The Value of Accreditation

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The Value of Accreditation

• Kurt A. Patton
• Executive Director, Accreditation Services JCAHO

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Table of Contents

• Overview of the Joint Commission
• The New Survey Process
• Literature on outcomes
• Sentinel events and root causes
• Future activities at the Joint Commission 
• Q A

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WHO IS JCAHO?

• Private, not for profit accrediting body since
  1951
• Board of Commissioners American Hospital
  Association, American Medical Association, public
  members, American College of Physicians, American
  Society for Internal Medicine, American Dental
  Association, American College of Surgeons.

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.And In The Beginning
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The American College of Surgeons1917The Minimum
Standard

• That physicians and surgeons privileged to
  practice in the hospital be organized as a
  definite group or staff. Such organization has
  nothing to do with the question as to whether the
  hospital is open or closed, nor need it
  affect the various existing types of staff
  organization. The word staff is here defined as
  the group of doctors who practice in the hospital
  inclusive of all groups such as the regular
  staff, the visiting staff, and the associate
  staff.
• That membership upon the staff be restricted to
  physicians and surgeons who are (a) full
  graduates of medicine in good standing and
  legally licensed to practice in their respective
  states or provinces, (b) competent in their
  respective fields, and (c) worthy in character
  and in matters of professional ethics that in
  this latter connection the practice of the
  division of fees, under any guise whatever, be
  prohibited.
• That the staff initiate and, with the approval of
  the governing board of the hospital, adopt rules,
  regulations, and policies governing the
  professional work of the hospital that these
  rules, regulations, and policies specifically
  provide
• That staff meetings be held at least once each
  month. (In large hospitals the departments may
  choose to meet separately.)
• That the staff review and analyze at regular
  intervals their clinical experience in the
  various departments of the hospital, such as
  medicine, surgery, obstetrics, and the other
  specialties the clinical records of patients,
  free and pay, to be the basis of such review and
  analyses.
• That accurate and complete records be written for
  all patients and filed in an accessible manner in
  the hospitala complete case record being one
  which includes identification data complaint
  personal and family history history of present
  illness physical examination special
  examinations, such as consultations, clinical
  laboratory, X-ray and other examinations
  provisional or working diagnosis medical or
  surgical treatment gross and microscopic
  pathological findings progress notes final
  diagnosis condition on discharge follow-up and,
  in case of death, autopsy findings.
• That diagnostic and therapeutic facilities under
  competent supervision be available for the study,
  diagnosis, and treatment pf patients, these to
  include, at least (a) a clinical laboratory
  providing chemical, bacteriological, serological,
  and pathological services (b) an X-ray
  department providing radiographic and
  fluoroscopic services.

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INITIAL SURVEY RESULTS 1919

• 692 hospitals of 100 or more beds are surveyed
• Only 89 meet the minimum standards
• Only 264 held regular medical staff meetings
• Only 301 keep medical records
• Findings burned in the boiler of the Waldorf
  Astoria Hotel.

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1951 A JOINT COMMISSION IS FORMED

• American Medical Association
• American Hospital Association
• American College of Surgeons
• American College of Physicians
• Canadian Medical Society

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1953- EARLY FINDINGS

• 1202 US hospitals seek accreditation
• 99 of hospitals gt300 beds
• 75 of hospitals 25-49 beds
• Hospitals lt 25 beds not surveyed

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JCAHO EVOLUTION

• 1962 3,947 Hospitals accredited
• 1964 Survey fees established
• 1965 Medicare legislation deems JCAHO
• 1967 Standards revision process with 21
  advisory panels
• 1986 Launch of Agenda for Change
• 2001 Launch of CAH program
• 2004 Launch of Shared Visions New Pathways
• 2005 Accredit 4500 hospitals, 260 CAH

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The Joint Commissions Mission
To continuously improve the safety and quality
of care provided to the public through the
provision of health care accreditation and
related services that support performance
improvement in health care organizations.
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Accreditation and Certification Programs
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JCAHO SIGNIFICANTLY CHANGED ITS PROCESS IN 2004

• New techniques of conducting the surveys
• Patient tracers
• Spontaneity, no script for anyone
• New pre-survey analysis of data
• New standards format
• New scoring methods
• New decision categories
• New post survey follow up

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GOALS OF THE NEW SURVEY PROCESS

• Shift the paradigm from survey prep to systems
  improvement
• Focus away from exam and score
• Focus toward using standards to achieve and
  maintain excellent operational systems
• Focus on
• Actual performance not stated capacity
• Execution not potential

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NEW ACCREDITATION PROCESS SETS THE STAGE FOR

• Continuous emphasis on operational performance
  improvement
• Focus on the quality and safety of direct patient
  care delivery systems
• A customized approach to the characteristics of
  the individual organization
• Reliance on new technology to facilitate the
  continuous flow of information between the
  organization and the Joint Commission

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ARE JCAHO ACCREDITED HOSPITALS BETTER?

• Health Affairs Vol 22 March/April 2003
• 134,579 AMI patients, 4,221 hospitals
• JCAHO scores did not correlate with outcomes for
  AMI patients.
• Accredited hospitals, as compared to non
  accredited hospitals did have better results.

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AMI OUTCOMES

• Accredited
• ASA on admission 54.5
• BB on admission 48.5
• Reperfusion 67.5
• 30d risk standardized mortality 18.4

• Not Accredited
• ASA on admission 51.8
• BB on admission 43.1
• Reperfusion 61.8
• 30d risk standardized mortality 20.4

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AMI OUTCOMES UPDATE WITH CORE MEASURES

• ASA on arrival 94, 286,000 cases
• BB on arrival 89, 253,000 cases 7th SOW 80
• Net inpatient mortality 9, 301,000 cases

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WHAT IS DRIVING HOSPITALS PATIENT SAFETY EFFORTS?

• Health Affairs Volume 23, Number 2
• March/April 2004
• The most frequently mentioned initiatives either
  explicitly noted they were designed to meet JCAHO
  initiatives, or mapped back to JCAHO policies and
  requirements.
• The only frequently mentioned activity not
  directly linked to JCAHO was IT

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WHAT IS DRIVING HOSPITALS PATIENT SAFETY EFFORTS?

• To a lesser extent
• Leapfrog, NPS Foundation, AHRQ, IHI
• Medicare
• Market forces

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THE JOURNAL OF RURAL HEALTH FALL 2000

• Quality Oversight Why are Rural Hospitals Less
  Likely to be JCAHO Accredited?
• Cost factors for meeting the standards, the
  survey process and ORYX.
• The least expensive hospital survey was 2
  surveyors for 2 days and 7,800
• The standards are perceived reasonably well

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ACTIONS TO MAKE ACCREDITATION MORE FEASIBLE FOR
RURAL HOSPITALS

• Flat fee pricing 6200 every 3 years
• Subscription payments annually
• Single surveyor techniques
• Unique accreditation manual for critical access
  hospitals
• New standards format adds clarity and
  transparency to the process

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CAHS AND QUALITY IMPROVEMENT

• Quality Improvement Activities in Critical Access
  Hospitals Results of the 2004 National CAH
  Survey
• September 2004
• Flex Monitoring Team
• University of Minnesota
• University of North Carolina, Chapel Hill
• University of Southern Maine

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CAHS AND QI

• Positive differences do exist between accredited
  and non accredited CAHs in their use of CPGs.
  Only pneumonia and CHF are statistically
  significant.
• Pneumonia CPG use in accredited CAH is 94 and
  non accredited is 82.8
• CHF is 94 vs 82
• AMI 92 vs 84.2

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CAHS AND PATIENT SAFETY

• Critical Access Hospital Patient Safety
  Priorities and Initiatives Results of the 2004
  National CAH Survey
• Flex Monitoring Team
• University of Minnesota
• University of North Carolina Chapel Hill
• University of Southern Maine

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CAHS AND PATIENT SAFETY

• 474 CAHs respond to the survey
• Only 11 are accredited
• 63 are familiar with JCAHOs NPSG
• Only 2.3 report focus on JCAHOs NPSGs
• Only 1.9 report focus on prevention of wrong
  site surgery.

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COLORADO ACCREDITATION

• 63/69 Hospitals are accredited by JCAHO
• 1 is dually accredited with AOA
• 2/24 Critical access hospitals are accredited.
• Does the state have the resources to review the
  non accredited CAHs on a regular basis?

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SENTINEL EVENTS

• Voluntary reporting of fatal errors or permanent
  loss of functioning.
• Sentinel events that are voluntarily reported are
  the tip of the iceberg
• They are identified and known
• Legal issues permit reporting
• Each must be accompanied by a root cause analysis
  and action plan.

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Sentinel Event Experience to Date

• 415 inpatient suicides
• 370 events of surgery at the wrong site
• 365 operative/post op complications
• 326 events relating to medication errors
• 221 deaths related to delay in treatment
• 144 patient falls
• 124 deaths of patients in restraints
• 107 assault/rape/homicide
• 85 transfusion-related events
• 84 perinatal death/injury
• 57 infection-related events
• 57 deaths following elopement
• 51 fires
• 49 anesthesia-related events
• 511 other

2966 RCAs
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Total "Reviewed" Events by StateJanuary 1995
through December 2004
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"Reviewed" Events per Million Population (by
State)
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Self-reported Events by StateJanuary 1995
through December 2004
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Total Sentinel Events Reported by Year
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Root Causes of Sentinel Events
Percent of 2966 events
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Root Causes of Wrong Site Surgery
Percent of 370 events
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Root Causes of Medication Errors
Percent of 326 events
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Staffing-related Factors Identified in RCAs
Completed in 2004
Percent of RCAs citing these staffing factors
37
Percent of RCAs Citing Staffingas a Root Cause
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Communication as a Root Cause

• Mode of communication
• Oral (55)
• Written (35)
• Electronic (10)
• Participants
• Among staff (60)
• With or among physicians (25)
• With patient or family (15)
• Other communication issues
• Transcription
• Change-of-shift report
• Paging systems

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JCAHO INTERVENTIONS AND TECHNIQUES

• Continual standards development and renewal
• Sentinel event alerts
• National Patient Safety Goals each year
• New survey process (tracers) and surveyor
  education
• Partner with others universal protocol, ISMP,
  patients and families

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HAP PTAC Organizations
PARTICIPATING ORGANIZATIONS Acute Long Term
Hospital Association American Academy of Family
Physicians American Academy of Nurse
Practitioners American Academy of
Pediatrics American Academy of Physician
Assistants American Association of Nurse
Anesthetists American College of Emergency
Physicians American College of Healthcare
Executives American College of Physician
Executives American College of Physicians American
College of Radiology American College of
Surgeons American Dental Association American
Health Information Management Association American
Hospital Association American Medical
Association American Medical Rehabilitation
Providers Association American Nurses
Association, Inc. American Psychiatric
Association American Society for Clinical
Pathology American Society for Healthcare Risk
Management (AHA-PMG) American Society of
Anesthesiologists American Society of
Health-System Pharmacists American Surgical
Hospital Association Association for
Professionals in Infection Control and
Epidemiology, Inc. Association of Health Facility
Survey Agencies Association of periOperative
Registered Nurses, Inc. Centers for Disease
Control and Prevention Centers for Medicare and
Medicaid Services Coalition of Rehabilitation
Medicine Organizations
College of American Pathologists Federal Nursing
Services Council Federation of American
Hospitals National Association for Healthcare
Quality National Association Medical Staff
Services National Association of Healthcare
Access Management National Association of
Psychiatric Health Systems National Association
of State Mental Health Program Directors National
Rural Health Association Public Members
(2) COALITION OF REHABILITATION THERAPY
ORGANIZATION American Physical Therapy
Association National Coalition of Creative Arts
Therapies Association American Therapeutic
Recreation Association American Occupational
Therapy Association American Osteopathic
Healthcare Association American Physical Therapy
Association American Speech-Language-Hearing
Association American Therapeutic Recreation
Association National Coalition of Creative Arts
Therapies Association National Therapeutic
Recreation Society
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UNIVERSAL PROTOCOL ENDORSEMENTS

• Accred Council for Grad Med Education
• Agency for HC Research Quality
• Amer Academy of Amb Care Nursing
• Amer Academy of Cosmetic Surgeons
• Amer Acad of Facial Plastic Recon Surg
• Amer Academy of Family Physicians
• Amer Academy of Ophthalmology
• Amer Academy of Orthopedic Surgeons
• Amer Acad of OtolarynHead Neck Surg
• Amer Academy of Pediatrics
• Amer Assoc of Amb Surgery Centers
• Amer Assoc of Eye Ear Hospitals
• Amer Assoc of Nurse Anesthetists
• Amer Assoc of Oral Maxillofacial Surg
• Amer College of Cardiology
• Amer College of Chest Physicians
• Amer College of Emergency Physicians
• Amer College of Foot Ankle Surgeons
• Amer College of Obstetrics Gynecology

• American Medical Association
• American Medical Group Association
• American Nurses Association
• Amer Organization of Nurse Executives
• Amer Pediatric Surgical Association
• Amer Society for Surgery of the Hand
• Amer Society of Anesthesiologists
• Amer Society of General Surgeons
• Amer Society of Ophthalmic RNs
• Amer Society of Perianesthesia Nurses
• Amer Society of Plastic Surgeons
• Amer Society of Plastic Surg Nurses
• American Urological Association
• Assoc of American Medical Colleges
• Assoc of PeriOperative Reg Nurses
• Assoc of Surgical Technologists
• Federated Ambulatory Surgery Assoc.
• Federation of American Hospitals
• Medical Group Management Assoc.

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Joint Commissions Safety Initiatives

• 1996- The Sentinel Event Policy is established
  requiring RCA, action plan and measurement
• 2001- New standards that focus directly on
  patient safety and medical error reduction are in
  
• 2002- Establishes the National Patient Safety
  Goals
• 2002- JCAHO CMS launch Speak Up Campaign
• 2003-Intensive analysis, FMEA standards
  introduced
• 2003 Universal protocol for prevention of wrong
  site surgery
• 2004- Patient and Family Notification
• 2004- QualityCheckR

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ENHANCING PATIENT SAFETY

• Are unapproved abbreviations just unapproved, or
  are they really dangerous abbreviations?
• That issue has never been a problem at our
  hospital
• Is a time out before surgery an unnecessary
  use of 60 seconds?

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DO NOT USE ABBREVIATIONS

• u
• IU
• qd
• qod
• Leading decimal point
• (always use a leading zero)
• Trailing zero
• MS
• MSO4
• MgSO4

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DANGEROUS ABBREVIATIONS
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WEVE NEVER HAD A BAD PATIENT OUTCOME AT OUR
FACILITY DUE TO..

• We can learn from the limited reported mistakes
  of others
• We dont have to wait for the adverse outcome to
  be replicated at every hospital.
• IOM report calls for national patient safety
  center and nationwide reporting so we can learn
  from the incidents occurring elsewhere

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CREATING A CULTURE OF SAFETY

• How is care provided?
• How are errors perceived?
• How are the reporters of errors perceived?
• Are they rewarded or punished?
• What are the barriers to reporting?
• How does the environment allow errors to occur?

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• CHANGING CULTURE

• Make the safest thing to do, the easiest thing to
  do
• Lessons from aviation
• Dishonorable not to report
• Neutral party reporting
• Separate from performance review
• Leadership involvement and commitment

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WHAT CAN JCAHO DO TO HELP AN ACCREDITED
ORGANIZATION?

• JCAHO can provide tools and a framework for
  accreditation
• Good outcomes are derived from their use of the
  tools and the framework
• The best outcome of accreditation is enhanced
  patient safety (not the survey score)

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JCAHO MOVING TO UNANNOUNCED SURVEYS IN 2006

• All full surveys will be unannounced
• Pilots have been conducted in 2004, 2005
• Pilots validate lack of ramp up
• Pilots validate enhanced credibility
• Supported by continuous access to the periodic
  performance review tool
• 2009 wide scheduling window.