Who’s on First?

Paul Levy

First published 4/18/11 on [Not] Running a Hospital

This story about the Joint Commission in the Boston Globe is disheartening.

The lede: The national organization that accredits hospitals will tackle the failure of medical staff to respond to patient alarms, making it a top priority this year.

But the real story is the failure of the Joint Commission to address this issue in a comprehensive and thorough manner. Indeed, it seems to have dropped the ball:

In 2004, the commission decided to make improving alarm safety part of its national patient safety goals, which signaled it was a high priority. However, the agency soon dropped the goal, thinking that hospitals had solved the problem.

The Joint Commission seems to need to spend some time getting a focus on things. It makes animated cartoons about avoiding the spread of germs. It refuses to make its library of hospital best practices widely available. Even in this story, it seems to fear transparency: “He wouldn’t release numbers, but Schyve said the Joint Commission is getting more reports of hospital staff not responding to crucial alarms, or alarms being shut off.”

This is the group that accredits hospitals for participation in Medicare. How can Congress let an accreditation agency that works for the public be so opaque with regard to clinical information and with regard to its progress in working on systemic change in hospitals?

Paul Levy is the former CEO of a large Boston hospital.

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