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					 The Value of Accreditation

         Kurt A. Patton
Executive Director, Accreditation
        Services JCAHO
             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
             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.
….And In The Beginning…
               The American College of Surgeons
                             1917
                                       The Minimum Standard


1. 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.”
2. 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.
3. 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:
     a) That staff meetings be held at least once each month. (In large hospitals the departments may choose to meet
        separately.)
     b) 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.
4. That accurate and complete records be written for all patients and filed in an accessible manner in the hospital—a 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.
5. 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.
   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.
   1951 A JOINT COMMISSION
           IS FORMED
 American Medical Association
 American Hospital Association
 American College of Surgeons
 American College of Physicians
 Canadian Medical Society
      1953- EARLY FINDINGS

 1202 US hospitals seek accreditation
 99% of hospitals >300 beds
 75% of hospitals 25-49 beds
 Hospitals < 25 beds not surveyed
            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
The Joint Commission’s 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.



                                      10
Accreditation and Certification
          Programs
                                        Health Care
                                         Staffing        Primary
                     Critical Access     Services
                                                          Stroke
                         Hospital
                                                          Center
                                                                      Lung
          Assisted                                                   Volume
           Living                                                   Reduction
                                                                     Surgery


    Ambulatory                                                             Disease-
     Health                                                                Specific
      Care                                Joint                              Care
                                       Commission


                                                                      Behavioral
       Network
                                                                      Health Care


              Long Term
                                                              Laboratory
                Care

                              Home Care           Hospital
           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
            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
    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
      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.
            AMI OUTCOMES

 Accredited             Not Accredited
   ASA on admission       ASA on admission

    54.5%                   51.8%
   BB on admission        BB on admission

    48.5%                   43.1%
   Reperfusion 67.5%      Reperfusion 61.8%

   30d risk               30d risk

    standardized            standardized
    mortality 18.4%         mortality 20.4%
      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
        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
      WHAT IS DRIVING HOSPITALS‘
       PATIENT SAFETY EFFORTS?

 To a lesser extent:
     Leapfrog, NPS Foundation, AHRQ, IHI
     Medicare
     Market forces
      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
   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
           CAH‘S 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
             CAH‘S AND QI

 Positive differences do exist between
  accredited and non accredited CAH‘s in their
  use of CPG‘s. 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%
          CAH‘S 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
           CAH‘S AND PATIENT
                SAFETY
   474 CAH‘s respond to the survey
   Only 11% are accredited
   63% are familiar with JCAHO‘s NPSG
   Only 2.3% report focus on JCAHO‘s NPSG‘s
   Only 1.9% report focus on prevention of wrong site
    surgery.
   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 CAH‘s on a regular basis?
          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.
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                 = 2966 RCAs
     57   infection-related events
     57   deaths following elopement
     51   fires
     49   anesthesia-related events
    511   ―other‖
Total "Reviewed" Events by State
             January 1995 through December 2004
                                             13
      100                                                                                   14          11
                       14                 5
                                                         57                                                    107
  19                                                                                             210
                                                                   55
             21                           4                                                                         12
                                                                             86
                            9                                                                                  27
                                                                                            128
                                          20              28                                              76
                                                                                  81
        18                                                          172 36                               16
                  10            63                                                     14    74
198                                            21             57              41                        75
                                                                                                 76     29
                                                                             75
             65                                     41         20                       45
                            19
                                                                        27   38    88
                                                                                                       International
                                              230              35                                           38

       17                                                                                   169

                                                                                                             VI: 1
                                     12
                                                                                                  PR: 38
             "Reviewed" Events per Million
    18
                 Population (by State)                                                         23
                                                                                                         11
                                                                                                              9
                       16              8
                                                     12                                                             18
    6                                                                                                12
                                                               11
              18                       6                                                                                12
                                                                             9
                            18                                                                                      8
                                                                                                11
                                       12             10                                                        9
                                                                                      7
         11                                                     14       6                                    23
                   5         16                                                            8        11
6                                           8             11                     11                           15
                                                                                                    10        58
                                                                         14
              14                                12         8                                   12
                            11
                                                                    10       9        12

                                           12              8

        28                                                                                      11


                                  10
                                                                                                         PR: 10
      Self-reported Events by State
                 January 1995 through December 2004
                                                  3
      64                                                                                     12           6
                         11                4
                                                          29                                                    57
     10                                                                                           120
                                                                    42
                20                         3                                                                         4
                                                                              60
                              6                                                                                 17
                                                                                             106
                                           20              21                                              49
                                                                                   55
           10                                                        115 27                               12
                     4            35                                                    12    56
85                                              15             34              35                        51
                                                                                                  59     18
                                                                              53
                39                                   22         15                       22
                              17
                                                                         20   29    64
                                                                                                        International
                                               164              20                                           38

          16                                                                                 95


                                       9
                                                                                                   PR: 32
Total Sentinel Events Reported by Year
600

500

400

300

200

100

  0
      1995   1996   1997   1998   1999   2000   2001   2002   2003   2004
  Root Causes of Sentinel Events
          Communication
       Orientation/training
     Patient assessment
                  Staffing
        Availability of info
Competency/credentialing
  Procedural compliance
 Environ. safety / security
              Leadership
       Continuum of care
            Care planning
                                                       Percent of 2966 events
     Organization culture

                               0   10   20   30   40     50   60    70   80     90 100
            Root Causes of Wrong Site
                    Surgery
          Communication
       Orientation/training
     Patient assessment
                  Staffing
        Availability of info
Competency/credentialing
  Procedural compliance
 Environ. safety / security
              Leadership
       Continuum of care
            Care planning
                                                       Percent of 370 events
     Organization culture

                               0   10   20   30   40     50   60   70   80     90 100
   Root Causes of Medication Errors
          Communication
       Orientation/training
     Patient assessment
                  Staffing
        Availability of info
Competency/credentialing
  Procedural compliance
 Environ. safety / security
              Leadership
       Continuum of care
            Care planning
                                                       Percent of 326 events
     Organization culture

                               0   10   20   30   40     50   60   70    80    90 100
Staffing-related Factors Identified in
      RCAs Completed in 2004
  Orientation & training
        process

      Competency
   assessment process


  Adequacy of staffing


      Staff supervision


          Staff skill mix


    Nursing leadership
                                          Percent of RCAs citing these
          issues                                staffing factors


                            0   10   20       30     40    50     60     70   80
      Percent of RCAs Citing Staffing
              as a Root Cause
35%

30%
                                                                   26.9%
                                                           25.1%
25%                                                                        23.6%

20%                                         19.0% 19.9%
                                    17.7%
                            15.6%
15%
                    10.8%
10%   8.7% 8.8%

5%

0%
      1995   1996    1997    1998    1999    2000   2001    2002    2003    2004
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
    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
                                     HAP PTAC Organizations


PARTICIPATING ORGANIZATIONS                                 College of American Pathologists
Acute Long Term Hospital Association                        Federal Nursing Services Council
American Academy of Family Physicians                       Federation of American Hospitals
American Academy of Nurse Practitioners                     National Association for Healthcare Quality
American Academy of Pediatrics                              National Association Medical Staff Services
American Academy of Physician Assistants                    National Association of Healthcare Access Management
American Association of Nurse Anesthetists                  National Association of Psychiatric Health Systems
American College of Emergency Physicians                    National Association of State Mental Health Program
American College of Healthcare Executives                   Directors
American College of Physician Executives                    National Rural Health Association
American College of Physicians                              Public Members (2)
American College of Radiology
American College of Surgeons                                COALITION OF REHABILITATION THERAPY
American Dental Association                                 ORGANIZATION –
American Health Information Management Association
American Hospital Association                               American Physical Therapy Association
American Medical Association                                National Coalition of Creative Arts Therapies Association
American Medical Rehabilitation Providers Association       American Therapeutic Recreation Association
American Nurses Association, Inc.                           American Occupational Therapy Association
American Psychiatric Association                            American Osteopathic Healthcare Association
American Society for Clinical Pathology                     American Physical Therapy Association
American Society for Healthcare Risk Management (AHA-PMG)   American Speech-Language-Hearing Association
American Society of Anesthesiologists                       American Therapeutic Recreation Association
American Society of Health-System Pharmacists               National Coalition of Creative Arts Therapies Association
American Surgical Hospital Association                      National Therapeutic Recreation Society
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
                 UNIVERSAL PROTOCOL
                   ENDORSEMENTS
   Accred Council for Grad Med Education         American Medical Association
   Agency for HC Research & Quality              American Medical Group Association
   Amer Academy of Amb Care Nursing              American Nurses Association
   Amer Academy of Cosmetic Surgeons             Amer Organization of Nurse Executives
   Amer Acad of Facial Plastic & Recon Surg      Amer Pediatric Surgical Association
   Amer Academy of Family Physicians             Amer Society for Surgery of the Hand
   Amer Academy of Ophthalmology                 Amer Society of Anesthesiologists
   Amer Academy of Orthopedic Surgeons           Amer Society of General Surgeons
   Amer Acad of Otolaryn—Head & Neck Surg        Amer Society of Ophthalmic RNs
   Amer Academy of Pediatrics                    Amer Society of Perianesthesia Nurses
   Amer Assoc of Amb Surgery Centers             Amer Society of Plastic Surgeons
   Amer Assoc of Eye & Ear Hospitals             Amer Society of Plastic Surg Nurses
   Amer Assoc of Nurse Anesthetists              American Urological Association
   Amer Assoc of Oral & Maxillofacial Surg       Assoc of American Medical Colleges
   Amer College of Cardiology                    Assoc of PeriOperative Reg Nurses
   Amer College of Chest Physicians              Assoc of Surgical Technologists
   Amer College of Emergency Physicians          Federated Ambulatory Surgery Assoc.
   Amer College of Foot & Ankle Surgeons         Federation of American Hospitals
   Amer College of Obstetrics & Gynecology       Medical Group Management Assoc.
   American College of Physicians                National Assoc. of Medical Staff Services
   American College of Surgeons                  North American Spine Society
   American Dental Association                   Radiological Society of North America
   American Hospital Association                 Society of Thoracic Surgeons
  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
       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?‖
DO NOT USE ABBREVIATIONS
     u
     IU
     qd
     qod
     Leading decimal point
       (always use a leading zero)
     Trailing zero
     MS
     MSO4
     MgSO4
 DANGEROUS
ABBREVIATIONS
    WE‘VE NEVER HAD A BAD PATIENT
     OUTCOME AT OUR FACILITY DUE
                TO…..

 We can learn from the limited reported
  mistakes of others
 We don‘t 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
        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?
    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
   ―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)
        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.

				
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