CATHY BARRY-IPEMA: Welcome to The Joint Commission’s news conference to discuss health care quality and safety in America’s accredited hospitals. We’ll be focusing on the findings of a new report from The Joint Commission that examines trends in using proven treatments and practices that result in better, safer care for patients.
The following experts are with us to discuss the significant progress that hospitals have made in quality and safety, and what that means to the millions of Americans who seek medical care. Joining us today are:
- Dennis S. O’Leary, M.D., president, The Joint Commission
- Carolyn M. Clancy, M.D., director, Agency for Healthcare Research and Quality
- Gerald M. Shea, assistant to the president for External Affairs, AFL-CIO
- Richard J. Umbdenstock, FACHE, president, American Hospital Association
They will each offer brief remarks and then we will answer questions.
DENNIS O’LEARY: Thank you for joining us today to talk about a new report from The Joint Commission that provides important information about the quality and safety of care provided in our nation’s hospitals.
The hard data portrayed in this report moves us ever closer to our goal of creating truly informed health care consumers who have the ability to ask searching questions and make good choices about where to go for their care.
The good news is that America’s hospitals have significantly and progressively improved the quality of care provided to patients admitted with heart attack, heart failure, or pneumonia. This is good news not only because it reflects improvement in health care as a whole; but also because heart attack, heart failure, and pneumonia are among the most common conditions for which patients are hospitalized. And these improvements have saved lives and resulted in better health and quality of life for tens of thousands of patients.
However, the data also identifies significant opportunities for improving the safety and quality of care being provided to patients. Among the specific findings in the report are the following: the magnitude of improvement and the safety and quality of care provided range from 1.1 percent to 42.8 percent over the four-year period covering 2002-2005 with performance improving most dramatically for measures where the initial level of performance was lowest. For example, the greatest improvement occurred in the provision of smoking cessation advice to patients admitted to the hospital with pneumonia. The national rate for telling these patients about the benefits of quitting smoking shot up from 37 percent in 2002 to 80 percent by 2005. The overall use of specific care interventions for patients admitted with heart attack, as well as the actual in-patient mortality rates also improved. These specific care interventions have clearly been shown to reduce the risk of future heart attacks and lower mortality.
Secondly, room for improvement exists for most of the quality measures. For example, hospitals are currently achieving 90 percent performance levels or higher for almost half of the measures tracked since 2002. However, hospitals are performing at a level of less than 65 percent for two of these measures, providing pneumococcal vaccinations to patients with pneumonia, and providing discharge instructions to patients admitted with heart failure.
Thirdly, considerable variability exists in the performance of hospitals by state on most measures. For example, the statewide averages for providing discharge instructions to patients admitted with heart failure ranged from 33.5 percent to 89 percent. On the measure of providing pneumococcal vaccination to patients admitted with pneumonia, performance ranged from 48 percent to 84 percent across the states.
Fourthly, there are significant differences in performance between the highest and lowest performing hospitals. Joint Commission data show that some hospitals perform better than others in treating particular conditions, and that more than 90 percent of the nation’s hospitals are achieving 90 percent performance levels on only one measure.
Fifthly, hospital compliance is lowest for Joint Commission patient safety requirements that a timeout be taken by the surgical team before surgery begins to confirm patient identity and correct location and correct procedure, and that certain potentially confusing abbreviations not be used in ordering medications.
Although compliance with the various National Patient Safety Goal requirements is trended over time in the report, the report suggests some caution in interpreting these trends because Joint Commission surveyors have become increasingly sophisticated in assessing compliance with some of these requirements during the time period covered by the report. As the report details, the improvements in hospital performance are quite real. But so to are the opportunities for further improvement in the safety and quality of care provided in America’s hospitals. We can and must do better.
This report is for consumers. But it is also for hospitals themselves to help them focus on their own individual opportunities for improvement. That is what The Joint Commission accreditation process and The Joint Commission’s performance measurement and patient safety initiatives are all about. I would now like to turn the discussion over to Dr. Clancy.
CAROLYN CLANCY: Thank you and good afternoon. I’m delighted to be here today to help The Joint Commission launch its first annual report, Improving America’s Hospitals: a Report on Quality and Safety.
More than ever before, the currency of health care is information. It’s evident in every encounter in health care, from patients who arrive for their clinical visits with information that they’ve obtained from the web, to providers who use scientific evidence to underpin the clinical decisions that they make, to purchasers and others who seek good information on which to base their pay-for-performance in quality improvement initiatives.
However, good information can’t be produced and quality improvement can’t occur without solid quality measurements. So today, we celebrate the critical role that The Joint Commission plays in providing the health care system with effective quality measurement and information that can make a difference in the quality and safety of our health care.
I’d like to commend and congratulate The Joint Commission on this report. It’s a very important addition to the array of data and information available to inform health care decision making. The findings of the report are the product of valid, reliable evidence-based measures that have broad-based consensus and support throughout the field. In addition, the findings here track very closely with the findings of my agency’s national health care quality report, which we submit to the Congress each year in January.
Together, the two reports provide a comprehensive picture of quality of care in hospitals. Our national health care quality report documented that the greatest and most significant quality gains occurred in U.S. hospitals this past year at an overall rate of 7.8 percent. Now, this compares to an overall rate—all settings, all populations, all measures—of 3.1 percent, and it also compares to an overall improvement rate for ambulatory or outpatient care of 3.2 percent.
More specifically, where we saw the greatest gains was for heart attack patients. We saw an overall improvement of 15 percent; overall improvement for patients with pneumonia of 11.7 percent; and steps taken to avoid complications after surgery improved just over 7 percent.
So the question is, why are hospitals doing better? Much of the success is due to public reporting of hospital quality by The Joint Commission’s Quality Check® and through other sources. And the availability of information on hospitals, as well as other entities accredited by The Joint Commission, is providing an unprecedented and effective level of accountability that we think is a model for other sectors of health care. We were very pleased to include Quality Check as a resource in a new website, which is called ‘Questions are the Answer.’ This is www.ahrq.gov/questionsaretheanswer that we launched a couple of weeks ago as part of a campaign to encourage consumers to become more involved in their care. This was a collaborative effort with the Ad Council, and it aims to encourage all patients and caregivers to become more active in their care by asking questions. Quality Check provides really good information that can help start important conversations between a patient and a clinician when it comes to choosing a hospital.
Just before closing, I’d like to take a moment to reflect on the overall state of quality in the health care system. Today, we can and should celebrate the accomplishments of hospitals to improve quality, but this is no time to be complacent. Our health care system continues to have significant gaps in quality that need to be addressed. For example, with the exception of vaccinations for children, adolescents and the elderly, the improvement rate for other preventive services—screenings, advice, prenatal care, and so forth—in our annual report was less than 2 percent. So what we’ve heard today is that hospitals stepped right up to the plate and they improved dramatically in terms of giving people advice about quitting smoking. We know if they can do it, that it can happen elsewhere in health care.
Our system also continues to experience very broad and pervasive disparities in care associated with individual race, ethnicity, income, education, and so forth. So I look forward to working with The Joint Commission and all my colleagues up here to address these and other critical challenges facing health care. Together, we can, and I would even assert we will, make a measurable difference in the quality and safety of all health care services provided in this country. Thank you.
GERALD SHEA: Good afternoon. I work for the AFL-CIO and I am also
a public (Board) member of The Joint Commission. I am pleased to be joining this panel today in unveiling this new report. All consumers need easy access to reliable, independent and actionable information about the quality of care. A comprehensive network to provide that information has been underway for several years; it’s being built as we speak. Unions, along with employers, who essentially function with us as co-purchasers—representatives of health care consumers—are working together with health care providers and with organizations such as The Joint Commission and AHRQ to put together a robust, comprehensive system of health care reports based on standardized national measures of care. We’re proud to be part of that effort.
You’ve heard some of the highlights of this important report, and I should say that The Joint Commission has distinguished itself, not only in much of the infrastructure work on quality reporting over many years, but in taking this step of providing us with a summary explanation of where we stand in this effort. It’s truly significant. It takes a step back and says here’s where we are, here’s where we need to go.
You’ve heard some of the highlights of that. From the consumer’s perspective, it’s important for all of us to understand that progress is being made. As much as we might want to focus on all of the progress that is yet to be made, serious advances have happened. In fact, hat’s off to American hospitals. This has been a tremendous, collegial, cooperative effort over the last few years, and the hospitals have really stepped up to the plate on this.
The report highlights the fact that there is a lot of difference in quality measured by these standard measures of performance. So it’s extremely important for consumers to inform themselves about the differences in quality among the organizations that they might choose for their site of care. And within those organizations, it is important for them to note there are distinctions between care for this diagnosis and that diagnosis. So there is a lot of variation, and the bottom line in this report is that measurement really does matter an awful lot.
It’s important to note that this is information that is not only usable and critical to consumers, but also to the people who we rely on for care, to practitioners and providers. Often, many of us commonly assume that we might not know all the answers, but our physicians do know the answers. Well, the truth is, the database is the same for both of us, both sets of people. We have been woefully short of having the kind of information that we need about the differences in quality and the actual standards of quality in various types of care.
So we celebrate this report. We welcome it. We look forward to the fact that The Joint Commission has committed to do this on an annual basis, and we want to continue to work with them. Obviously, lots of work lies ahead of us as the report indicates. But it’s important that we take this moment to look at where we are and to think about where we need to be, and to continue the collegial effort that is embodied in this report in terms of making steady and hopefully, in the future, very rapid improvements in the reporting of the quality of care overall.
RICHARD UMBDENSTOCK: Thank you, Gerry. I am very pleased to be here today for a couple of reasons. Number one: as one of the sponsoring organizations of The Joint Commission, we’ve been involved in this journey in many ways for a long time, and want to thank the Commission for the outstanding work that it’s done in compiling this report and making this report available. Also, I’m glad to be here because our hospitals are committed to making more available the information that consumers need to make proper health care decisions, and that we need, as providers of health care, to continuously improve our work on behalf of our patients and communities. So this is important work, as my colleagues have said, and we’re very pleased to be part of it.
Each year, America’s hospitals treat over 37 million people. And the proper care of each and every individual patient is our absolute goal. Our people working at the bedside and throughout our organizations are deeply committed to improving care at every opportunity, and running as fast as they can to keep up with the ever-increasing amount of clinical knowledge and performance improvement opportunities and experiences that are occurring across the health care system. Unfortunately, as the report indicates, sometimes it doesn’t work out the way we’d like it to work out, and we want to be sure that we do take every step and learn at every opportunity on how we can improve those situations. The good news is, as Dr. O’Leary and others have pointed out, that care is improving significantly in many areas. But also, this report is good news for us in the sense that it does point out where we can and must focus our improvement efforts. So it’s another terrific resource for hospitals and physicians and other clinicians to use.
The AHA, on behalf of our member hospitals, is aggressively doing what we can to identify performance improvement strides in individual organizations, and spreading that knowledge to others in our membership. In 2006, we created the AHA Quality Center as a knowledge- transfer vehicle that makes available to our members open access to leading practices, tools, and resources that they can take advantage of if they’re not already doing so.
Certainly, as has been emphasized here, better communication and better reporting is key to improving this health system from within and also on the outside as patients enter into it. In that regard, the AHA has been very pleased to be part of the Hospital Quality Alliance, a public/private effort at the national level to identify agreed upon consensus measures in clinical treatment, which you see embodied in the measures tracked by this report. And we actively push out to our members their individual results as they appear on the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. That, too, is a very collaborative effort. The organizations you see represented on this panel today and several others in the room and out across the field are participating actively to continue to build out the Hospital Quality Alliance efforts and the array of measures that are being defined, measured, and reported. Also, the AHA is supportive of another effort out in the field being led by the Institute for Health care Improvement called the Five Million Lives Campaign, and there, we’ll not only again encourage participation in those collaborative efforts, but expand the involvement to others, including boards of trustees, so that everyone can contribute to quality improvement within the hospital setting.
Lastly, we’re anxiously awaiting the regulations on provider safety organizations so that hospitals can become involved in that effort, something that we’ve been supportive of from the outset and another vehicle to make sure that quality is improved, and again, properly directed at every opportunity. So sharing information is important; it’s important for us to demonstrate our commitment to it and we are. That’s why we’re here today and why we’re part of these collegial efforts that others have spoken to. I want to underscore, once again, that improving quality at every opportunity is a never-ending task for hospitals as organizations, and for the professionals who work within them. Thanks very much.
CATHY BARRY-IPEMA: Thank you very much. We’d like to open the discussion for questions.
QUESTION: Why do you think more hospitals made the effort to extol the benefits of quitting smoking than being vaccinated against pneumococcal pneumonia?
DENNIS O’LEARY: Why do they extol it?
CALLER: Well, apparently, they explained the benefits of quitting smoking more often than the benefits of pneumococcal vaccination.
DENNIS O’LEARY: Well, one can only speculate on that; although we did cite both of these measures as areas that have been problematic, and where we are now starting to see some significant improvement. These are two rather different areas, and like a lot of things, they have to do with the beliefs and behaviors of practitioners. I am personally pleased to see the amount of improvement that we have seen in both of these areas. Smoking cessation obviously has some considerable benefits across all of the measurement areas that we are talking about today, both for heart attack patients, for heart failure patients, and for pneumonia patients. One of the interesting things that we’ve observed over time is that smoking cessation counseling rates have differed across those three conditions. But the levels are going up across the board. Jerod - do you want to comment any further on that question?
JEROD LOEB: This is Jerod Loeb from The Joint Commission. Clearly the issue of smoking cessation, in terms of public health, has been more widely touted than the use of a pneumococcal vaccination in patients who are admitted to the hospital. So there is a very significant difference in terms of the public aura relative to smoking versus pneumococcal vaccination.
QUESTION: The data in this report is coming from the CMS Hospital Compare measures, is that right? Or how is this data different from what is already out there? Is this just summarizing it annually, or could you just clarify that, please?
DENNIS O’LEARY: The data that populate Quality Check, our reporting system, and Hospital Compare, basically are transmitted from hospitals through performance measurement systems that contract with The Joint Commission, but also relate to the QIO data warehouse in Iowa that produces the Hospital Compare data, Ninety-two percent of the data that are on Hospital Compare come through our contracted vendors. It is the same data. The difference between the two sites is that Quality Check includes the performance data relative to quality; but also includes patient safety requirement compliance levels as well as accreditation status, and, if an organization is in some difficulty with us, the areas in which they have difficulties. So, Quality Check provides a broader array of information that is in a very real sense peculiar to the priorities of The Joint Commission. But the data relative to the quality measures is fundamentally the same between the two. We do portray it in a different way.
GERALD SHEA: I just want to footnote what Dr. O’Leary just said. Hospital Compare is a reporting site that is one of the results of this collaboration that is now six or seven years in the making between America’s hospitals, a number of consumer organizations, practitioners, and agencies, and it’s been led by CMS. It is a public website that is financed and organized by CMS and made available to all Americans through the HHS website. It reflects, as Dr. O’Leary said, a lot of the data. In fact, a majority of the data on that website comes from arrangements that have been constructed as part of The Joint Commission’s ongoing quality reporting mechanisms. And I just wanted to—a little kudos to The Joint Commission here—The Joint Commission has been the workhorse of this quality reporting for many years. It is now gaining national notoriety because it is the main contributor to the Hospital Compare website. It’s a great example of people coming together and sharing data and making it available as widely as possible.
DENNIS O’LEARY: I’d just also note, if you don’t know, that The Joint Commission has a formal, contractual relationship with CMS to maintain essential identity between our measures, and that is an active process involving weekly, lengthy meetings. This is not lightweight work; this is heavy investment in this partnership.
QUESTION: What will be the next measure set that we expect to see?
DENNIS O’LEARY: You’ve already started to see part of that with the surgical infection prevention measures, and I think the next major kick here is going to be the expanded application of the surgical care improvement measures. We will also be bringing online the pediatric asthma measures. This is going to be an interesting issue because we will probably collect the data and also transmit it to Hospital Compare since those are pediatric cases and CMS can’t gather that data directly. It’s another example of the collaborative relationship that we have. There are also, in the pipeline, some critical care or ICU-related measures, which do have some overlap with the surgical care improvement measures. And we’re actually coordinating that effort, so that we don’t create any confusion when we present those data. Those are the main things coming.
Further back in the pipeline are some other issues. For instance, we have a nursing sensitive measure set that is currently in final field testing. I should also note that there are some more immediate measures coming online, and these are principally coming through Hospital Compare, and those will be provided through Quality Check as well. But those are the HCAHPS measures, where both AHRQ and CMS have made a major investment. This is the first venture into patient experience-of-care measures. We also have the 30-day mortality measures for heart attack, heart failure, and hopefully soon, for pneumonia. Those are gathered through Medicare claims data and require no effort on the part of hospitals, but they will obviously only be Medicare patients and something that no one could collect except CMS, so we are making arrangements to have that data transferred to our site as well.
QUESTION: I’m an emergency physician and a health-policy fellow working with the U.S. Congress this year. On page eight in the executive summary, you’ve got a very important table that looks at the achievement rates of 90 percent or better by hospitals with a number of the key quality measures that you focused on. I noticed that of the four that had the greatest opportunity for improvement, three of those involve initiation of time-critical, potentially life-saving treatments in emergency rooms. The Joint Commission and American Hospital Association have both, as well as others, focused on the tremendous problems we have with crowding and diversion of ambulances from America’s hospitals over the last several years. This was the focus of a big IOM report back in June. And a lot of that is being driven by the fact that we can’t get patients who have been admitted—and that’s about half of all hospital admissions—out of the ER and into the hospital in a timely manner because our hospitals are very crowded. Does The Joint Commission, AHA, or others have any plans in mind to facilitate the prompt movement of admitted patients out of the ER so the ER staff can quickly and effectively meet incoming patients and initiate these very important treatments and interventions?
DENNIS O’LEARY: We actually had a public policy roundtable, as I’m sure you know, that looked at the overcrowding issue, and most of our public policy initiatives are based on the thesis that we, as an accrediting body, have done everything that we could to address the problem. But in this instance, the roundtable came up with a major issue around patient flow and patient throughput which has led us to create an additional set of standards requiring this. Standards that require organizations to address the issue of patient flow and patient throughput are fine. We find a very high rate of compliance with those, but I am not persuaded that we are there yet. And this may be more an issue of how well we execute the onsite survey process, because most of our survey activities are done during the day and the overcrowding tends to occur in the evening shift, when things really start to stack up.
So, we have to, first of all, devise a better strategy for assessing compliance with this standard, because intuitively, I know that overcrowding is still a major issue, and I can’t believe that 98 percent of hospitals are doing excellent patient throughput right now. A much higher percentage than were doing it are doing a better job, but we couldn’t still be having that level of overcrowding and have everybody be doing a good job on throughput. And it is an operational or an engineering challenge to actually make that happen. So we are very tuned into this and we are actually actively talking internally now about doing some survey process redesign so that we can really get our arms around that. If we don’t have a good baseline as to whether that problem exists or not, we’re not going to be able to get underneath it to find out exactly what needs to be done.
RICHARD UMBDENSTOCK: Just recently, late last week, we came off of a round of regional policy board meetings from the AHA nine regions across the country. Between 25 and 35 people attend each of those. One of our major subjects was exactly this issue around emergency department capacity, flow issues, and overcrowding. It is a significant issue. I know a lot of hospitals have been tackling it. One of the hospitals out of the system I came from had a particularly large challenge in this regard as a regional trauma center and did just what Dennis was talking about, when through the reengineering of processes, and as you all know, found that it backs right up into the rest of the house. So the ER is in many ways just that early indicator of capacity and flow challenges throughout the rest of the hospital system and hospitals are getting on it. We’ll do our best to share what those experiences and best practices are.
QUESTION: Public attention has been drawn to hospital quality by recent reporting and hearings on the troubles at Walter Reed Army Hospital and its outpatient centers. The Joint Commission had given Walter Reed a gold seal and it won accreditation. I want to give you the opportunity to comment on that and the difference between measuring certain things and an overall look at quality.
DENNIS O’LEARY: First of all, let me state the obvious and that is that neither The Joint Commission nor CMS nor state agencies nor Army inspector generals can be onsite there all the time to monitor organization performance. And so, the next best thing that we can do is do a thorough evaluation when we are onsite, and when we get wind of a problem; to come in and do a thorough evaluation.
Walter Reed and a couple of other hospitals have been favorite poster children in the media recently, but I sign off probably on four or five special for-cause unannounced surveys every week. And we do that because we learn of things that are of concern to us that in our mind mandate a special onsite review. We went into Walter Reed. We had originally two surveyors for two days, and decided, based on that review, to extend the survey to bring in two additional surveyors for a third day. And based on that review, we found that the organization did have some requirements for improvement, but in that regard, it was a fairly typical hospital. It was not in jeopardy of losing its accreditation. It is not a disaster area. This was a thoroughly objective review. And it’s not going to lose its accreditation or even be close to conditional.
Now, having said that, I also want to point out that this was an evaluation of Walter Reed Army Hospital. That is the accredited entity. The accredited entity, from our charge, does not include the outpatient rehabilitation areas. Now, it happened that on this occasion, because of the tracer methodology that we used that we were able to trace a patient into the somewhat storied Building 18 where, of course, already a huge amount of repair work was in place. I would comment that the kinds of problems that we did surface at Walter Reed are fairly typical problems around discharge planning. Walter Reed is not unique in that regard and I think, particularly with regard to attention to the psychological components of injuries and illness. This is a commentary not on the Army, but on how this country pays attention or does not pay sufficient attention to the psychological needs of patients with physical illness, whether that comes from injuries or from anything else. And so, Walter Reed and the Army will need to pay attention to this issue. But I would hope that there is a message here also to the American public and to American policymakers and people up on the Hill that attention needs to be paid to this issue on a broader scale in our society.
QUESTION: This report, along with others that come out—the CMS Premier project, Quality Checks out in California and elsewhere—focus a lot on the process of care that is administered. At one point do we start moving to measuring the outcomes, whether patients actually got better?
DENNIS O’LEARY: There are a lot of people who believe outcomes measures are the Holy Grail. And I’m as much enthusiastic about outcomes measures as anyone else. But there are a number of process measures that are scientifically established to be good proxies for eventual outcomes. If you only wait for the outcomes, you may miss a lot of care that is not at the level that you want it to be. I always like the comment of David Eddy when he was talking about outcomes measures, and he said, do you know how long it takes to measure five-year survival rates for breast cancer? It takes about five years. And that’s true for a lot of these things. Now, that’s not to say that we shouldn’t have outcomes measures, but a good measurement profile includes both process measures and outcomes measures. That’s just a fact that we’re all going to have to get used to.
QUESTION: May I ask a follow-up? And maybe Rich Umbdenstock can address this. Again, we see a lot of reports. There is this report; there is the CMS Compare site; there is the pay-for-performance stuff. At what point do we need to have basically one report, both from consumers and hospitals. Is there an overload and is there the potential to confuse folks on which reports to look at?
RICHARD UMBDENSTOCK: First of all, for the Quality Check and the Hospital Compare reports, the data that is presented being the same. The major achievement that we’ve reached in the last couple of years is this national collaborative to focus the emerging numbers of clinical measures through a common process courtesy of the National Quality Forum and then on to the Hospital Quality Alliance, so that at least we’re talking about the same sets of measures, and providers are able to focus on those that are deemed ready to be used and counted upon.
Having said that, I think we’ll see a variety of organizations take that data and work with it and make it available to people, maybe in different formats, maybe from different perspectives. I don’t see a problem with that. I think through that process, we’ll learn the best way to communicate with providers and patients once we have this growing body of data. So it may be confusing for some and it may actually be confusing a little bit for those using the data. But I think that’s how we learn what’s best; what will help the patient best and what will help the practitioner best. The key thing for us is that we work off of a common set of agreed upon definitions and measures so that providers are not jumping to dozens of different requests, because this is—as Dennis mentioned on The Joint Commission side and I can certainly vouch on the hospital side—this is very intensive work that is costly. So we want to make sure that we invest our resources in the best places.
GERALD SHEA: I just wanted to add to Rich’s comments. You know, from the consumer point of view, at this stage in the development of reporting, it’s not a bad thing that there are many different initiatives. Ideally, we want to get to a streamlined, uniform approach. But the fact that there is now reporting going on by The Joint Commission, by CMS, by 40 or so states at this time on quality performance measures is actually an indication of how intensely people are working on this. And so, in the short term, we might have a little bit of, well, which one do you want to look at kind of question; and that’s fair. But in fact, as Rich said, we’ve made great strides in making sure that we’re using the same performance measures. We’re not 100 percent there yet. We still have some ways to go to get everybody on that train. But I really feel proud of the work that everybody has done, particularly the organizations like hospitals that have been doing the reporting, and organizations like The Joint Commission that have been enabling that reporting and doing the actual measures, and the leadership of the federal government through Health & Human Services and a lot of the states for providing this material for consumers. So this is a good news story, even though I would agree with the implication of the question that it would be best if we got to uniform reporting at some point.
DENNIS O’LEARY: For those who are really down in the weeds and know this stuff, there are some subtle differences in the data report in Quality Check and Hospital Compare. And that’s not because there are differences in the measures per se, but because of the population being reported. Hospital Compare does include some unaccredited organizations. They’re not a lot, but some. And Quality Check includes all of the Veterans Administration and Department of Defense hospitals, which Hospital Compare does not include. We could change things, I guess, at some point, to make those all common. But those really account for differences in denominators. So if you see disparities, that’s really the reason for them.
QUESTION: You mentioned that there are some nursing sensitive measures in final field testing. Is this an important area to get up? I mean, most people stay in hospitals because they need nursing care, so they have to be a major part of what you look at. What is going on in looking at those measures and will they be next in line or what?
JEROD LOEB: Nurses, you’re right, are the glue that holds health care together. This is a set of 15 measures that have been through the NQF—National Quality Forum—endorsement process. They represent a variety of different kinds of process measures, as well as measures that speak to the nursing workforce, things like voluntary turnover and so on. The problem with those measures at this point in time is they were each developed in silos, and The Joint Commission received a grant from the Robert Wood Johnson Foundation to undertake a two-year test of these measures in combination—that is, collecting the data across all 15 measures. There will be some dials tweaked at the end of that period; those measures will then be provided back to the National Quality Forum and the NQF may decide to either place those measures through the consensus development process again, or perhaps the material changes will not be significant enough to do so. And then there will be fair game for implementation either on the part of the Hospital Quality Alliance or certainly within the context of the library of endorsed measures that The Joint Commission has on its website.
DENNIS O’LEARY: I just want to be clear that the term nursing sensitive measures is a term of ours. These are not measures of nursing; they are measures of care provided to patients that are more and more likely to be sensitive to the quality of nursing care being provided.
QUESTION: I’m interested in behavioral care performance measures. Is it correct you’re developing measures for seclusion and restraint? And will those be included in future public reports?
JEROD LOEB: We do have a set of measures that are in testing right now for hospital-based inpatient psychiatric services, one of which does address restraint and seclusion. This test will continue through 2007. We’ll see the status at the end of 2007 relative to implementation. But clearly, there are approximately 600 facilities that have been very clear with us that they would like to see measures that are more pertinent to the care that is provided within behavioral health care settings. Thus, we have moved into that arena with a number of partners. This was not done entirely on the part of The Joint Commission. We were working with the National Association of Psychiatric Hospitals and there is a variety of other entities with whom we are working on that.
QUESTION: I was curious that the compliance was lowest for, among others, for the timeout taken by the surgical team. Not being a member of a surgical team, it strikes me as something – well, for example, there was a recent paper coming out of Johns Hopkins. They came up with a process that took about two minutes and seemed to be fairly effective. I’m just wondering your thoughts as to why that does seem to be an area in which compliance is low and what might be done about it?
DENNIS O’LEARY: This has been an area of some significant frustration for us, because the timeout is probably the embodiment of opportunity to prevent wrong site, wrong person, wrong procedure surgery. We did issue a universal protocol about two years ago. And after we did that—and that includes the timeout—it was endorsed by about 50 surgical societies and nursing groups. And after we did that, the number of reported wrong site surgeries went up. But every time we draw attention to it, the rate goes up. Now, we may be just seeing increased reporting, but we have to remember that this is an occurrence that should never happen. And so whatever the level is, it’s too much. But having said that, if you’re in a hospital and the surgeons there, none of them, or maybe one of them has ever had a wrong-side surgery case, it’s not real to them. They will say that happens some place else, not me; this is never going to happen to me until it happens to them.
And I’m an internist. My surgical colleagues tend to be somewhat strong-minded in their beliefs about things, and so some of them are less inclined to take the requirement for the timeout seriously. We convened a summit on wrong-site surgery several years ago, and we just had our second summit, which reaffirmed the value of the Universal Protocol; but suggested that we become even more prescriptive about the steps that need to be taken as part of a timeout, and that process is now moving forward, and it is entirely possible that there will be tightening of the requirements of the timeout procedure.
We are dealing with two issues here. One is care process design, an engineering question, if you will, which can be solved in part by integrating required steps into the usual processes that patients go through as they enter the operating room. But the other is attitude and behavior and that is simply going to require increased attention to peer pressure and leadership in organizations. We’ll get there; sometimes you just have to tenacious about it.
QUESTION: What do you see as driving the rate of improvement seen so far? My reporting indicates that in terms of consumer attention to these reports, perhaps it’s because there are so many of them, or whatever reason, is not certainly – it is not consistent follow up or clear that it its determining what hospitals folks choose to go to. So then what do you see as driving the improvement that this report shows? Thanks.
DENNIS O’LEARY: Most organizations want to do the best jobs they can, for openers. And once the information is in their hands, they have something hard to work with. Obviously when you make that data public, it raises the ante a little bit further, and we have certainly done that through Quality Check. Of course, looming on the horizon is all of the pay-for-performance stuff, and that is in the back of people’s heads as well.
But I would say of the hospital community in particular that the long-standing commitment to accreditation, which actually antedates the creation of The Joint Commission, is part of the culture. You know, the hospitals don’t have to do this. And the fact that they do it and commit themselves to continuous improvement is a wonderful part of the culture of that community.
RICHARD UMBDENSTOCK: I would agree with Dennis. I think what is driving it is the professional ethic of the health care community and the concern for patients. That it is every practitioner and organization’s concern. I lived through the beginning of this era out in the field at a hospital system and watched the changeover as more information became available.
For a variety of reasons, we generally talk about the web and electronic communications capability. But the same thing was going on in health care. And we moved from just looking at the science of medicine to looking at the science of quality and quality improvement.
And I saw a terrific quick shift—not immediately—lots of debate; lots of dragging of heals, and so on; I wouldn’t kid you, but I can look back on that period in the late ’90s and early part of the 2000s and say that there was a very discernable uptake on the part of hospital personnel and physicians once this information became available, and once there was a consensus process that said chase this; this is worth it. We have chased a lot of things that weren’t worth it in the past, and so there is some skepticism, but I think this movement and what I call the science—emerging science around quality—is really rolling, and it has been welcome by our folks as Dennis indicated.
GERALD SHEA: It is the ethics of the profession that are the primary driver of this improvement. Now, it doesn’t hurt that purchasers of care like Medicare say we’re going to tie your payment to whether or not you make measurable improvements, and private purchasers, long before Medicare, have been pounding the table and saying, we want to see improvements in some of these critical areas.
But this is not an adversarial proceeding as much as it is an example of people working together— different perspectives, different points of view—coming together to produce a good result.
The other dimension of the question that was raised, and that is consumer use of this information…we have to recognize we have a long way to go to making this data easily usable. We have made it available. The number of inquires that are made on the website of The Joint Commission for this information, and the number of inquiries that are made to the CMS website are testimony to how people are interested in this.
We have yet, I think, to make it usable in an actionable way for consumers. That is a task which all of us are focused on and recognize, and one that we are prepared to tackle. But as has been said, this has been a lot of work to get to the point we are, and shame on us that we haven’t gotten the whole job done, but we know that we have got a lot more to do.
QUESTION: With respect to the National Patient Safety Goal compliance, the report urges caution in interpreting those trends. What do you mean by the surveyors’ increasingly sophisticated assessment of compliance?
DENNIS O’LEARY: This probably gets into a little bit of a technical area, but it’s easy to say, well, how do you assess that people are washing their hands? Well, you could stand in the hall and see who washes their hands every time, but it’s not that easy. Or how do you assess a timeout is being taken before a surgical procedure. So there are techniques for observing performance and for interviewing that turn out to be fairly effective in eliciting information that will tell you whether this is or is not happening here.
It is both the awareness of the techniques that work and making sure that the surveyors are trained and all use the same techniques. That is really what we are referring to. We continue to bring on new patient-safety goal requirements. So when we do something like medication reconciliation or patient care handovers, these are very complex systems issues—complex for the organizations to figure out how to do them and complex for us to assess whether the organization is doing well or not.
At some point, the surveyor’s sophistication in assessing compliance levels off. We have been on an upslope over the past few years, and that’s the whole purpose of being a little cautious about the interpretation.
CATHY BARRY-IPEMA: I’d like to thank everyone for participating—all the attendees here, our callers, and most importantly thank you to our panelists. Remember to visit The Joint Commission website, www.jointcommission.org, for the complete report. Good day and thank you.