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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.


A Sunny Response to the CMO Academy Launch

Jul 16, 2014 | Comments (0) | 574 Views

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

When the people of Seattle get behind something, they really get behind it. Just look at Starbucks, grunge music or how they embrace the rain. The fans of the Seattle Seahawks even once got so loud during a game that the vibrations registered as an earthquake.

This past weekend, we made plenty of waves in our own right.

With The Joint Commission partnering with the American College of Physician Executives (ACPE) to develop a CMO Academy, I was fortunate to attend the ACPE summer institute. This marked the launch of the academy, with the focus being on the needs of chief medical officers less than three years into their leadership roles.

The academy also was an opportunity for physician leaders to learn about the new Joint Commission. Attendees were introduced to our performance improvement expertise, tools and, most importantly, our commitment to support physician leaders as they work to meet or exceed their quality improvement and patient safety goals.

After one of my talks, a CMO approached and exclaimed, “Wow, I didn’t know that The Joint Commission was doing all of this. This is great!” I can’t tell you how many more reactions like this I received, as I simply lost count. I do know that enthusiastic remarks like those make me hopeful that the online CMO Academy – coming in the near future – will be valued and well received.

While the attendees in Seattle came from all across the country, they certainly caught the Seattle bug, getting fully behind the CMO Academy. Here’s hoping the rest of the health care world does, too. 

Don’t make me wait!

Jul 02, 2014 | Comments (0) | 1534 Views

Ronald Wyatt, Medical Director, The Joint CommissionBy Ronald M. Wyatt, M.D., M.H.A.
Medical Director
The Joint Commission

People hate to wait. They don’t like waiting in line for their coffee. They don’t like waiting to find out the latest gossip. They don’t even like waiting for water to boil.

Coffee, gossip and boiling water – three non-life-threatening things in which the time frame is of little to no consequence, yet we hate waiting for them.

Now imagine how much people hate to wait for something in which the time frame is critical – even potentially life threatening, if delayed.

Unfortunately, it happens in health care far too often.

Sentinel event statistics from The Joint Commission show that one of the top reported events from 2004-2013 is delay in treatment. In 2013, delay in treatment was the third most common reviewable sentinel event.

With increased demands for health care services and clinicians, and a renewed focus on improved health outcomes, there is an urgent need to find ways to prevent these delays.

Whether it be delays in medication, a lab test, physical therapy, or any kind of treatment, these delays don’t just happen, but instead often have proximal contributing factors, such as misdiagnosis, failure to treat, failure to communicate a significant lab result, delay in diagnosis, or misunderstanding of the underlying disease process.

These proximal factors, and the delays they cause, have dangerous outcomes, as an Agency for Healthcare Research and Quality (AHRQ) study found that 28 percent of 583 diagnostic mistakes were life threatening or had resulted in death or permanent disability (Schiff G.D., et al: Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med. 2009; 169(20):1881-1887).

Meanwhile, the most common root causes of delays in treatment reported to The Joint Commission include:

  • Communications failures
  • Failed hand offs and care transitions
  • Inadequate staff orientation and training
  • Inadequate staffing levels
  • Clinician availability
  • Failures in the patient-assessment process

So, how to we begin unclogging the timeline and eliminating delays?

One way The Joint Commission is working to help organizations address delays is by increasing patient engagement through its Speak Up program. Started in 2002, the program encourages patients to:

Speak up if they have questions or concerns.
Pay attention to the care they receive.
Educate themselves about their illness or condition.
Ask a trusted family member or friend to be their advocate.
Know the type of medicines they receive.
Use hospitals, clinics and surgery centers that have been carefully assessed by The Joint     Commission.
Participate in all decisions about their care.

If you’re looking to diagnosis areas that might be causing delays in your organization, it would be wise to focus your organizational attention on:

  • Scheduling processes
  • Ordering and reporting test results
  • Improving access to care
  • Implementing a standardized communications method, such as Situation Background Assessment Recommendation (SBAR)
  • Maintaining adequate staffing levels (expect the unexpected)

In 2013, The Joint Commission reviewed 107 sentinel events that were a result of delays in treatment. This means there was either a patient death or permanent loss of function as a result of that delay.

With the combined commitment and efforts of organizational leadership, clinicians and patients, we can reduce that number.

Now is the time to act. Don’t wait.


The Integration of Mental Health and Medical Care – The Future

Jun 18, 2014 | Comments (0) | 1051 Views

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

Two forces are fueling national changes to the practice of psychiatry – and potentially bringing two health care services together.

Conversation at the annual American Psychiatric Association (APA) conference last month in New York City centered around the Mental Health Parity and Addiction Equity Act, and of course, the Patient Protection and Affordable Care Act of 2010 (commonly called the Affordable Care Act or ACA). Vice President Joe Biden was on hand to talk about the mental health parity law increasing access to mental health care. There are concerns about how this law will be enforced, with current court cases establishing those legal parameters at this time.

The ACA has created several mandates for health care changes, including an increase in care integration. One aspect of that is the integration of psychiatric and mental health care services with medical care.

The incoming president of the APA, Paul Summergrad M.D., emphasized at a recent meeting that the integration of mental health and substance abuse treatment, and general medical care was crucial to achieving the Institute for Healthcare Improvement’s (IHI) Triple Aim: improving patient experience of care, improving the health of populations, and reducing per capita cost of health care.

It has long been believed that the integration of mental health and medical care has the potential to lower health costs overall. Mental health disorders are the strongest predictor of disability. An APA-commissioned actuarial study concluded that general medical costs for treating people with chronic medical problems and mental disorders are two to three times higher than those for treating people with only physical health conditions. 

Presenting at the APA conference, Gary Gottlieb M.D., President and CEO of Partners HealthCare in Boston, Massachusetts, said that a study of Massachusetts General Hospital’s ED showed 50 percent of patients with more than 12 emergency department visits a year had a psychiatric or substance abuse disorder.

What are the best ways to move beyond our siloed health care system?

A continuum for levels of collaborative integration between mental health and medical care has been proposed by the Substance Abuse and Mental Health Services Administration-Health Resources Services Administration (SAMHSA-HRSA) Center for Integrated Health Solutions. These range from basic coordination of care to co-location of care to complete integration of care exemplified by certification programs, such as The Joint Commission’s Behavioral Health Home. This is where primary care and behavioral health care clinicians work as a team with shared information systems and treatment plans.

There are big challenges to implementing these integrated models of care, among them the cultural differences in practice between medical and behavioral health, and coming up with the payment structure to support them. These issues will be explored in future Physician Blogs.

Culture Trumps Policies

Jun 04, 2014 | Comments (0) | 1086 Views

blog-PZiaya1By Paul Ziaya, M.D.
Field Director
The Joint Commission

In April, the office of Senator Barbara Boxer published a report that highlighted the continuing problems with "medical errors" and the impact on patient morbidity and mortality. 

Her staff queried 283 acute care hospitals in California, asking them to indicate what actions they were taking to address nine of the most common health-care-associated adverse events. Fifty-three percent responded, with multiple organizations describing progress made through programs they have created. All responding hospitals described "at least some steps to address the most common medical errors."

This sounds like good news, right? After all, sound policies and systematic processes implemented and followed are proven to make a difference. Yet, risk remains, and there is much work to be done.

Recently, an organization’s ICU staff were going between rooms using the same stethoscope without cleaning it, and in one room, staff dropped a patient’s pillows on the floor and reused them on the patient without changing the pillow cases. This same organization had a strong policy and excellent data showing improvement in hand hygiene.

Another organization had a comprehensive policy on falls prevention. One patient had been evaluated and was rated as a "high" fall risk. There was a designation on her door and one on the message board in her room. The organization even had a policy on hourly rounding, and nursing staff faithfully documented those hourly rounds.

At 7:30 a.m. a nurse rounded, and the patient didn’t indicate needing anything. Through multiple medication administrations, staff had been working to help the patient regain elimination. At 7:45 a.m., the patient called indicating the urgent need to do so. A nurse popped in saying she would be right back with help to get the patient to the bedside commode.  By the time staff returned for their hourly rounds at 8:30 a.m. it was too late. The patient had followed instructions and not gotten up, but the bed now needed changing. The nurse documented the hourly rounding and there was no fall, but it was only due to the compliance of the patient.

These are just a couple examples of things that will not show up in any data. They will not appear in any incident reports or on any dashboard unless the patients complain. These organizations all had policies in an effort to prevent these things, but they happened anyway.

Organizations can make large inroads to improvement through the policies they create and the practices they expect, but if we are truly to get to "zero" we must do more than create policies. We must do more than create metrics.

To get to zero, we must change culture. Culture will always triumph over policy, because a culture of safety is the mindfulness by each individual to look for and eliminate risk. Policies and processes give us framework, but care is delivered by individuals, and it is through the mindfulness of individuals and the appreciation and celebration of that mindfulness that we have a chance of getting to zero.

Violence in the Health Care Setting

May 14, 2014 | Comments (0) | 3633 Views

By Paul M. Schyve, M.D.
Senior Advisor
The Joint Commission

Schyve 11 10Many physicians have witnessed it. A few of us have personally experienced it. All of us have heard about it – patients, nurses, staff or physicians injured or killed by violence in the workplace. 

Injuries to medical personnel in a war zone during military service are part of the job. That’s where a nurse or physician knows injury is a real risk. Unfortunately, the risks today occur closer to home in urban and rural hospitals – especially in Emergency Departments and substance abuse units – physicians’ offices and mental health clinics. 

Can this violence be reduced, and do physicians have a role in its reduction?

Physicians have ethical obligations to patients – expressed since the time of Hippocrates – to “first, do no harm.”  (Florence Nightingale extended the same obligation to nurses.) Traditionally, we associated this obligation to the clinical care each physician provides to his or her own patients. However, we now recognize that the culture, systems and processes that we work within are major contributors to safety in patient care. Consequently, we realize that to “do no harm” requires us to contribute to improving the culture, systems and processes within which all of our patients – both our own and our colleagues – receive care. To make our own patients safe, we must contribute to making all patients safe. 

Violence in the workplace is, in fact, a source of harm to our patients that we are obligated to reduce if we are to “do no harm.” To achieve this goal, physicians must become involved in assessing and improving the culture, systems and processes not only of clinical care, but also of the organizations in which we work – hospitals, clinics, private offices, etc.

But, as leaders in health care organizations, physicians also have an obligation to each other, nurses and other staff to create a safe environment.

Nursing is, in fact, one of the most dangerous professions, according to an article in Medical News Today and numerous other sources, In addition, if violence – from whatever source -- is ignored, nurses begin to believe that violence is endemic in their profession, and that organizational leaders, including physicians, have a “culture of acceptance” of violence. Nurses then leave for safer nursing environments or for safer professions. 

So what can physicians do? 

First, we can demonstrate our commitment to a culture of safety by avoiding intimidating behaviors in our interaction with colleagues (See Sentinel Event Alert, Issue 40, “Behaviors that undermine a culture of safety” . Second, we can urge and support our organizations’ leaders to making a reduction in violence a priority for the organization (See Sentinel Event Alert, Issue 45, “Preventing violence in health care settings” . And third, we can improve our knowledge and skills in detecting signs of impending violence and in de-escalating situations of potential violence.

Violence in the health care workplace is a threat to all – physicians, nurses, staff, patients and their families. Physicians have an important role in reducing and eliminating this violence, and we have an obligation to ourselves and others to do so.


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