Physicians and medical staff members who have concerns about the safety and quality of care at their hospital should report those concerns without fear of retaliatory disciplinary action, according to explicit new rules announced by The Joint Commission. The Accreditation Participation Requirement previously referred generally to hospital staff. Though physicians and medical staff were intended to be included as part of ‘Good Faith Participation’ in the accreditation policy, it was not explicit. The revised requirement, which will become effective January 1, 2008, means that accredited hospitals must educate staff and medical staff that any employee or any physician who has concerns about the safety or quality of care provided in the hospital may report these concerns to The Joint Commission. Hospitals also are expected to inform staff and medical staff that no disciplinary action will be taken if concerns are shared with The Joint Commission, and hospitals should demonstrate this commitment by refraining from taking action against employees or physicians who report their concerns to The Joint Commission. Anyone who has concerns about the safety or quality of care at an accredited organization may share those concerns with The Joint Commission Office of Quality Monitoring by phoning (800) 994-6610, or by sending an e-mail to complaint@jointcommission.org. (Contact: Gail Weinberger, gweinberger@jointcommission.org)
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Effective immediately, any draft standards that are posted on The Joint Commission website as part of a field review will be pulled from the website at the conclusion of the field review period. Final standards will be published in a subsequent issue of Perspectives or the next accreditation manual update. (Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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At its June meeting, the Joint Commission Board of Commissioners approved revisions to Standard MS.1.20, which addresses medical staff bylaws, rules and regulations, and policies. These revisions were written with the intent of supporting and reinforcing a productive working relationship between the organized medical staff and the governing body – consistent with the requirements of the new Leadership Chapter – while minimizing disruptions to the hospital, including its medical staff. All of the requirements in Standard MS.1.20 must be jointly approved by the organized medical staff (or the medical staff executive committee, if so delegated by the organized medical staff) and the governing body. The main revisions to Standard MS.1.20 are as follows:
- The Introduction was revised to include a discussion of the relationship between the organized medical staff and the medical staff executive committee, and the definitions of “process” and “procedural detail.”
- A note was added referring the organization to Standard LD.2.40 for guidance on managing conflict that might arise concerning the medical staff bylaws, rules and regulations, and policies.
- A note was added to explain the revised structure of the standard.
- Lead-in sentences to groups of elements of performance were added to clearly delineate what must be in the medical staff bylaws, and what must be either in the bylaws, or in rules and regulations or policies.
- Two new EPs were added to align the standard with the Centers for Medicare and Medicaid Services’ requirements regarding medical staff bylaws.
- An EP was added to underscore the organized medical staff’s ability to propose medical staff bylaws, rules and regulations, and policies directly to the governing body.
- A requirement was added that the medical staff bylaws must indicate the authority delegated to the medical staff executive committee by the organized medical staff to act on its behalf, and how that authority is delegated and removed.
The revised standard seeks to resolve several important issues. First, it addresses situations in which a medical staff believes that its medical staff executive committee is not representing its views on issues of patient safety and quality of care. The revised standard now states that the medical staff bylaws must indicate what authority the medical staff has delegated to the medical staff executive committee, and how that authority is delegated and removed. Also, the revised standard now states that the medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies and propose them directly to the governing body, even if the subject matter had been delegated to the medical staff executive committee. While the revised standard does not state what a medical staff should do if it does not agree with an action taken by its medical staff executive committee, the Introduction to the standard urges the medical staff to consider in advance what action it would take if such a situation occurred.
The revised standard also seeks to allow for an efficient process, for the hospital and its medical staff, for creating and maintaining medical staff bylaws, rules and regulations, and policies. To do this, the standard indicates what must appear in the medical staff bylaws, and what must appear either in the bylaws, or in rules and regulations or policies. The requirements in EPs 9 through 33 must appear in the medical staff bylaws. However, the procedural details associated with the processes listed in EPs 26 through 33 must appear either in the medical staff bylaws, or in rules and regulations or policies (see text of standard). The organized medical staff may, if it desires, delegate to its medical staff executive committee approval of the procedural details associated with the processes listed in EPs 26 through 33, when these procedural details are placed in rules and regulations or policies.
To understand these requirements, the difference between “process” and “procedural detail” needs to be explained. A process is a series of steps taken to accomplish a goal. A procedural detail describes in detail how each step in the process is to be carried out. For example, the process for credentialing licensed independent practitioners (see EP 26) can be stated in several steps such as collecting information on a physician, evaluating the information, and making a decision about the information. That process will be contained in the medical staff bylaws. The procedural details associated with this process might include who collects the information, how files are kept, what organizations need to be contacted to collect all the necessary information, etc. For EPs 26 through 33, the medical staff decides whether such procedural details will be retained in the medical staff bylaws (which must be approved by the entire organized medical staff), or in rules and regulations or policies (whose approval may be delegated to the medical staff executive committee).
Revised Standard MS.1.20 becomes effective July 1, 2009. The Joint Commission is allowing two years for the field to make any changes to medical staff bylaws that may be necessary to bring organizations into compliance with the revised standard. In the meantime, the current version of Standard MS.1.20 will be in effect. (Contact: Lynn Berry, lberry@jointcommission.org)
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For the Standards Improvement Initiative, The Joint Commission is reviewing input received from the recently concluded website surveys of the chapters on Surveillance, Prevention and Control of Infection (IC), Improving Organization Performance (PI), and Management of Information (IM). Also, the Professional and Technical Advisory Committees for the ambulatory, hospital, critical access hospital, home care and office-based surgery programs are reviewing these chapters. In addition, the SII section of The Joint Commission website has been updated. The site includes updated FAQs with new information from the May audio conferences with hospitals and ambulatory care providers; membership lists of the Accredited Customer Groups for the hospital, ambulatory care and home care accreditation programs; and an updated fact sheet. SII is part of a continuous effort to eliminate non-essential standards and to ensure that the remaining standards are understandable and relevant to the care setting to which they apply. The initiative is limited to changes of current standards; it is not designed to introduce new requirements. The redesign of the manuals will result in the renumbering of the standards. Questions and suggestions can be sent to standardsimprovement@jointcommission.org.
SII Timeline
October 2006: The Standards Improvement Initiative was launched. The Joint Commission began seeking feedback through an on-line opinion survey and public comment on standards for the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.
August 2007: The Surveillance, Prevention and Control of Infection Control (IC), Improving Organization Performance (PI) and Management of Information (IM) chapters will be presented to the Standards and Survey Procedures Committee for approval.
June and November 2007: “Virtual” pilot testing will take place with selected surveyors and Central Office staff.
First Quarter 2008: The Joint Commission will begin conducting mock surveys using the improved standards and manuals.
May 2008: The Joint Commission will begin seeking feedback through an on-line opinion survey and public comment on standards for the behavioral health care, laboratory and long term care accreditation programs.
June 2008: Target date for completing improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals. Begin standards improvements for the behavioral health care, laboratory and long term care accreditation programs.
January 2009: Improvements to the standards are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs.
(Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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On June 11, The Joint Commission and Joint Commission International hosted health care and patient advocates from North and South America for an intensive three-day workshop focused on efforts to improve patient safety in mother and child health care. Part of the World Health Organization World Alliance for Patient Safety—Patients for Patient Safety initiative, the solutions-driven workshop aimed to create a network of patient-advocacy leaders who could help expand opportunities for patient involvement in efforts to improve care. The Regional Workshop on Patients for Patient Safety—Patient Safety Solutions offered participants training in the design, implementation and evaluation of patient safety solutions that they can use to influence health policies and programs in their own countries and regions. Specific workshop segments were devoted to a broad review of mother and child safety initiatives, analysis of maternal deaths, kernicterus (brain damage from neonatal jaundice), and lessons from the experiences of Parents of Infants and Children with Kernicterus (PICK).
Among workshop participants were patient advocates from North and South America who have personally experienced health care errors. Sue Sheridan is leading the Patients for Patient Safety program of the World Alliance for Patient Safety, and the cofounder of the U.S. group PICK. Sheridan’s son, Cal, suffered kernicterus due to an error in 1995, and her husband, Pat, died in 2002 from spinal cancer after a break-down in communication which caused a significant delay in telling the couple that his tumor was malignant. Evangelina Vásquez from Mexico has a son, Uriel, who also suffered kernicterus due to a series of health care errors. Alfonso Maldonado from Peru lost his son Augusto because of a misdiagnosis and delayed treatment of cancer. Professional health care participants include Jorge Martínez, director of the Department of Pediatrics at Argentina’s Universidad del Salvador, and Gerardo Cabrera-Meza, director of international neonatology at Texas Children’s Hospital. The workshop was organized by the Pan American Health Organization/World Health Organization (PAHO/WHO), PICK, Consumers Advancing Patient Safety, and The Joint Commission and Joint Commission International. See the news release. (Contact: Laura Botwinick, lbotwinick@jcrinc.com)
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As of March 31, 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 4,234 reports of sentinel events. A total of 4,362 patients were affected by these events, with 3,115, or 71 percent, resulting in patient death. The 10 most frequently reported sentinel events are:
| Wrong-site surgery |
552 |
| Patient suicide |
533 |
| Operative/post-operative complication |
504 |
| Medication error |
392 |
| Delay in treatment |
317 |
| Patient fall |
235 |
| Patient death or injury in restraints |
156 |
| Assault, rape or homicide |
156 |
| Perinatal death/loss of function |
129 |
| Transfusion error |
102 |
(Contact: Anita Giuntoli, agiuntoli@jointcommission.org)
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Joint Commission accreditation is a key predictor in the implementation of systems that promote patient safety by hospitals, according to a new study published in the May/June 2007 issue of the Journal of Healthcare Management. The study considered factors such as hospital size, management (i.e., investor-owned or not-for-profit), and rural or urban location, but found that accreditation by The Joint Commission was the most significant factor in whether the facilities engaged in actions widely recognized to improve patient safety. These patient safety initiatives include computerized physician order entry systems, computerized test results, assessment of adverse events, use of data in patient safety programs, specific patient safety policies, handling adverse event/error reporting, root cause analysis, and medication management. The study, led by Daniel R. Longo, Sc.D., of the Virginia Commonwealth School of Medicine, was based on two surveys of hospitals in Utah and Missouri that were conducted at 18-month intervals.
The new study, which follows Health Affairs articles that also called accreditation by The Joint Commission a driving force in patient safety efforts, advocates accreditation as a means for improving health care. The authors credit The Joint Commission’s National Patient Safety Goals and public reporting of accreditation findings, as well as the more than 50 percent of standards that focus on safety, for making accreditation a “facilitator in changing hospital behavior” related to patient safety.
“By incorporating real ‘teeth’ into its patient safety standards as well as into its accreditation process, The Joint Commission provides the motivation for hospitals nationwide to follow its lead. This is a public trust that The Joint Commission must keep sacred,” Robert G. Kiely, FACHE, president and chief executive officer, Middlesex Health System, Middlesex, Connecticut, writes in the “Practitioner Application” commentary that accompanies the study. For more information about the publication, go to http://www.ache.org/pubs/jhm523.cfm. See the news release. (Contact: Paul Schyve, pschyve@jointcommission.org)
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Many physicians experience significant emotional distress and job-related stress following near misses and medical errors, according to a new study published in the August 2007 issue of The Joint Commission Journal on Quality and Patient Safety. The findings point out the need to improve organizational resources for all health care professionals to receive the support they need following an error. The study of more than 3,100 physicians in the United States and Canada examined the impact of errors on physicians, which physicians are most affected, and how physicians could be better supported after errors occur. Ninety-two percent of the surveyed physicians had been involved with a near miss, or a minor or serious error. The study—“The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada”—is the first large study of its kind to demonstrate that physicians can also be negatively affected by medical errors.
Approximately half of the physicians surveyed reported that their involvement in medical errors increased their job-related stress. One in three physicians involved only with near misses also reported that their lives were negatively affected, indicating that physician distress after errors is not limited to the occurrence of serious errors. However, the greater the severity of the error, the more likely it was that the physician would be affected. Although more than 80 percent of physicians expressed interest in counseling after serious errors, many also agreed that a variety of barriers might prevent them from seeking it out. The authors of the study, led by Amy Waterman, Ph.D., at Washington University in St. Louis, Missouri, and her colleagues at the university and elsewhere, note that hospitals and other health care organizations should consider broadening the array of formal and informal sources of error-related support available to physicians during and after work hours.
“Everyone involved with a medical error—the involved patient, the patient’s family, and the physicians and health care team providing care—is affected by it,” says Amy Waterman, Ph.D., psychologist and assistant professor of medicine, Washington University School of Medicine. “Counseling needs to be made available to patients and health care professionals so that everyone involved with errors receives the support they need.”
Other notable findings in the study include:
- Physicians reported increased anxiety about future errors (61 percent), loss of confidence (44 percent), sleeping difficulties (42 percent), reduced job satisfaction (42 percent), and harm to their reputation (13 percent) following errors.
- Physicians were more likely to report that their job-related stress increased when they had been involved with a serious error. However, one-third of physicians only involved with near misses also reported increased stress.
- Physicians were more likely to be distressed after serious errors when they were dissatisfied with how error disclosure to patients went.
- Only 18 percent of physicians had received education or training in disclosure of errors, and 86 percent expressed interest in such education or training.
- Only 10 percent of physicians surveyed agreed that health care organizations adequately supported them in coping with error-related stress.
- More than one-third of physicians felt that taking time away from work for counseling was difficult (43 percent), did not believe that counseling would be helpful (35 percent), were concerned that what was said in a counseling session would not be kept confidential if they were sued (35 percent), and were concerned that their counseling history would be placed in their permanent record (34 percent).
- In addition, 23 percent of physicians were concerned that receiving counseling could affect their malpractice insurance costs, and 18 percent were concerned that they would be judged negatively by their colleagues for receiving counseling.
The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources, features peer-reviewed research and case studies on improving quality and patient safety in health care organizations. To subscribe to The Joint Commission Journal on Quality and Patient Safety, please call JCR Customer Service toll-free at 800.746.6578, or visit www.jcrinc.com. (Contact: Steve Berman, sberman@jcrinc.com)
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On June 25th, The Joint Commission’s Division of Research began pilot testing an Internet-based collaborative forum called WikiHealthCareTM (http://wikihealthcare.jointcommission.org/). This unique website is designed to harness the collective brain power of front-line providers, health care administrators, researchers and other health care professionals across the globe. The site promotes the free exchange of information, peer networking, the sharing of performance improvement implementation experiences, and collaboration with other professionals to co-create performance improvement solutions. Development of the site was funded, in part, through a research grant from the Smoking Cessation Leadership Center at the University of California, San Francisco, and the first quality improvement topics posted to the site address smoking cessation counseling programs and smoke-free hospital campuses.
Once users are registered on WikiHealthCare, they can discuss content, edit existing content, and create new content which is available to the entire community. Use of the test site is available at no cost. Although the site is sponsored by The Joint Commission, the content developed on the site is non-proprietary, open source information (i.e., owned by the community of contributing users). The WikiHealthCare site can also be accessed via a link on The Joint Commission’s home page. Note: Participation within this collaborative forum has NO impact upon an organization's accreditation status. All users participate as individuals, not as representatives of their organization. (Contact: Scott Williams, swilliams@jointcommission.org)
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The Joint Commission is conducting free monthly one-hour audio conferences on topics of interest. All audio conferences begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Information is sent to accredited organizations via list-serve approximately one week prior to each call. To sign up to receive registration information on upcoming audio conferences, go to your organization’s extranet site on The Joint Commission Connect. Below is the schedule of upcoming audio conferences:
| August 16 |
Strategic Surveillance System—Understanding Reports |
| September 13 |
National Patient Safety Goals |
| October 24 |
Standard MS 1.20 (Note new call topic) |
| November 8 |
Hospital Leadership: Administration, Governance and Medical Staff Working Together |
| December 12 |
Transplant Center Certification |
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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