"The mission of The Joint Commission is 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."
This mission statement continues to reflect the fundamental purposes set forth by the American College of Surgeons when it created its Hospital Standardization Program in 1917. That program would transition into the Joint Commission on Accreditation of Hospitals in 1951 when it acquired a group of additional major professional organization sponsors.
In 1988, the corporate name was changed to the Joint Commission on Accreditation of Healthcare Organizations to reflect the expanded array of accreditation programs that then included hospices and long term care, ambulatory care, home care, managed care, and behavioral health care programs. Program expansions in subsequent years have included those for clinical laboratories, critical access hospitals, and a broad spectrum of disease-specific care and other certification programs.
Four major themes are inherent in the Joint Commission’s mission statement:
- The purposes of the Joint Commission are backed and driven by the health care professional community—physicians, health care executives, nurses, pharmacists and others.
- The principal responsibility of the Joint Commission is in service to the public (its “beneficiaries”). It seeks to fulfill this responsibility through working with accredited organizations (its “customers”) and various other stakeholders.
- The fundamental goal of the Joint Commission’s mission-related activities is improvement in organization performance. Evaluation of organization performance is a means to that end, not an end in itself.
- The phrase “and related services” underscores the intent of the Joint Commission to do whatever it takes to meet its mission-related responsibility. Thus, accreditation is one way—but not the only way—in which the Joint Commission seeks to fulfill its mission.
Accreditation is the principal set of services that distinguishes the Joint Commission from other organizations that promote continuous improvement in health care quality and patient safety. Thus, the Joint Commission’s own continuous improvement efforts have focused on its accreditation process for the past two decades. However, it has become apparent over this time that accreditation is a necessary but not sufficient means for achieving fulfillment of the Joint Commission’s mission. For this reason, four major sets of supporting activities have evolved since the mid-1980s. Today, the Joint Commission’s portfolio of mission-related services includes:
- Accreditation
- Performance measurement
- Patient safety
- Information dissemination
- Public policy initiatives
We explore each of these service areas in greater depth below.
Accreditation
It is through the accreditation process that the Joint Commission expresses its core competency as an evaluator. A thorough and relevant evaluation process is a necessary precursor to any meaningful ensuing improvement efforts.
The critical elements underlying this core competency are:
- The setting and maintenance of state-of-the-art (“optimum achievable”) standards.
- The conduct of a rigorous, patient-centered on-site evaluation process.
- The determination of accreditation decisions through a rules-based process that assures consistency and fairness in the decisions rendered.
The Joint Commission is a recognized national and international leader in the design and promulgation of the foregoing “art forms.” Its successes in this regard have arisen in large part from its long-established ability to convene recognized experts and opinion leaders who bring to the table in-depth knowledge and experience on a wide variety of health care quality and patient safety-related issues.
The Joint Commission’s accreditation process has undergone two major re-inventions since 1986. The first of these—the “Agenda for Change” project—was implemented in 1994 and 1995. This initiative formally focused the accreditation standards and survey process on the care being provided to patients and the organization management functions that support patient care; codified the emphasis of the standards on patient safety; introduced quality improvement (versus quality assurance) concepts into the standards; and established an expectation that all standards relate directly or indirectly to patient outcomes. Corresponding changes were also made to the accreditation decision process. An important by-product of this initiative was an 80% reduction in the number of standards.
The second re-invention initiative—the “Shared Visions/New Pathways” project—was implemented in 2004. This initiative was designed to make the accreditation process more continuous and, ideally, to encourage its on-going application by accredited organizations as a management framework to support organization continuous improvement efforts. Key components of the new accreditation process include a now-annual self-assessment process (the Periodic Performance Review); a data-based algorithm that is used to set priorities for the on-site survey process (the Priority Focus Process); and the on-site application of a tracer methodology that establishes the actual care of real patients as the principal focus of the on-site evaluation. Through this initiative, a further substantial reduction in the number of standards has been realized, and a more rigorous process for oversight of surveyor performance has been established. Again, corresponding changes have been made to the accreditation decision process. As part of the continuous improvement efforts since 2004, increased attention is being devoted to the known problem areas of infection control and medication management during on-site surveys. In addition, the conduct of virtually all accreditation surveys on an unannounced basis was introduced earlier this year.
From the Joint Commission’s perspective, the new accreditation process is currently well-designed to meet its intended goals. However, further attention to refinements of the standards is needed. The reaction of accredited organizations to the new accreditation process has thus far been quite positive. That includes receptivity to unannounced surveys to date.
Performance Measurement
The Joint Commission has been involved in the performance measurement realm since 1986. This contemplated new capacity was indeed a key component of the Agenda for Change initiative. This was because direct performance measurement was seen as a critical means through which the reach and sophistication of the accreditation process could be extended. In addition, performance measurement was recognized as the foundational basis for all quality improvement activities. Although the hospital field was clearly not ready in 1994 for the initial Joint Commission performance measurement work product (the Indicator Measurement System), the Joint Commission’s publication in 1990 of the Primer on Clinical Indicator Development and Application—its all-time best-selling technical book—created a readily-adaptable template for performance measure development that is still in wide use today, and established the Joint Commission as a major leader in this arena as well. While appropriate attribution has not always been provided, the methodology described in the Primer appears to have underlain subsequent measure development efforts by NCQA, the Health Care Financing Administration (now CMS), and others.
The subsequent elaboration of the ORYX initiative drew the Joint Commission back to its roots as a convener and collaborator. Measure development priorities for hospitals were established by the hospital field, and the development of the initial measure sets involved the convening of expert panels, the conduct of an intensive field review process, and ultimately close collaboration with CMS. Three of the four initial measure sets developed through this process (for Acute Myocardial Infarction, Heart Failure, and Community-Acquired Pneumonia) would eventually become the centerpiece of the Hospital Quality Alliance’s “voluntary” reporting initiative through the CMS-operated Hospital Compare. Going forward, the Joint Commission has carefully tailored its planned future roll-out of expanded performance measurement requirements to correspond closely with the expanded menu of performance measures recently adopted by the Hospital Quality Alliance.
Today, all organizations accredited by the Joint Commission are required to collect and analyze performance data and utilize the derivative information to drive on-going performance improvement activities. However, only accredited hospitals are currently required to report measure results to the Joint Commission.
Through the years, the Joint Commission has also become a recognized leader in performance measurement internationally. Its ORYX core measures are now in use in a growing number of Joint Commission International-accredited hospitals around the world. Meanwhile, the Joint Commission has progressively amassed a substantial base of extramural funding to support an array of measurement-related research initiatives.
To support the actual reporting of performance measure data, the Joint Commission created a network of performance measurement systems (linked databases). Today, the existing network of 47 measurement systems, each of whom are under contract to the Joint Commission, is the source of all quality-related data on the Joint Commission’s Quality Check website, and also provides 92% of the data displayed on the CMS Hospital Compare website. As designed, the inherent efficiency of this process requires hospitals to report performance data only once to serve two (and often more) purposes.
The very nature of this performance data reporting process has required careful attention to data quality issues from the beginning. To this end, the Joint Commission established an Advisory Council on Performance Measurement which oversaw development of the initial criteria for qualifying performance measurement systems, and then assisted the staff in evaluating applicant systems. Over time, the Joint Commission has introduced increasingly stringent data quality control requirements into its measurement system contracts. A GAO report issued earlier this year cites the Joint Commission’s data quality control methods as worthy of adoption by CMS as part of its data quality oversight efforts.
While the Quality Check web site is perhaps the most visible outlet for performance measurement data reported to the Joint Commission, the most critical use of these data lie in their application in the new accreditation process—specifically as a central element of the Priority Focus Process tool. In the future, the use of performance measures and performance measurement data are likely to become even more integral to the Joint Commission’s accreditation process. This direction will be driven in substantial measure by heightened governmental priorities for improvements in the inter-linked domains of health care quality, patient safety, and efficiency. In this regard, the Joint Commission and other quality oversight bodies will be looked to as key “effectors” of these measurement mandates.
Patient Safety
The Joint Commission’s patient safety initiatives are at once its greatest asset and its greatest liability. While widely applauded and recognized for its patient safety efforts, the Joint Commission is “where the buck will stop” if and when it is determined that patient safety improvement efforts in this country have failed to demonstrate sufficient progress. This is, first, because the accreditation process is—at its most fundamental level—a risk-reduction exercise. Here, the thesis is that if organizations are in full compliance with the extant accreditation standards, preventable adverse events should simply not occur. Further, the CMS response to the 1999 IOM report, To Err Is Human, has been to place its principal reliance regarding patient safety on Joint Commission patient safety requirements, most notably its National Patient Safety Goals.
The Joint Commission’s conscious awareness of its patient safety role emerged in the early 1990s in the course of the design of the Agenda for Change standards and survey process. However, the gross insufficiency of this effort was driven home to the Joint Commission in the spring of 1995 when a closely-spaced (in-time) series of serious adverse events (“sentinel events”) captured public attention nationally. In the ensuing five years, the Joint Commission established a Sentinel Event Policy that encourages the voluntary reporting of sentinel events and requires the conduct of Root Cause Analyses for these and other reported sentinel events; created a Sentinel Event Database which includes both adverse events and identified “root causes;” began to issue “lessons learned” advisory Sentinel Event Alerts; and established new standards requiring the internal reporting, analysis, and address of sentinel events.
In the early 2000s, these efforts would culminate in the establishment of National Patient Safety Goals and related requirements. These were accompanied in time by the issuance of additional standards encouraging organizations to establish internal patient safety programs, to undertake proactive risk analyses (e.g., through Failure Mode and Effects Analysis), and to be transparent in sharing information about adverse events with patients and their families. Today, well over 50% of Joint Commission standards relate directly to patient safety.
The National Patient Safety Goals (NPSGs) have enjoyed the high visibility intended for them. The requirements embodied therein spotlight consensus high priority patient safety issues that should command the attention of accredited organizations. The NPSG requirements are essentially equivalent to standards, but compliance with these requirements is separately reported for each accredited organization on Quality Check.
Oversight for the on-going review, development, and updating of the NPSG requirements is provided by an expert-and-user-based Sentinel Event Advisory Group which annually determines NPSG priorities across the Joint Commission’s seven accreditation programs, and assesses field readiness for new or altered requirements. “Retired” NPSG requirements are usually retained in the accreditation standards for the appropriate programs. Thus, standards and NPSG requirements are viewed by the Joint Commission as being interchangeable. In the past year, the Joint Commission has participated in an intensive effort to achieve consistency among its NPSGs, the National Quality Forum’s Safe Practices, and the Leapfrog Group’s patient safety priorities.
Other Joint Commission patient safety initiatives have included a leadership role in advocating for the patient safety legislation that was enacted by the Congress last year and hopefully will eventually lead to the creation of Patient Safety Organizations; the preparation—in collaboration with the Joint Commission’s Corporate Members—of a Patient Safety Events Taxonomy that was endorsed as the national standard by the National Quality Forum in 2005 and is serving as one of four international patient safety classifications used to develop an international classification for patient safety under the auspices of the World Health Organization (WHO), World Alliance for Patient Safety and an on-going set of patient engagement activities through its Speak Up Campaign. Last year, the Joint Commission and Joint Commission International were designated by the WHO as a Collaborating Centre for Patient Safety Solutions as part of the broader World Alliance for Patient Safety. The Centre expects to issue its first set of 6-9 international “solutions” in the spring of 2007.
Interest in patient safety appears likely to grow further as more sophisticated pay-for-performance programs are formulated. One of the great imponderables is how one measures the success of patient safety improvement efforts—i.e., how to measure prevented adverse events. Conversely, what patient safety-related outcomes, efforts, and investments should be rewarded? It seems inevitable that the Joint Commission will be drawn into these future discussions and debates.
Information Dissemination
The Joint Commission’s information dissemination activities—specifically those relating to organization-specific performance—are being undertaken in service to its responsibilities to the public. It is through these disclosures that both the Joint Commission and the organizations that it accredits demonstrate their public accountability. In addition, the public disclosure of organization-specific performance information provides an on-going stimulus for continuous improvement in organization performance. Transparency respecting the performance of health care organizations is fundamental to maintaining public trust in the Joint Commission and its accredited organizations, regardless of whether consumers use the information provided to make choices among potential health care providers.
The Joint Commission first began to make available individual organization Performance Reports in 1994. While novel at the time, these Reports focused almost exclusively on comparative standards compliance performance and over time became of relatively little interest to consumers, accredited organizations, and other users. In the early 2000s, the introduction of National Patient Safety Goals, the availability of standardized performance measurement data, and the imminent introduction of a new accreditation process set the stage for the transition to a new Quality Report and creation of the Quality Check web site.
While the Quality Check web site contains much of the performance data portrayed on Hospital Compare, it also provides information on organization accreditation status, identifies standards compliance problem areas in those organizations that have an encumbered accreditation decision, displays performance against the specific NPSG requirements, and lists distinctive organization achievements (“merit badges”). In addition, Quality Check offers more explicit performance data comparisons among hospitals than does Hospital Compare.
The Joint Commission has also invested in creating secure information portals for each accredited organization. While currently used primarily to transmit accreditation-related information, these extranet sites will in the future become the on-going source of a portfolio of data-based management reports—to be known as the Strategic Surveillance System—to support organization monitoring and continuous improvement efforts. These organization-specific reports—to be derived initially from the Priority Focus Process tool and ORYX data submissions—will be for the sole use of accredited organizations and will not be publicly disclosed by the Joint Commission.
Following upon the Joint Commission’s misadventures last year with the ill-fated BlueCross/BlueShield Association contract, the Board of Commissioners has created a new Data Use Oversight Committee and has adopted a new Joint Commission Data Policy. The new Policy bars the sale of any performance data by the Joint Commission, and provides for open access to any data displayed on Quality Check. Recent changes to Quality Check facilitate the ready download of data reports from Quality Check that the user can tailor to his or her own needs. Beginning next year, Quality Check will be expanded to include all non-Joint Commission accredited organizations in the fields in which the Joint Commission offers accreditation services.
Quality Check currently is attracting approximately 90,000 unique visitors per month. As such, it is providing the most widely used free report on health care quality on the web today. As the Hospital Quality Alliance and the Joint Commission expand their corresponding performance measurement portfolios over the next few years, it is anticipated that these measures will be integrated into Quality Check as soon as the related measurement data become available.
Public Policy Initiatives
The Joint Commission’s public policy initiatives were launched in 2001 with a major study on the nurse staffing crisis. For a number of years, the Joint Commission had acknowledged the existence of major health care quality and patient safety-related problems which simply dwarfed and sometimes engulfed any potential impact of related Joint Commission standards. The Board of Commissioners reasoned that the Joint Commission should capitalize on its long-established convener capabilities to mobilize the parties at interest respecting priority problem areas to develop and eventually drive the implementation of specific recommendations to address the identified problem.
The elaboration of each public policy initiative usually involves the convening of an expert Roundtable for two or three full-day sessions, the conduct of a national summit, the issuance of an authoritative white paper, and the determination and implementation of appropriate follow-up strategies. Each public policy initiative drives from an established health care quality or patient safety platform. Most of the Joint Commission Corporate Members have been involved in each of the public policy initiatives undertaken thus far.
The Joint Commission has to date convened nine Roundtables, and has issued four white papers. The latter have addressed nurse staffing, emergency preparedness, organ donation, and medical liability reform. The white papers have attracted considerably greater attention than the Joint Commission anticipated, becoming not only fodder for public policy discussions in Washington but also course materials in university-based graduate programs, among other uses. To date, there have been over 1.6 million downloads of these white papers from the Joint Commission web site.
Public policy initiatives still in various stages of evolution include ED overcrowding, health professions education reform, health literacy, and the hospital of the future. The most recent public policy initiative on the development of a national data management strategy is expected to lead to the issuance of a white paper by year-end. Planned initiatives on the drawing board include those relating to measuring and improving efficiency in health care and to the use of health IT to address priority health care quality and patient safety needs.
The Joint Commission has thus far experienced no dearth of candidate public policy initiatives and anticipates continuation of these efforts into the future.
The Future
The priority Joint Commission activities described herein constitute the platform upon which the Joint Commission leadership transition will occur over the next year or so. The Joint Commission has been in virtually continuous change over the past 20 years. That is because the environment in which it and its accredited organizations operate has also been in virtually continuous change. If anything, the evolution of the health care environment is likely to intensify in the near-term future, and that will mean more change for the Joint Commission, among others. Indeed, for those who long wished that a high priority be placed on health care quality and patient safety in the health care environment, that reality—and all of its attendant consequences-- is at hand.