Second, TJC should require that every accredited hospital demonstrate a hand hygiene rate of greater than 80 percent, assessed through a rigorous audit strategy (not the floor’s nurse manager standing in the hallway with a clipboard). This would involve secret and certified audits of hand hygiene conducted periodically (not during the TJC visit, when everyone’s on good behavior). Most hospitals have hand hygiene rates in the 40-60 percent range, and a TJC requirement would save countless lives. Believe me, hospitals would figure out how to meet the new standard, both by improving their hand hygiene systems and by enforcing accountability standards when providers habitually fail to clean their hands.

But these are for tomorrow. For today, kudos to TJC for doing more and more things right. Just as providers and hospitals need to continuously improve, so too do accrediting and regulatory agencies. At the risk of ending up on a Tea Party enemies list, I will state my belief that the Joint Commission is doing just that.

7 Responses to “The New Joint Commission: Much Improved, With Room for More”

  1. evidence April 23, 2010 at 9:17 pm #

    It’s good to be concerned about the evidence. Could you point to the evidence for the following statement and maybe say a few words about the quality of this evidence?

    “And the 4-hour “door-to-antibiotic” pneumonia rule was a disaster, leading to the administration of thousands of doses of unnecessary antibiotics …”

  2. Bob Wachter April 24, 2010 at 1:18 am #

    Dear “Evidence”:

    Thanks for your comment. There are several relevant studies, most of which I cite in my 2008 Annals of Internal Medicine review of the unanticipated consequences of the 4-hour door-to-antibiotics measure. The best are probably the study by Kanwar (Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule) in Chest, 2007; and the study by Welker (Antibiotic timing and errors in diagnosing pneumonia) in the Archives of Internal Medicine, 2008.

    Both studies found a marked increase in ED misdiagnoses of pneumonia associated with implementation of the 4-hour rule; the Kanwar study showed a 20% increase in inappropriate antibiotic utilization. The Joint Commission relaxed the standard from 4 to 6 hours after examining these studies and other evidence that the rule was promoting inappropriate antibiotic administration.

     Bob

  3. menoalittle April 24, 2010 at 3:56 am #

    Your perspective is perennially interesting and valued, Bob.

    In this case, The Joint Commission conducts business attending to the picayune, such as chastising hospitals to chase its professionals for not entering a time next to a chart entry. That is trivial in importance when compared to the following Joint Commission writings, and inconsistencies.

    The Joint Commission has done little to mitigate the risks patients face from deployments of healthcare information technology, which is not ready for prime time. It provided a Sentinal Alert, and then did nothing. It does not enforce its own Standards pertaining to conduct of hospitals’ leadership, which is more often than not, hell bent on profits while ignoring the patients. Concomitantly, they deploy difficult to use HIT, making life miserable for doctors and nurses, and then for the patients (1). You might know about that, Bob.

    The Joint Commission has not provided any help in improving on its reported concern of a “dearth of data on the incidence of adverse events directly caused by HIT overall” (2). The Huffington Post has done a better job: http://www.huffingtonpost.com/2010/04/20/electronic-medical-record_n_545441.html

    http://huffpostfund.org/stories/2010/04/amid-digital-records-surge-lack-policing-fda

    The Joint Commission owes it to the patients to actually assure they are in a safe hospital, but then again, the Joint Commission accreditation is for the hospitals.

    Best regards,

    Menoalittle

    References:

    1. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_43.htm

    Existing Joint Commission requirements_The Leadership chapter in the standards manual addresses leadership and safety, specifically relating to the organization’s governing body, the chief executive and senior managers, and medical and clinical staff leaders. The standards specifically require that these three leadership groups create a culture of safety (11) by creating an atmosphere of trust and fairness that encourages reporting of risks and adverse events, by allocating the resources necessary to support safety, by discussing and reporting safety issues and indicators, and by developing plans to assure and improve safety performance, especially in relation to high-risk or problem-prone processes.

    2. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

    Safely implementing health information and converging
    technologies

    As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations,1,2 users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate…

    There is a dearth of data on the incidence of adverse events directly caused by HIT overall. The United States Pharmacopeia MEDMARX database includes 176,409 medication error records for 2006, of which 1.25 percent resulted in harm. Of those medication error records, 43,372, or approximately 25 percent, involved some aspect of computer technology as at least one cause of the error.

  4. Brian Clay, MD April 25, 2010 at 8:11 pm #

    I share your hope that The Joint Commission will move away from the nitpicky details of documentation and policy and more toward initiatives and goals that truly foster patient safety. As the physician champion for medication reconciliation at my institution (and as part of the SHM-led task force that worked with TJC to revise the National Patient Safety Goal for med rec), I am very pleased with the new version, which is less process-oriented and devolves more of the process design to individual institutions.

    My hope for The Joint Commission is that they add as part of the National Patient Safety Goal phenomenon encouragement for individual institutions to report back successes for general sharing and dissemination — let hospitals that seem to have cracked a particular regulatory nut use TJC as a mechanism to share that information more widely.

  5. dZA April 27, 2010 at 12:31 pm #

    kabuki dance

    brownian motion

    peek under the hood

    safety police

    lofty mission statements

    playing small ball

    Tea party enemies list

    /cracked me up

  6. Jackie Murray May 3, 2010 at 7:10 am #

    I had an incident at a hospital a while back. The hospital was cited for various things (major problems, not bedpan changing stuff) related to my care. I also contacted the JC, but it took YEARS for them to finally be convinced that my complaints had merit! Then all I got was a letter explaining that the investigation had been done, but that the results are “confidential.” WHAT!!! I want to know that what happened to me isn’t repeated. As an aside the Board of Health and Welfare, while citing the hospital for many problems with “standard of care” and violations of the law, never did a follow up to acertain whether any changes were actually instituted. I don’t trust anybody involved in health care any more. I hope that my NP will just give me pain pills if I get really sick as I won’t be subjecting myself to a hospital! Its all one big huge secret and it doesn’t seem like anybody is actually DOING anything to protect patients.

  7. Tex Bryant May 14, 2010 at 1:30 pm #

    I concur with Dr. Clay about the promotion of best practices that it finds as it reviews various hospitals; it could, for instance, promote best practices that it finds in reducing 30 day readmission rates. Rather than making hospitals reactive to shortcomings that it finds, it should encourage a proactive stance. It should at the same time retain some its clout as an accrediting body. I think that its promotion of best practices could be even stronger if it collaborates with other bodies involved in similar activities, such as IHI.

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