The Joint Commission Tries To Lead Hospital Leaders

Posted by

Paul Levy

Posted 1/23/12 on Not Running A Hospital

I was intrigued to read of a new standard, effective July 1, 2012, adopted by The Joint Commission regarding the need for hospital leaders to create and maintain a culture of safety and quality throughout a hospital.  Here it is:

I do not know how to find the previous standard for this topic, so I don’t know how different it is.  But this one seems to reflect comments made in the past by JC president Mark Chassin that the industry needs to get better creating and maintaining a true culture of process improvement.  For example, an article by him and Jerod Loeb in Health Affairs centers on this topic.  In a town hall meeting back on April 13, 2011, Mark also noted:

The first premise for taking on this new topic is that I believe we need to do something different in quality improvement. . .  . Our public stakeholders are clamoring for much more rapid improvement that extends over more aspects of the way care is provided . . . . So, the fact that we’ve made some progress is important, but it’s not enough. 

[W]e can learn from organizations that are outside of health care that have managed to deal with very serious hazards much more successfully than health care has. . . . When we’re talking about organizations known in this literature as High Reliability organizations—commercial air travel, aircraft carrier, flight decks, even nuclear power—have much better safety records than health care does. [W]hat they actually have in common is that they have very effective process improvement tools that allow them to create nearly perfect processes and a safety culture that wraps around those very highly performing processes and keeps them working at high levels of safety over long periods of time.

This is an excellent diagnosis of the problem, and the contrast between those industries and most hospitals is dramatic. How, then, to draw the nexus between where hospitals need to be and this newly adopted JC standard?  Face it.  If this standard were enforced today, most hospitals would not be accredited.

Sure, a hospital could create pro forma policies that would appear to represent compliance with the standard, but that is quite different from establishing a true culture of process improvement.  In my former hospital, with a full-fledged effort, it took five years to get to the point that we understood pretty wellhow to accomplish process improvement.  I think if you talked with other leaders like Gary Kaplan at Virgina Mason and Jeff Thompson at Gundersen Lutheran, they would say the same.  And look here for the exposition by Jack Billi at the University of Michigan Health System, who modestly explains that, after years of dedicated work, they still have a long way to go.

As I have stated, The Joint Commission has the unenviable task of enforcing the CMS Conditions of Participation, a hugely bureaucratic set of standards.  Its surveyors’ manual relating to these regulations goes into excruciating detail.  Given those requirements, I always found the Joint Commission surveyors to be thoughtful, helpful, and highly experienced people; but to evaluate the new standard copied above will require an entirely different set of assessment skills and personal experience from the surveyors.  How will they be trained to be fair and accurate judges of this standard, to know the difference between real progress in a hospital and window dressing?  Given that they drop in for just a few days every three years, how will they judge progress over an extended period of time?

Finally, this kind of standard is quite different from, for example, the one requiring 16 inches clearance above shelves in a storeroom.  With those detailed standards, when you “fail” enough of them, you need to have improvement plans and you risk loss of accreditation.  If a hospital is found not to comply with this new standard, what will be the remediation process?

So, good for the JC in setting for this standard.  The jury is out as to how it will be enforced and how meaningful it will be.

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