AHA Regional Policy Board Meeting June 2001

1
AHA Regional Policy Board Meeting
June 2001

Joint Commission on Accreditation of Healthcare
Organizations
2
Hospital Patient Safety Standards

• Nearly 50 percent of current standards relate to
  patient safety
• New standards effective July 1, 2001
• Hospital leaders must ensure organization-wide
  patient safety program
• Implement proactive program for identifying risk
  to patient safety
• Create a non-punitive environment that encourages
  the identification of safety risks and the
  reporting of errors
• Communicate outcomes of care, including
  unanticipated outcomes to patient and family
  members

Joint Commission on Accreditation of Healthcare
Organizations
3
Proposed Patient Safety Management Profile

• Other organizations will collect and report
  hospital safety information, ex Leapfrog Group,
  HCFA
• Hospitals want confidentiality of adverse event
  information
• Purchasers and the public want to know if
  hospitals are safe
• JCAHO can provide credible, standards- based
  information

Joint Commission on Accreditation of Healthcare
Organizations
4
Proposed Patient Safety Management Profile
(continued)

• Current proposal Portrayal of performance in
  seven safety-related groupings of standards that
  would include
• Safety culture of hospital
• Safety of physical environment
• General health care services
• Safe infection control practices
• Safe use of medications
• Safe surgery/anesthesia/transfusion services
• Safety-related qualifications of caregivers
• Portrayal would be included in organizations
  performance reports

Joint Commission on Accreditation of Healthcare
Organizations
5
Standards Review Project

• A 21-member task force to review the relevance
  and effectiveness of existing standards and
  burden of compliance requirements
• Task force will consider the following criteria
  when reviewing standards
• Continuing relevance in promoting patient safety
  and/or quality of care
• Applicability of standards to hospital care
• Clarity of the standard and associated
  requirements
• Linkage to patient outcomes

Joint Commission on Accreditation of Healthcare
Organizations
6
Staffing Effectiveness

• Expert panel formed to analyze proposed models
  for assessing staffing and rate sensitivity of
  indicators
• Hospitals to utilize screening indicators to
  assist in assessing staffing effectiveness
• Field review conducted March-May 2001
• Pilot testing for hospitals began in
• April 2001

Joint Commission on Accreditation of Healthcare
Organizations
7
Staffing Effectiveness Potential Screening
Indicators

• Human Resource
• Nursing care hours per
• patient day
• On call or per diem use
• Overtime
• Sick time
• Staff injuries on the job
• Staff satisfaction
• Staff turnover rate
• Staff vacancy rate
• Understaffing as compared to organizations
  staffing plan

• Clinical/Service
• Patient falls
• Injuries to patients
• Length of stay
• Adverse drug events
• Patient/family complaints
• Pneumonia
• Postoperative infections
• Skin breakdown
• Shock/cardiac arrest
• Upper GI bleeding
• Urinary tract infections

Joint Commission on Accreditation of Healthcare
Organizations
8
Initiatives to be tested in 2001

• More continuous survey process, including a
  survey process with an
• 18-month visit
• Use of pre-survey self-assessment of compliance
  with standards
• Migration toward a secure, automated
  internet-based application process

Joint Commission on Accreditation of Healthcare
Organizations
9
Disease-Specific Care Certification Program

• Evaluation of services provided to patients with
  chronic care conditions
• Twelve certification products to be developed
  over the next four years
• Diabetes care certification under development
  to be completed by December 2001

Joint Commission on Accreditation of Healthcare
Organizations
10
Disease-Specific Care Certification Program
(continued)

• Certificate of Distinction to be offered based on
  assessment utilizing
• Standards-based criteria
• Clinical practice guidelines
• Process outcomes and performance measures
• Benefit Allows hospitals, health plans, and
  other service providers to differentiate their
  services in the marketplace

Joint Commission on Accreditation of Healthcare
Organizations