How many ambulatory care professionals does it take to improve patient safety processes? More than it takes to change a light bulb, that’s for sure.
Too often, we think improving patient safety is the responsibility of organization leaders or the person whose title includes the word “safety” or “quality.” Although these individuals may champion the commitment to improving safety and quality, the ultimate responsibility must be shared by all employees—clinical and administrative alike.
However, when we talk about improving safety and quality, the discussion must also focus on the systems and processes at an organization. When processes break down, people make mistakes. When the proper defenses are not in place to prevent mistakes, we up the ante for human error.
Joint Commission President Mark Chassin, M.D., recognizes the current challenges in quality and safety. He believes there are five steps to robust process improvement in any organization:
- Specify the improvement target
- Measure the size of the problem
- Identify specific causes
- Target interventions to the most important causes
- Embed interventions into routine work
People make mistakes every day. The challenge is to fortify the defenses that protect your patients—and your staff. Do you agree? What defenses have you put in place at your organization? E-mail me at mkulczycki@jointcommission.org.
Michael Kulczycki, MBA, CAE
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A new law that took effect in January requires New York State physician practices that perform office-based surgical procedures to achieve accreditation—either by The Joint Commission or two other approved agencies on or before July 14, 2009. A main component of the law is that office-based surgeries must be performed by physicians in a setting that achieves and maintains accreditation from a nationally recognized accrediting organization.
The need for strengthened quality oversight for office-based surgery has grown as the number of increasingly complex surgical and invasive procedures performed in doctors’ offices has more than doubled in the last decade, with nearly 10 million surgical procedures performed annually in office-based settings nationwide since 2000.
The Joint Commission began accrediting office-based surgery practices in 2001 and more than 20 percent of its current OBS customers are in the state of New York. The office-based surgery standards were established specifically for physicians offering surgical or invasive procedures in an appropriate physician-based setting.
Currently, 25 states recognize Joint Commission accreditation for ambulatory care settings—in whole or in part—in fulfillment of regulatory requirements. Thirteen states recognize Joint Commission accreditation for office-based surgery. For more information about office-based surgery accreditation,
call (630) 792-5286, e-mail OBS@jointcommission.org, or visit www.jointcommission.org/NYOBS.
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Karpinski Ambulatory Surgery in Manhattan has been accredited by The Joint Commission since 2002. According to Chief Executive Richard H.S. Karpinski, M.D., “I initially chose The Joint Commission over other accreditors because the requirements weren’t so prescriptive. It seemed to me that we could create our own rules, and as long as we followed them, and they were sensible rules, we would be OK.
“Preparing for accreditation made us rethink some of our processes and, I believe, improve safety for our patients. For example, previously we used disposable paper sheets on our operating table. When we considered the possibility of an anesthetized patient being present during an actual fire, we switched to cloth sheets. Now we know that in an emergency, we could carry out an anesthetized patient using the sheet.
“Achieving Joint Commission accreditation is a way of saying to our patients, ‘we’re trying hard, we’ve managed to satisfy a national accrediting agency and your safety is very important to us.’ ”
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More than 10 million MRI scans are performed each year in the United States, and while most cause no harm, the inherent dangers of the process are not well known. The Joint Commission recently issued a Sentinel Event Alert that urges ambulatory care organizations to pay special attention to preventing accidents and injuries that can occur during MRI scans.
According to the Alert, the Food and Drug Administration has received nearly 400 reports of MRI-related accidents over the past decade. Most were burns, followed by projectile-related injuries. To reduce the risk of harm, the Alert recommends that organizations take steps that include:
- Restrict access to MRI sites by creating safe zones recommended by the ACR.
- Ensure that the MRI technologist has the patient’s complete and accurate medical history.
- Use trained screeners to perform double checks of patients for metal objects, implanted or other devices, drug delivery patches and tattoos.
- Have a trained staff person accompany patients, visitors and staff into the MRI suite.
- Annually educate staff who accompany patients into the MRI suite about risks.
- Take precautions to prevent patient burns.
- Only use fire extinguishers, oxygen tanks and other equipment that have been tested and approved for use during MRI scans.
- Manage critically ill patients to assure that their care needs are met.
- Provide all MRI patients with ear plugs to diminish the equipment noise.
- Never run a cardio-pulmonary arrest code or resuscitate a patient in the MRI room.
Linda Massaro, director of Quality Improvement at INSIGHT IMAGING, based in Lake Forest, California, believes that management should provide technologists with tools to help avoid mistakes that occur due to complacency. “At INSIGHT, we have created a checklist to assure that safety measures are in place for each patient,” says Massaro. “This includes restricting access to the MRI suite. No one is allowed to cross the scan room threshold without having everything checked off. On a recent Joint Commission survey, even the surveyor had to complete a safety sheet before walking into the MRI suite.”
According to Massaro, communication is the key to preventing accidents. “The sharing of information with your staff—including mistakes or near misses at your organization or elsewhere—reinforces the idea that accidents can happen anywhere. It’s also important to educate patients and their families, as well as local fire, police and EMT professionals about how to remain safe in the MRI environment. The bottom line is the diagnostic imaging industry must be vigilant in its approach to maintaining everyone’s safety.”
Read the complete Sentinel Event Alert. For additional resources on MRI safety, visit The Joint Commission Resources website.
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The National Quality Forum recently endorsed five quality measures for ambulatory surgery centers developed by the ASC Quality Collaboration. The five measures are:
- Patient burn
- Timing of prophylactic IV antibiotics
- Patient fall in the ASC
- Wrong site, side, patient, procedure, or implant
- Hospital transfer or admission
Comprised of industry leaders and representatives from accrediting bodies and associations, the ASC Quality Collaboration was formed to develop, support and promote quality measures appropriate to ASCs. Michael Kulczycki, executive director of The Joint Commission’s Ambulatory Care Accreditation Program, and Sharon Sprenger, senior advisor of Measurement Outreach in The Joint Commission’s Division of Quality Measurement and Research, are members of the ASC Quality Collaboration’s Expert Group.
“It was critical for The Joint Commission to participate in this collaboration on behalf of our largest ambulatory customer base—ASCs,” says Michael Kulczycki. “I have been quite impressed with the knowledge, dedication and tenacity of this group. The Joint Commission is keenly interested in a future accreditation process that encompasses standardized performance measures for ambulatory surgery centers.”
For more information about the ASC measures, visit www.ascquality.org.
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Q: What is the expectation for meeting National Patient Safety Goal 13A?
A: “The purpose of NPSG 13A is to assure that each patient and family is educated and actively encouraged to be aware of problems and adverse events that might occur,” says Jim Bersot, M.D., ambulatory care surveyor. “Patients and their families should be informed about how to communicate concerns about care, treatment, services and safety. NPSG 13A requires proactive and preventive action with each patient and family related to patient safety. Having posters or brochures with related information available in your facility, or providing a patient handbook that explains how to express concerns or ask questions about care does not meet the requirement for this NPSG. Surveyors want to know how patients and their families are actively encouraged to express these concerns. If you review a pertinent statement, document, handbook, or brochure such as The Joint Commission’s SpeakUP: Help Prevent Errors in Your Care with each patient and family, you are actively educating them and encouraging their expression of concern.”
To submit a question for an upcoming “Ask the expert,” send an e-mail to abrown@jointcommission.org.
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As of January 1, 2008, BlueCross BlueShield of Louisiana requires all sleep centers to be accredited by The Joint Commission or one other accrediting body. BCBS of Louisiana is the largest payer in the state with more than 1.1 million members. For more information, visit http://www.bcbsla.com/.
Communication between health care professionals and patients continues to be a challenge. If your organization serves non-English speaking patients, don’t miss the article in the February issue of The Joint Commission Perspectives, “Promoting Effective Communication—Language Access Services in Health Care.”
Publication
2008 Accreditation Process Guide for Ambulatory Care includes a step-by-step example of a tracer from the surveyor’s perspective, sample survey agendas, information about unannounced surveys, and a compliance assessment checklist. An electronic format is also available. To order, visit www.jcrinc.com, or call toll-free (877) 223-6866.
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The 13th Annual Ambulatory Care Conference will be held Thursday and Friday, October 2-3, at the Westin River North Hotel in downtown Chicago. Details to follow!
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- Midwest Podiatry, Chicago, Ill., March 27-29
- American Society of Cataract and Refractive Surgery, Chicago, Ill., April 5-8
- Medical Society of the State of New York, Rye, NY, April 10-12
- Society of American Gastrointestinal Endoscopic Surgeons, Philadelphia, Pa., April 10-12
- National Society of Orthopaedic Administrators, Charlotte, N.C., April 13-15
- American College of Surgeons, New York Chapter, Cooperstown, NY, April 26
- Urgent Care Association of America, New Orleans, La., April 29-May 1
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Michael Kulczycki, executive director - (630) 792-5290
Mike Dye, senior associate director - (630) 792-5259
Darrell Anderson, business development specialist - (630) 792-5292
Account representative - (630) 792-3007
Standards Interpretation Group - (630) 792-5900
JCR Customer Service - (877) 223-6866
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