Holding Up Both Ends of the Quality Partnership | Joint Commission
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This blog shares experiences, case studies and news that add insight and value to the accreditation and certification journey.

Holding Up Both Ends of the Quality Partnership


Dec 15, 2017 | 426 Views

Mark PelletierBy Mark Pelletier
Chief Operating Officer, Accreditation and Certification Operations
The Joint Commission

In my last post, I shared a look at the 750 U.S. hospitals that The Joint Commission surveyed from Jan. 1 through June 30 this year and made some high-level observations about the outcomes. I talked about how our surveyors found deficiencies at every hospital during each of those surveys, and how we work with hospitals to address them—which is exactly how the accreditation and quality improvement process is supposed to work. It’s a “quality partnership” and each party must hold up their end of that partnership to make accreditation work.

Obviously, The Joint Commission can’t be on site at any hospital all the time to observe everything that takes place 24/7/365.  So over the time that we are conducting a hospital survey, surveyors are carefully:

  • examining processes and identifying breakdowns and deficiencies in real time

  • guiding the hospitals in correcting those deficiencies as swiftly as possible

  • assessing compliance with our standards to ensure processes are strong, sustainable and can consistently deliver the safest and highest quality patient care

Among the 750 hospitals surveyed earlier this year:

  • 99 percent had deficiencies presenting a moderate risk of harm, such as storing keys for a locked medication cabinet in an unsecured desk drawer, or failing to document an anesthesia follow-up to assess for complications

  • 50 percent had deficiencies presenting high risk of harm—for example, lack of physician participation in surgical time-outs; issues with sterilization and high-level disinfection; open-ended or no parameters on a sedation order; lack of response to discovery of a medication error; and incompatible supplies for resuscitation services

  • 2 percent had deficiencies presenting immediate threats to health and safety

All examples above are general for the sake of illustration; actual risk levels might be higher or lower depending on particulars and context.

Dealing with Immediate Threats to Health and Safety (ITHS)

ITHS findings are situational and dependent on a combination of factors and findings. When surveyors identify a deficiency at this level, they immediately:

  • contact our central office staff to confirm ITHS status 

  • review the finding with hospital leadership

  • support hospital leadership and staff in mitigating the threat while we remain on site

  • discuss expectations that the hospital will identify where breakdowns leading to the ITHS occurred

  • notify the Centers for Medicare & Medicaid Services (CMS), which determines any appropriate regulatory action

  • share finding when appropriate with the state department of health, which determines if the ITHS falls within its purview for public action—for example, problems with sterilization of instruments

Our Standards Interpretation Group and other staff are available to the hospital for guidance on questions and support over the next 23 days, before we return on-site to make sure the organization has implemented sustainable solutions.  During that time, we report the immediate threat status on our public Quality Check® website.  

Improvement in these cases is not always an easy fix. Sometimes it requires the organization to close whole services or components until the problem is eliminated.  The Joint Commission is not an enforcement agency and doesn’t have that authority to require closure or discontinuation of service, however an organization may make that decision on its own, or it may be required by a state or federal enforcement agency. 

Working on Deficiencies

If our surveyors cite a deficiency, they explain to hospital leadership and staff exactly how it impacts quality and safety and why it’s important to fix. They offer perspective and a knowledge base from having seen problems at hospitals they’ve surveyed all over the country.  They also offer support and knowledge available through The Joint Commission to help improve, resources such as our:

  • Web-based topic library and website portals with guidance and practices on subjects such as infection prevention, emergency management, physical environment, transitions of care, and much more.

  • Tools like the Preventing Falls Targeted Solutions Tool® available through our Center for Transforming Healthcare

  • Publications such as our Quick Safety reports and Sentinel Event Alerts

  • Ongoing webinars, conferences, training and other resources throughout our organization, including the Center for Transforming Healthcare and Joint Commission Resources

Necessary Confidentiality

There is ongoing argument from some that the details of our findings and work in these situations as a private accreditor—our accreditation survey reports and details of our deficiency findings—should be made public.  There are important reasons they are not. 

Our surveyors see, work with and discuss patient care, deficiencies and business processes that are highly sensitive to the hospitals they are surveying, and often confidential by law. 

Importantly, if our work identifying every potential and real problem at a hospital during our survey at a particular moment in time was reported to the public: 

  • Would hospitals be as open to candidly discussing their improvement needs and efforts?

  • Would our surveyors get the information they need to identify deficiencies? 

  • Would we be able to report serious findings to regulatory agencies to take appropriate public action?  

  • Would it help reduce serious patient care issues and improve patient safety?  

I don’t think so. Why would any organization want to talk to an outsider about its problems and process breakdowns if every conversation and the information gleaned about it was fair game for public scrutiny?  

As a private accreditor, just like those in aviation, nuclear safety and other high-stakes industries: We maintain necessary business confidentiality with the organizations we accredit to accomplish the important job we have.  Hospitals do their jobs, public regulators do theirs and we as a private accreditor do ours. 

New Performance Improvement Plan Programs

Last year, The Joint Commission implemented a sustaining improvement program to help hospitals that are struggling the most with standards compliance. I, and The Joint Commission’s chief medical officer, work individually with hospital CEOs and leaders to identify why processes broke down—and how they specifically will be involved in assessing, determining and implementing solutions. We review how improvements are being implemented and how the organization is measuring their progress. 

For some, it take time to fully embrace the level of change we advocate. Others act quickly and are proud of the accomplishments they’ve made. They express they’re grateful to us for identifying problems for them to address before harm can occur.

For those CEOs, it’s clear the experience working with us has changed how they look at their involvement with quality. Sometimes we even get board members involved. No other healthcare accreditor does this. 

This is when accreditation is most effective—when we and the organizations we accredit act on shared commitment to improving quality at an organization. This is the realization of our mission: “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”  It is when patients benefit the most.

Mark G. Pelletier, RN, MS is the chief operating officer for Accreditation and Certification Operations for The Joint Commission. His responsibilities include executive leadership for the accreditation and certification of more than 21,000 health care organizations and programs, all activities related to surveys, eligibility and application processes, customer account management, and federal deeming compliance requirements. Mr. Pelletier also administers accreditation and certification policy development, surveyor education and development, survey technology, and the ongoing development and refinement of the accreditation process. Prior to his current position, Pelletier served as the executive director for the Hospital Accreditation Program, and was also responsible for business development in the Hospital, Critical Access Hospital, and Laboratory accreditation programs. Previously, he was the senior vice president and chief operating officer of Condell Medical Center, Libertyville, Illinois. He has also served in executive positions over 30 years for several hospitals in the Chicago area including Resurrection Health Care, Northwestern Memorial Hospital, Children’s Memorial Medical Center, and Mercy Hospital Medical Center.

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