The Joint Commission held its Annual Invitational Training Conference in Chicago on January 3-5 for surveyors, reviewers and life safety code specialists. New Joint Commission President Mark R. Chassin, M.D., opened the conference with a discussion of the current quality and safety challenges facing the health care field and potential roles The Joint Commission might play in helping health care organizations meet these challenges.
In his remarks on the state of quality, Dr. Chassin delineated three kinds of quality problems that can result in harm to patients: overuse, underuse and misuse. The majority of patient safety initiatives and public reporting efforts focus on underuse and misuse. “The major barriers to improving safety and quality include a lack of capacity to execute and disseminate robust process improvement and poor understanding of how to greatly reduce rates of serious adverse events,” said Dr. Chassin.
He challenged surveyors to help The Joint Commission transform health care into a high-reliability industry. “We have an obligation to maximize the benefit of health care,” said Dr. Chassin. “The goal of The Joint Commission is to drive the delivery system to achieve major, durable improvement.” Dr. Chassin identified five steps of robust process improvement:
- Specify the improvement target.
- Measure the size of the problem.
- Identify specific causes of the problem.
- Target interventions to the most important, modifiable causes.
- Embed intervention into routine work.
“The Joint Commission should lead the effort to facilitate more rapid and widespread development and adoption of generalizable, proven solutions, as well as training programs to accelerate building capacity for robust improvement,” said Chassin. Dr. Chassin also said that The Joint Commission will invest in producing new knowledge and tools to guide more effective investigation and analysis of adverse events. Dr. Chassin’s vision of the next generation of The Joint Commission includes:
- Harnessing global investment to produce generalizable, durable solutions.
- Creating a training initiative to embed improvement capacity throughout the health care delivery system.
- Developing the next generation of standards that will challenge organizations to assess their capacity for robust process improvement.
(Contact: Cathy Barry-Ipema, cbarry-ipema@jointcommission.org)
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Beginning with January 2008 onsite surveys of hospitals and critical access hospitals, surveyors will conduct a new system tracer to identify problems with patient flow. The rationale for the new tracer centers on patient safety. Treatment delays, medical errors and unsafe practices thrive during times of patient congestion and can contribute to sentinel events. Joint Commission accredited hospitals are required to identify and correct patient flow issues organization-wide. Evidence of poorly managed patient flow often surfaces first in the emergency department, critical care units and surgical areas, but can be found throughout the hospital.
The patient flow standard (LD.3.15), implemented in 2005, details leadership responsibility for evaluating patient flow, accepting responsibility and making necessary changes to improve throughput. Leaders are responsible for developing and implementing plans that allow them to evaluate patient flow in the entire organization. They must identify where in the organization problems exist and take action to prevent barriers to patient flow. If patient flow issues are identified during the onsite survey, the surveyor will interview hospital leaders about actions they have taken to mitigate consequences of patient flow, how they have shared accountability with medical staff, evidence of their shared accountability, what indicators exist throughout the hospital, how indicator results are reported to leadership, and how this information has been used to improve patient flow. (Contact: Deborah Ondeck, dondeck@jointcommission.org)
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In December, The Joint Commission established a special fact-finding task force that will examine implementation issues related to revised hospital medical staff standard MS.1.20 and address issues of concern that have been raised. The revised standard MS.1.20 was approved by The Joint Commission’s Board of Commissioners in June 2007 and will become effective in July 2009. The 16-member task force will analyze the potential impact of implementing the revised standard through the examination of case examples and factual information and will suggest mitigating remedies that will support achievement of the objectives of the standard revision. The task force meets for the first time on January 17. A listing of the members of the MS.1.20 Implementation Task Force is below. For more information, see the entire press release .
MS.1.20 Implementation Task Force members
Gene Blumenreich, New England Baptist Hospital, Boston, MA
Tucker Bonner, FACHE, King’s Daughters Hospital, Temple, TX
Gregory L. Brown, Legacy Health System, Portland, OR
Jill Fainter, Hospital Corporation of America, Nashville, TN
James Goodyear, MD, Lansdale, PA
Lance Grenevicki, DDS, MD, FACS, West Melbourne, FL
Gerald Healy, MD, FACS, Boston, MA
Stephen House, MD, Miamisburg, OH
Paul Kettler, MD, Minneapolis, MN
Ann O’Connell, Nossaman, Guthner, Knox, and Elliott, LLP, Sacramento, CA
Maynard Oliverius, Stormont-Vail HealthCare, Topeka, KS
Carol A. Ostermann, CPMSM, CPCS, San Jose, CA
Garry Scheib, Hospital of the University of Pennsylvania, Philadelphia, PA
Sarah J. Schermerhorn, Ellis Hospital, Schenectady, NY
Jeffrey Selberg, Exempla Healthcare, Denver, CO
Elizabeth Snelson, St. Paul, MN
(Contact: Robert Wise, rwise@jointcommission.org)
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The potential 2009 National Patient Safety Goals and potential changes to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™ are now available for field review . The field review is available through February 27. In addition to the potential changes to the Universal Protocol, the field review focuses on new and revised NPSGs for the following topics: patient identification; transfusion errors; prevention of multiple drug resistant organism (MDRO) infections; prevention of catheter-associated bloodstream infections (CABSI); prevention of surgical site infections (SSI); medication reconciliation; providing patients with information about certain infection control measures; providing patients with information about the prevention of certain adverse events in surgery; and, for laboratories, reporting of International Normalized Ratio (INR) for anticoagulant (warfarin) therapy. (Contact: Lisa Vidovic, lvidovic@jointcommission.org)
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The World Health Organization (WHO) Collaborating Centre for Patient Safety and the WHO World Alliance for Patient Safety invited health ministries, health care provider organizations, health care professionals, patient safety advocates, consumers and other interested parties to comment on five proposed, potentially life-saving Patient Safety Solutions that have been selected as priorities by the Collaborating Centre’s International Steering Committee. The Collaborating Centre, jointly sponsored by The Joint Commission and Joint Commission International, develops selected Patient Safety Solutions in coordination with the WHO World Alliance for Patient Safety. This activity represents the “Solutions” program of the WHO World Alliance for Patient Safety, which translates knowledge about patient safety interventions into practical solutions for use by the global community. The electronic Patient Safety Solutions survey will be available online until February 29, 2008.
This new set of Patient Safety Solutions addresses the following challenges: prevention of patient falls; prevention of pressure ulcers; response to the deteriorating patient; communication of critical test results; and prevention of bloodstream infections associated with central lines. The intent of these Solutions and others that have been issued previously is to guide the re-design of patient care processes to prevent inevitable human errors from actually reaching patients. The Collaborating Centre is specifically interested in comments regarding the content and feasibility of these Solutions and would particularly value input from those who have actually experienced adverse health care events that relate to the proposed Solutions. After the feedback from the field review has been incorporated into the Solutions, they will again be reviewed and then acted upon by the International Steering Committee in the spring of 2008. Read the entire news release. Click here for more information about the Patient Safety Solutions project. (Gerry Castro, gcastro@jointcommission.org)
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As of September 30, 2007, The Joint Commission’s sentinel event statistics have been updated and are available on the Joint Commission website. Since the sentinel event database was implemented in January 1995, the Joint Commission has received 4,693 reports of sentinel events. A total of 4,820 patients were affected by these events, with 3,394, or 70 percent, resulting in patient death. The 10 most frequently reported sentinel events are:
- Wrong-site surgery 615
- Suicide 574
- Operative/post-operative complication 557
- Medication error 438
- Delay in treatment 354
- Patient fall 271
- Patient death or injury in restraints 173
- Assault, rape or homicide 171
- Perinatal death/loss of function 141
- Unintended retention of foreign body 130
(Contact: Anita Giuntoli, agiuntoli@jointcommission.org)
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The Joint Commission website now has two new list serves available. Sign-up to receive news and other information about The Joint Commission’s:
- New Health Care Services Certification program, which certifies direct patient care services such as ventilator care, wound care, and care of brain and spinal cord injury patients.
- Public Policy Initiatives, which include white papers and seminars on current issues.
Click here to sign-up. (Contact: Frank Barancyk, fbarancyk@jointcommission.org)
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The deadline to submit applications is nearing for The Joint Commission’s 2008 Ernest Amory Codman Award, the first national health care award designed to recognize excellence in performance measurement. The completed application must be submitted by Friday, February 15. This year, the innovation criterion has been elevated and now garners 20 percent of the weight of the application. If your organization has implemented an innovative health care solution that has made a significant improvement in quality or patient care and you relied on performance measurement data to get this result, the Codman Award is the perfect way to recognize this accomplishment. Click here for the award application. It is also available by calling the Joint Commission's Customer Service Center at (630) 792-5800. (Contact: Teena Wilson, twilson@jointcommission.org)
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The Joint Commission recently conducted a readership survey to gather feedback about This Month and how it can be improved. The survey revealed that the majority of respondents:
- Always or sometimes read This Month (96 percent)
- Say the length of the newsletter is about right (87 percent)
- Say the length of individual articles is about right (87 percent)
- Share This Month with others (54 percent)
- Have an improved impression of The Joint Commission because of This Month (56 percent)
- Would like to see more information about standards, performance measurement, patient safety, and the accreditation process.
Approximately 160 people participated in the survey, with 36 percent representing health care organizations (mostly hospitals—42 percent), followed by doctors (27 percent), nurses (16 percent) and health care administrators (11 percent). The Joint Commission will be looking at making changes based on comments from the survey. (Contact: Caron Wong, cwong@jointcommission.org)
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