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JC Physician Blog

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JC Physician blog – News for M.D.s from M.D.s at The Joint Commission

Written by and for physicians, the biweekly JC Physician blog discusses health care issues of interest to doctors as well as other topics that may touch on ethics, the environment and current affairs.

NOTE: Physician are encouraged to submit guest blogs for the JC Physician blog. Those interested should contact Social Media Specialist Sean Ostruszka.


Taking a stand against costly and complex

Apr 16, 2014 | Comments (0) | 691 Views

Daniel J. Castillo, M.D., M.B.A.By Daniel J. Castillo, M.D., M.B.A.
Medical Director
The Joint Commission

In 2006, McKinsey Global Institute compared health care spending by country and concluded the U.S. spent nearly $650 billion more than other developed countries on health care. You read that right – $650 billion.

You might think this large discrepancy was caused by our population being sicker, but it’s not. Instead, the factors identified were the growing capacity of outpatient services, the cost of technological innovation, and the increase in patient demand in response to the available services. Approximately $91 billion, or 14 percent of the total, was due to inefficiencies or redundant administrative practices. More recently, former CMS administrator Donald Berwick estimated that waste consumed between $476 to $992 billion, or 18-37 percent of health care spending, in 2011.

No wonder the U.S. health care system has been described by The Institute of Medicine (IOM) as far too complex and costly. And those are not the only alarming statistics. Despite this higher spending, studies have shown that compared with other developed nations, the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity and healthy lives.

It’s this alarming trend that I tackle in an upcoming article in The Journal of Integrated Healthcare Delivery. In the article, I begin to lay out a roadmap to assist the adaptation of organizations’ delivery models from fragmented and costly to integrated and efficient.

Please stay tuned for this upcoming article, and to this blog, as we try to better our health care systems.

Taking care of my parents

Apr 02, 2014 | Comments (0) | 955 Views

Ana Pujols McKee, M.D.By Ana Pujols McKee, M.D.
Executive Vice President and Chief Medical Officer
The Joint Commission

My father died the day after Christmas. It would have been much earlier had I not stepped in.

His last six months – after being moved to the city in which my sister and I live – saw him under the care of physicians and nurses that understood his goals of care and what mattered to him most. This was in striking contrast to the disjointed care, with seemingly endless tests, his physicians had imposed on him in his home city.

We know the reasons for overuse of medical treatments and tests are multifactorial. We also know that most of the time, the clinician has good intentions. But ordering dangerous tests for frail elderly patients who do not want them demonstrates lack of both knowledge and caring.

With first-hand experience with this dangerous situation, I proposed a call to action in JAMA Internal Medicine.

Leading improvement: Go to the gemba

Mar 05, 2014 | Comments (0) | 1391 Views

By Erin DuPree, M.D., Chief Medical Officer and Vice President, The Joint Commission Center for Transforming Health care

Erin DuPreeThe knowledge needed for improvement is seldom found in the conference room.

Some of you may be familiar with the term “gemba,” while for others it may be new. Gemba is the Japanese term for “the real place.” So, going to the gemba is going to the place where value is created, where the real work is taking place. It stems from the Japanese mindset that when there is a problem, one should get as close to it as possible and learn BEFORE proposing a solution.
Problems are visible. For detectives, gemba is the crime scene. In manufacturing, it is the factory floor. In health care, it is wherever there is patient interaction. In hospitals, the real place can be on the units or in the operating room. 

This gets me back to the conference room. How often have we as leaders in health care tried to solve a problem in a meeting when the real knowledge and real experts were at the bedside, delivering care? Too often in health care we jump to solutions. After all, we were trained to know the answer. When leading improvement, though, we must resist the impulse to ‘solve’ the problem right away. In practice, this results in short office meetings, with the brunt of the work being done in a gemba walk, on a hospital unit, for instance. 

Health care leaders can achieve multiple objectives when going to the gemba. The main objective is to obtain a comprehensive understanding of the process through a series of interviews in the relevant place. In health care, this is often on the floors, in the operating rooms, doctor’s offices and labs. Sometimes, it brings us to the patient’s home. We are tempted to overlook this critical step in improvement, especially if we are rushed, think that we already know the answer, have preconceived ideas of the primary issues, or get consumed in large volumes of data. By going to the unit, observing and talking with care providers involved in the actual process at the actual place, one can obtain actual data, which is critical for improvement. The best improvement ideas often come from going to the gemba. Importantly, it also helps to build trust between management and front-line care providers -- a critical element in a safety culture.

The way to “go to gemba” was perhaps best expressed by Toyota Chairman Fujio Cho when he said, "Go see, ask why, show respect.” 

When taking a gemba walk, see if processes are designed to enable people to work toward achieving organizational purpose. Is leadership working to align people and process to achieve purpose? Be prepared to accept the differences in the process -- between what is and what it should be, much less what the organization wants it to be. You might find that the policy that you sweated over is found to be fictional because workarounds have been developed and training was inadequate.

Although it is the second element of Cho’s mantra, "why" is not actually the first question we want to ask at the gemba. First ask “what,” then “why,” then “what if” ... and, lastly, “why not.”

Finally, show respect. When visiting any gemba, through showing respect for the workers we also show respect for patients and the organization. Look for evidence of disconnects between stated objectives, perhaps those expressed in the organization's vision statements, versus what we actually observed at the gemba. Also look for signs of disrespect, such as overburdened nurses. Certainly as health care leaders, we respect people because we believe it's the right thing to do and simply because it makes good business sense. Respect means doing what we can to make things better for the people delivering care, which starts by not making things worse. The first rule of gemba walking is “Do no harm!”

So, next time you are in a meeting and find the group is trying to diagnose and prescribe a solution from the conference room, get up and go to the gemba. Confirm what is actually happening, as it is happening. It is one of the most important principles and practices of leadership.

Help your medical staff shine during survey

Feb 19, 2014 | Comments (0) | 4055 Views

By Anne C. Bauer, M.D.
Field Director, Accreditation and Certification Operations

Anne_BauerIt was always easy to tell the medical staffs that were prepared.

As a hospital physician surveyor for a number of years before becoming a field director, I had the opportunity to observe and interact with medical staffs from all kinds of hospitals.  During that time, I noticed a simple trend – organizations that took time to prepare their physicians for their on-site surveys had better experiences.
Physicians want the opportunities to shine and be credited for their excellent work.  They don’t want to be put on the spot, not knowing what is being asked of them.  Frankly, that is not what the physician surveyor is looking for either.  Preparing the medical staff for the activities of the survey and when they are likely to encounter the surveyors tends to prevent awkward and “defensive” encounters.

It’s true that this survey is unannounced, but the accreditation coordinator will usually alert the hospital staff as to the “window” in which the next full survey is likely to take place. This is a prime opportunity to schedule some time for multiple short discussions with the medical staff.

Here’s how to make your medical staff look their best come survey time:

  • During the opening meeting, make sure the staff has prepared a brief overview of their work, including challenges they has tackled, such as patient flow issues in the ED, infection rates or improved hand-off communications. This shows a hospital that is proactive in dealing with the challenges all hospitals face.

  • For the session on the hospital’s medication management system, members of the Pharmacy and Therapeutics Committee should be prepared to talk about their analysis and response to medication variance and adverse reaction data.  This is an area that medical staffs know a great deal about, so being prepared allows them to show off their knowledge.

  • Concerning the maintenance of credentialing and privileging and how they are “overseeing” care at your hospital, the surveyor will want to know how the staff is monitoring the quality of history and physical exams.  The surveyor will also want to understand the staff’s system for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).  Making sure everyone knows what these acronyms stand for is a good first step.  Even better, medical staff members should be actively involved in discussion of what quality indicators are being used to evaluate their care of patients.

  • Alert the medical staff that they may be asked to talk about how aspects of care are provided on their service, such as how treatment went in a specific case. Also, stress that this doesn’t mean the surveyor has found a “problem.”  More often, it means that the surveyor is trying to understand this service’s particular approach when they are tracing patient care on the units.

  • Finally, on the last day of the survey there will be a leadership session. This is an open discussion; one in which the medical staff should actively participate to showcase performance improvement projects they have undertaken and their engagement in the hospital. Topics include strengths and weaknesses identified during the survey or “big topics,” such as how organizations achieve high reliability in health care or are anticipating health care reform.

Physicians want to shine and to be credited for their excellent work – the on-site survey presents the perfect opportunity to do just that!


Using OPPE as a performance improvement tool

Feb 05, 2014 | Comments (0) | 2955 Views

By Paul Ziaya, M.D., Field Director, The Joint Commission

blog-PZiaya1Processes for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) offer valuable tools that medical staffs can use to determine if care provided by a practitioner is below an acceptable level. The ongoing monitoring process significantly contributes to:

  • evaluation and decision making on the maintenance or alteration of privileges

  • the early identification of trends

  • any needed proactive education and collegial intervention.

However, OPPE can also be used as a tool for performance improvement to avoid adverse outcomes, not just react to them. Ultimately, the value of OPPE depends on:

  • the measures selected by the medical staff

  • how well those measures represent activities that reflect the quality of care and performance

  • how effectively the resulting information is used.

For instance, looking at postoperative infection rates can result in an evaluation of practices and the potential prevention of future infections. 

Organizations that have been able to collect meaningful data in an ongoing way, and provide that data to individual practitioners (particularly if accompanied by peer or benchmark data) have found that practitioners become actively engaged both in validating the data and in self-evaluation and modifications in practice. Some organizations that provide ongoing computerized access to data have found that practitioners will look at their own data even before the semi-annual review and proactively implement changes to their practices. 

Vital to success of the OPPE as an improvement tool is the use of measures that departments agree are valuable. In an effort to drive improvement, some creative departments have selected one or two metrics that reflect areas that they are finding challenging, such as consistent use of an agreed-upon clinical practice guideline or protocol.

Most practitioners will make the changes needed when presented with data showing they are not performing to the same level as their peers. However, there will be those who, despite the data, will not take the appropriate action. For these individuals, the OPPE and FPPE processes provide documentation and powerful tools for making necessary privileging decisions. In the end, professional practice evaluation will be as valuable as each medical staff makes it.


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