In preparation for the submission of its application to the Centers for Medicare & Medicaid Services (CMS) for continued hospital deeming authority, The Joint Commission will be making some necessary changes to its accreditation processes beginning January 1, 2009. Joint Commission accredited hospitals are already meeting the spirit of many of these revised requirements. Some of these requirements simply add additional specificity to existing Joint Commission standards and others have led to entirely new Joint Commission requirements. Compliance with any requirements that are completely new will be reviewed by surveyors beginning January 1, 2009, but will not be scored until July 2009, consistent with The Joint Commission’s policy to provide organizations with six months notice of any changes to the requirements, whenever possible.
In the past, The Joint Commission has allowed some flexibility on the part of hospitals to meet specific standards; many of the deeming-related changes do not allow for that flexibility. The Joint Commission also added some new requirements where it was believed they were needed. Some changes are merely minor language changes to align with CMS language. For example, the current EP states: The hospital stores controlled (scheduled) medications to prevent diversion, in accordance with law and regulation. The revised EP states: The hospital stores controlled (scheduled) medications in a locked, secured area to prevent diversion, in accordance with law and regulation. Some of the requirements align with current standards and elements of performance (EPs); others result in new EPs for clarity purposes. Both the new and revised EPs will be posted to The Joint Commission Web site on January 5, 2009. Organizations with questions about the posted EPs can call The Joint Commission’s Standards Interpretation Group at (630) 792-5900. In March, The Joint Commission will host a free audio conference on the deeming-related changes; look for more information in future issues of This Month.
The submission of The Joint Commission’s hospital deeming application to CMS is on target for January 2009. After the application is submitted, CMS will review the application prior to publishing its final decision, which is expected by the end of 2009. The Joint Commission fully expects to receive a positive decision from CMS for the continuation of its Medicare recognition under the regulatory process. As mentioned in the August 2008 This Month article, the law provides for a transition period in order to minimize any potential disruption to our accredited hospitals. Specifically, any Joint Commission hospital accreditation award – and corresponding Medicare deemed status – granted prior to July 15, 2010, will remain in effect for the full term of that hospital’s accreditation. For example, a hospital receiving an accreditation award in May 2010 will continue to have deemed status for the duration of its three-year accreditation period ending May 2013, subject to current Joint Commission policies and procedures. (Contact: Patricia Kurtz, pkurtz@jointcommission.org and Kevin Hickey, khickey@jointcommission.org)
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Over the next year, the current National Patient Safety Goals will undergo an extensive review. As a result, there will be no new NPSGs developed for 2010. Responding to concerns about the challenge some Goals represent and the need for information about effective approaches to addressing these challenges, The Joint Commission and its Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group), which helps develop the NPSGs, are undertaking a thorough review of the goals and the process for their development. The NPSGs highlight serious patient safety issues that need to be addressed by health care organizations. As NPSGs have evolved over time, some have become more specific and detailed, and therefore, require more time and resources to implement.
The success of the Standards Improvement Initiative (SII) demonstrated a way to thoroughly review the current NPSGs. The SII process will be used to clarify language, ensure that NPSGs are program-specific, delete NPSGs that are redundant or non-essential in specific programs, and consolidate similar NPSGs. The SII process also incorporates feedback from health care organizations and other stakeholders. The extensive review process includes a baseline survey, review of potential changes by the PSAG and the Standards and Survey Procedures (SSP) Committee, and final approval by the Board of Commissioners. Revisions to the current NPSGs based on SII recommendations will be effective in 2010. Through December 24, the Joint Commission is conducting a baseline survey to gather input from the field on the 2009 NPSGs. To access the survey, visit the Web site. The Joint Commission will continue to work with the PSAG and the SSP throughout 2009 to review and refine the process for future NPSG development. (Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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Technology is often touted as the “cure” for health care, but a new Joint Commission Sentinel Event Alert warns that implementation of technology and related devices is not a guarantee for success, and may actually jeopardize the quality and safety of patient care. The Joint Commission’s Alert urges greater attention to understanding when a technology may (or may not) be applicable, choosing the right technology, understanding the impact technology can have on the quality and safety of patient care, and attempting to quickly fix technology when it becomes counterproductive. The Alert makes clear that the overall safety and effectiveness of technology in health care ultimately depends on its human users, and that any form of technology can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted. The Alert notes that there is very little data on the number of errors directly caused by the increasing combined use of health information and devices. As an example, however, root cause analysis of errors shows that computerized medication orders and automated dispensing cabinets for medications are frequently involved.
In addition to specific recommendations contained in the Alert, The Joint Commission urges health care organizations to use its Information Management accreditation standards to improve patient safety while using technology. The Alert notes that the implementation of technology can threaten care and patient safety when:
- Clinicians and other staff are not included in the planning process
- Providers do not consider the impact of technology on care processes, workflow and safety
- Technology is not fixed when it becomes counterproductive
- Technology is not updated
To reduce the risk of errors related to health information and technology, The Joint Commission’s Sentinel Event Alert recommends that health care organizations take a series of 13 specific steps. The Alert is available on the Web site. (Contact: Robert Wise, rwise@jointcommission.org)
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In March, organizations will receive via The Joint Commission Connect extranet site their National Quality Improvement Goal data for the last four reporting quarters (October 2007 through September 2008). Hospitals will have one month to review this data before it is posted on Quality Check in April 2009. As a reminder, this data will use “target” measure ranges instead of national averages to reflect organization performance on measures. The bar continues to be raised for measure improvement “targets” as organizations improve their performance on the NQIGs. A target measure range has an upper and a lower limit. For The Joint Commission’s performance measurement reporting purposes, the lower limit will be the national average, unless the national average is greater than 95 percent, in which case the lower limit would be set to 95 percent. For measures with overall national rates below 95 percent, the target range will be set higher than the national average to spur improvement in measure performance.
A performance confidence interval is calculated for each hospital’s measure rate and a comparison of this interval to the target range determines the rating reported for the NQIGs. Performance will still be illustrated with the star, plus, check and minus symbols:
- The star represents 100 percent
- The plus represents a performance interval higher than the upper limit
- The minus represents a performance interval lower than the lower limit
- The check represents a performance interval that overlaps the area between the upper and lower limits
(Contact: Stephen Schmaltz, sschmaltz@jointcommission.org)
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In some very critical areas, Joint Commission-accredited hospitals in America have steadily improved the quality of patient care over a six-year period, saving lives and improving the health of thousands of patients, according a Joint Commission report. Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2008, an analysis of National Patient Safety Goal compliance, and hospital quality measures related to heart attacks, heart failure, pneumonia, or surgical conditions, provides scientific evidence of improved patient care. There were some dramatic improvements over the six-year period of data collection, especially in providing smoking cessation advice. For example, hospitals provided this advice to 98.2 percent of heart attack patients in 2007 compared with 66.6 percent in 2002. Hospitals greatly improved their results from 2002 to 2007 in providing this advice to heart failure patients (from 42.2 percent in 2002 to 95.7 percent in 2007) and patients with pneumonia (from 37.2 percent to 93.7 percent). Other strong improvements included providing discharge instructions to heart failure patients (from 30.9 percent to 77.5 percent) and providing pneumococcal screening and vaccination to pneumonia patients (from 30.2 percent to 83.9 percent).
However, the report does show that, for the third consecutive year, not all hospitals deliver the same level of quality and that some hospitals perform better than others in treating particular conditions. For example, hospitals provided discharge instructions to heart failure patients on average 92.1 percent of the time in the highest performing state, but provided discharge instructions 56.5 percent of the time in the lowest performing state. The performance difference among states is greater than 10 percentage points on 12 of the 24 quality measures tracked by The Joint Commission in 2007. There are exceptions to this variability. For example, virtually all—99.1 percent to 100 percent—accredited hospitals in the United States report that they measure oxygen in the bloodstream of patients with pneumonia. The Joint Commission issues this report as part of its ongoing efforts to emphasize the importance of accountability and continuous improvement for hospitals, and to empower consumers with information that will make them more active participants in their health care. Hospital-specific performance on specific measures for Joint Commission accredited organizations can be found on Quality Check® at http://www.qualitycheck.org/. For a complete copy of the report, visit http://www.jointcommissionreport.org/. (Contact: Stephen Schmaltz, sschmaltz@jointcommission.org)
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This year, The Joint Commission has initiated a comprehensive internal improvement effort utilizing robust process improvement methods like Lean, Six Sigma and change acceleration to better meet customer’s needs and expectations of value. The Joint Commission has gathered suggestions for improvement from its customers and has targeted high-priority concerns for its initial improvement projects. The Joint Commission is committed to improving its business processes so that it can better help accredited organizations deliver safe, high-quality care. The initiative—called Robust Process Improvement (RPI)—is enterprisewide, encompassing The Joint Commission and its affiliate, Joint Commission Resources. The Joint Commission is tackling a number of projects to improve the accreditation process including customer service, standards development and communication. For example, one of the first projects will focus on improving the consistency of surveyor findings. Approximately one-third of the staff are intimately involved in the initiative and more staff will be involved in 2009. (Contact: Anne Marie Benedicto, abenedicto@jointcommission.org)
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A report released from The Joint Commission offers guiding principles and actions for the hospital of the future to meet the daunting challenges of older and sicker patients, patient safety and quality of care, economics and the work force. As these challenges escalate, hospitals can lead the effort to meet these demands. Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future contends that hospitals must respond in new ways as escalating health care costs are hitting record highs and the conditions and care needs of hospitalized patients are growing more complex. The report is the work of an expert panel comprising hospital executives and clinical leaders, as well as experts in technology, health care economics, hospital design and patient safety. The expert panel analyzed how socio-economic trends, technology, the physical environment of care, patient-centered care values and ongoing staffing challenges will impact the hospital of the future. The report recommends action in five core areas: economic viability, technology adoption, patient-centered care, staffing and hospital design. To read the entire news release, visit the Web site. The white paper is also available on the Web site. (Contact: Terri Tye, ttye@jointcommission.org)
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Intravenous patient-controlled analgesia (PCA) allows patients to control their own pain medication, but a new study published in the December 2008 issue of The Joint Commission Journal on Quality and Patient Safety shows that errors related to this practice are four times more likely to result in patient harm than errors that occur with other medications. The study of more than 9,500 PCA errors over a five-year period in the United States showed that patient harm occurred in 6.5 percent of incidents, compared to 1.5 percent for general medication errors. The PCA errors examined also were more severe—harming patients and requiring clinical interventions in response to the error—than other types of medication errors. Most errors involved either the wrong dosage or the wrong drug caused by human factors, equipment or communication breakdowns. For example, one case involved a patient who received several 10mg doses instead of 1 mg medication doses after surgery because of an incorrectly programmed dispensing pump. The PCA errors examined also were more severe—harming patients and requiring clinical interventions in response to the error—than other types of medication errors. 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 safety in health care organizations. To order the article or to subscribe to The Joint Commission Journal on Quality and Patient Safety, call JCR Customer Service toll-free at 800-746-6578, or visit http://www.jcrinc.com/. (Steve Berman, sberman@jcrinc.com)
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Five prominent health care leaders—David L. Bronson, M.D., F.A.C.P., Benjamin Chu, M.D., M.P.H., M.A.C.P., T. Anthony Denton, J.D., M.H.A., Mary Anne McCaffree, M.D., and Mary H. McGrath, M.D., M.P.H.—have joined the Board of Commissioners of The Joint Commission.
- David L Bronson, M.D., F.A.C.P., is a general internist and serves as the chair of the Medicine Institute at the Cleveland Clinic Foundation. He was instrumental in the development of the Cleveland Clinic regional health system including 14 family health centers and nine community hospitals in the Cleveland area.
- Benjamin Chu, M.D., M.P.H., M.A.C.P., is regional president of Kaiser Permanente Southern California. Dr. Chu has been a strong proponent of the use of electronic health records as a powerful tool for improving quality and outcomes for patient care.
- T. Anthony Denton, J.D., M.H.A., is the senior associate director and chief operating officer (COO) of the University of Michigan Hospitals and Health Centers and a member of the University of Michigan Health System’s executive group.
- Mary Anne McCaffree, M.D., is a pediatrician from Oklahoma City and a member of the American Medical Association (AMA) Board of Trustees. She also partnered with the Litigation Center of the AMA, state medical societies and AAP leaders in the fight against low Medicaid reimbursement, leading to a landmark case increasing Medicaid reimbursement in Oklahoma.
- Mary H. McGrath, M.D., M.P.H., is professor of surgery in the Division of Plastic and Reconstructive Surgery at the University of California San Francisco and actively practices plastic surgery. Dr. McGrath has been a panel member and consultant for the Food and Drug Administration (FDA) for more than 20 years and serves regularly on review panels at the National Institutes of Health.
David A. Whiston, D.D.S., who is a practicing oral and maxillofacial surgeon from Falls Church, Virginia, will serve as chair of the The Joint Commission Board of Commissioners beginning in January 2009. Isabel V. Hoverman, M.D., M.A.C.P., an internal medicine physician in private practice from Austin, Texas, will serve as vice chair. See the entire news release on the Web site. (Contact: Kim Andersen, kandersen@jointcommission.org)
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