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1、The Value of Accreditation,Kurt A.PattonExecutive Director,Accreditation Services JCAHO,Table of Contents,Overview of the Joint CommissionThe New Survey ProcessLiterature on outcomesSentinel events and root causesFuture activities at the Joint Commission Q&A,WHO IS JCAHO?,Private,not for profit accr
2、editing body since 1951Board of Commissioners American Hospital Association,American Medical Association,public members,American College of Physicians,American Society for Internal Medicine,American Dental Association,American College of Surgeons.,.And In The Beginning,The American College of Surgeo
3、ns1917The Minimum Standard,That physicians and surgeons privileged to practice in the hospital be organized as a definite group or staff.Such organization has nothing to do with the question as to whether the hospital is“open”or“closed,”nor need it affect the various existing types of staff organiza
4、tion.The word“staff”is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the“regular staff,”the“visiting staff,”and the“associate staff.”That membership upon the staff be restricted to physicians and surgeons who are(a)full graduates of medicine in goo
5、d standing and legally licensed to practice in their respective states or provinces,(b)competent in their respective fields,and(c)worthy in character and in matters of professional ethics;that in this latter connection the practice of the division of fees,under any guise whatever,be prohibited.That
6、the staff initiate and,with the approval of the governing board of the hospital,adopt rules,regulations,and policies governing the professional work of the hospital;that these rules,regulations,and policies specifically provide:That staff meetings be held at least once each month.(In large hospitals
7、 the departments may choose to meet separately.)That the staff review and analyze at regular intervals their clinical experience in the various departments of the hospital,such as medicine,surgery,obstetrics,and the other specialties;the clinical records of patients,free and pay,to be the basis of s
8、uch review and analyses.That accurate and complete records be written for all patients and filed in an accessible manner in the hospitala complete case record being one which includes identification data;complaint;personal and family history;history of present illness;physical examination;special ex
9、aminations,such as consultations,clinical laboratory,X-ray and other examinations;provisional or working diagnosis;medical or surgical treatment;gross and microscopic pathological findings;progress notes;final diagnosis;condition on discharge;follow-up and,in case of death,autopsy findings.That diag
10、nostic and therapeutic facilities under competent supervision be available for the study,diagnosis,and treatment pf patients,these to include,at least(a)a clinical laboratory providing chemical,bacteriological,serological,and pathological services;(b)an X-ray department providing radiographic and fl
11、uoroscopic services.,INITIAL SURVEY RESULTS 1919,692 hospitals of 100 or more beds are surveyedOnly 89 meet the minimum standardsOnly 264 held regular medical staff meetingsOnly 301 keep medical recordsFindings burned in the boiler of the Waldorf Astoria Hotel.,1951 A JOINT COMMISSION IS FORMED,Amer
12、ican Medical AssociationAmerican Hospital AssociationAmerican College of SurgeonsAmerican College of PhysiciansCanadian Medical Society,1953-EARLY FINDINGS,1202 US hospitals seek accreditation99%of hospitals 300 beds75%of hospitals 25-49 bedsHospitals 25 beds not surveyed,JCAHO EVOLUTION,1962 3,947
13、Hospitals accredited1964 Survey fees established1965 Medicare legislation deems JCAHO1967 Standards revision process with 21 advisory panels1986 Launch of Agenda for Change2001 Launch of CAH program2004 Launch of Shared Visions New Pathways2005 Accredit 4500 hospitals,260 CAH,10,The Joint Commission
14、s Mission,To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.,Accreditation and Certification Programs,JCAHO SIGNIFICANTLY CHANGED ITS
15、PROCESS IN 2004,New techniques of conducting the surveysPatient tracersSpontaneity,no script for anyoneNew pre-survey analysis of dataNew standards formatNew scoring methodsNew decision categoriesNew post survey follow up,GOALS OF THE NEW SURVEY PROCESS,Shift the paradigm from survey prep to systems
16、 improvementFocus away from“exam”and“score”Focus toward using standards to achieve and maintain excellent operational systemsFocus on Actual performance not stated capacityExecution not potential,NEW ACCREDITATION PROCESS SETS THE STAGE FOR,Continuous emphasis on operational performance improvementF
17、ocus on the quality and safety of direct patient care delivery systemsA customized approach to the characteristics of the individual organizationReliance on new technology to facilitate the continuous flow of information between the organization and the Joint Commission,ARE JCAHO ACCREDITED HOSPITAL
18、S BETTER?,Health Affairs Vol 22 March/April 2003134,579 AMI patients,4,221 hospitalsJCAHO scores did not correlate with outcomes for AMI patients.Accredited hospitals,as compared to non accredited hospitals did have better results.,AMI OUTCOMES,AccreditedASA on admission 54.5%BB on admission 48.5%Re
19、perfusion 67.5%30d risk standardized mortality 18.4%,Not AccreditedASA on admission 51.8%BB on admission 43.1%Reperfusion 61.8%30d risk standardized mortality 20.4%,AMI OUTCOMES UPDATE WITH CORE MEASURES,ASA on arrival 94%,286,000 casesBB on arrival 89%,253,000 cases 7th SOW=80%Net inpatient mortali
20、ty 9%,301,000 cases,WHAT IS DRIVING HOSPITALS PATIENT SAFETY EFFORTS?,Health Affairs Volume 23,Number 2March/April 2004The most frequently mentioned initiatives either explicitly noted they were designed to meet JCAHO initiatives,or mapped back to JCAHO policies and requirements.The only frequently
21、mentioned activity not directly linked to JCAHO was IT,WHAT IS DRIVING HOSPITALS PATIENT SAFETY EFFORTS?,To a lesser extent:Leapfrog,NPS Foundation,AHRQ,IHIMedicareMarket forces,THE JOURNAL OF RURAL HEALTH FALL 2000,Quality Oversight:Why are Rural Hospitals Less Likely to be JCAHO Accredited?Cost fa
22、ctors for meeting the standards,the survey process and ORYX.The least expensive hospital survey was 2 surveyors for 2 days and$7,800The standards are perceived reasonably well,ACTIONS TO MAKE ACCREDITATION MORE FEASIBLE FOR RURAL HOSPITALS,Flat fee pricing$6200 every 3 yearsSubscription payments ann
23、uallySingle surveyor techniques Unique accreditation manual for critical access hospitalsNew standards format adds clarity and transparency to the process,CAHS AND QUALITY IMPROVEMENT,Quality Improvement Activities in Critical Access Hospitals:Results of the 2004 National CAH SurveySeptember 2004Fle
24、x Monitoring Team University of MinnesotaUniversity of North Carolina,Chapel HillUniversity of Southern Maine,CAHS AND QI,Positive differences do exist between accredited and non accredited CAHs in their use of CPGs.Only pneumonia and CHF are statistically significant.Pneumonia CPG use in accredited
25、 CAH is 94%and non accredited is 82.8%CHF is 94%vs 82%AMI=92%vs 84.2%,CAHS AND PATIENT SAFETY,Critical Access Hospital Patient Safety Priorities and Initiatives:Results of the 2004 National CAH SurveyFlex Monitoring TeamUniversity of MinnesotaUniversity of North Carolina Chapel HillUniversity of Sou
26、thern Maine,CAHS AND PATIENT SAFETY,474 CAHs respond to the surveyOnly 11%are accredited63%are familiar with JCAHOs NPSGOnly 2.3%report focus on JCAHOs NPSGsOnly 1.9%report focus on prevention of wrong site surgery.,COLORADO ACCREDITATION,63/69 Hospitals are accredited by JCAHO1 is dually accredited
27、 with AOA2/24 Critical access hospitals are accredited.Does the state have the resources to review the non accredited CAHs on a regular basis?,SENTINEL EVENTS,Voluntary reporting of fatal errors or permanent loss of functioning.Sentinel events that are voluntarily reported are the tip of the iceberg
28、They are identified and knownLegal issues permit reportingEach must be accompanied by a root cause analysis and action plan.,Sentinel Event Experience to Date,415inpatient suicides370events of surgery at the wrong site365operative/post op complications326events relating to medication errors221deaths
29、 related to delay in treatment144patient falls124deaths of patients in restraints107assault/rape/homicide 85transfusion-related events 84perinatal death/injury 57infection-related events 57deaths following elopement 51fires 49anesthesia-related events511“other”,=2966 RCAs,Total Reviewed Events by St
30、ateJanuary 1995 through December 2004,Reviewed Events per Million Population(by State),Self-reported Events by StateJanuary 1995 through December 2004,Total Sentinel Events Reported by Year,Root Causes of Sentinel Events,Percent of 2966 events,Root Causes of Wrong Site Surgery,Percent of 370 events,
31、Root Causes of Medication Errors,Percent of 326 events,Staffing-related Factors Identified in RCAs Completed in 2004,Percent of RCAs citing these staffing factors,Percent of RCAs Citing Staffingas a Root Cause,Communication as a Root Cause,Mode of communicationOral(55%)Written(35%)Electronic(10%)Par
32、ticipantsAmong staff(60%)With or among physicians(25%)With patient or family(15%)Other communication issuesTranscriptionChange-of-shift reportPaging systems,JCAHO INTERVENTIONS AND TECHNIQUES,Continual standards development and renewalSentinel event alertsNational Patient Safety Goals each yearNew s
33、urvey process(tracers)and surveyor educationPartner with others universal protocol,ISMP,patients and families,HAP PTAC Organizations,PARTICIPATING ORGANIZATIONSAcute Long Term Hospital AssociationAmerican Academy of Family PhysiciansAmerican Academy of Nurse PractitionersAmerican Academy of Pediatri
34、csAmerican Academy of Physician AssistantsAmerican Association of Nurse AnesthetistsAmerican College of Emergency PhysiciansAmerican College of Healthcare ExecutivesAmerican College of Physician ExecutivesAmerican College of PhysiciansAmerican College of RadiologyAmerican College of SurgeonsAmerican
35、 Dental AssociationAmerican Health Information Management AssociationAmerican Hospital AssociationAmerican Medical AssociationAmerican Medical Rehabilitation Providers AssociationAmerican Nurses Association,Inc.American Psychiatric AssociationAmerican Society for Clinical PathologyAmerican Society f
36、or Healthcare Risk Management(AHA-PMG)American Society of AnesthesiologistsAmerican Society of Health-System PharmacistsAmerican Surgical Hospital AssociationAssociation for Professionals in Infection Control and Epidemiology,Inc.Association of Health Facility Survey AgenciesAssociation of periOpera
37、tive Registered Nurses,Inc.Centers for Disease Control and PreventionCenters for Medicare and Medicaid ServicesCoalition of Rehabilitation Medicine Organizations,College of American PathologistsFederal Nursing Services CouncilFederation of American HospitalsNational Association for Healthcare Qualit
38、yNational Association Medical Staff ServicesNational Association of Healthcare Access ManagementNational Association of Psychiatric Health SystemsNational Association of State Mental Health Program DirectorsNational Rural Health AssociationPublic Members(2)COALITION OF REHABILITATION THERAPY ORGANIZ
39、ATION American Physical Therapy AssociationNational Coalition of Creative Arts Therapies AssociationAmerican Therapeutic Recreation AssociationAmerican Occupational Therapy AssociationAmerican Osteopathic Healthcare AssociationAmerican Physical Therapy AssociationAmerican Speech-Language-Hearing Ass
40、ociationAmerican Therapeutic Recreation AssociationNational Coalition of Creative Arts Therapies AssociationNational Therapeutic Recreation Society,UNIVERSAL PROTOCOL ENDORSEMENTS,Accred Council for Grad Med EducationAgency for HC Research&QualityAmer Academy of Amb Care NursingAmer Academy of Cosme
41、tic SurgeonsAmer Acad of Facial Plastic&Recon SurgAmer Academy of Family PhysiciansAmer Academy of OphthalmologyAmer Academy of Orthopedic SurgeonsAmer Acad of OtolarynHead&Neck SurgAmer Academy of PediatricsAmer Assoc of Amb Surgery CentersAmer Assoc of Eye&Ear HospitalsAmer Assoc of Nurse Anesthet
42、istsAmer Assoc of Oral&Maxillofacial SurgAmer College of CardiologyAmer College of Chest PhysiciansAmer College of Emergency PhysiciansAmer College of Foot&Ankle SurgeonsAmer College of Obstetrics&GynecologyAmerican College of PhysiciansAmerican College of SurgeonsAmerican Dental AssociationAmerican
43、 Hospital Association,American Medical AssociationAmerican Medical Group AssociationAmerican Nurses AssociationAmer Organization of Nurse ExecutivesAmer Pediatric Surgical AssociationAmer Society for Surgery of the HandAmer Society of AnesthesiologistsAmer Society of General SurgeonsAmer Society of
44、Ophthalmic RNsAmer Society of Perianesthesia NursesAmer Society of Plastic SurgeonsAmer Society of Plastic Surg NursesAmerican Urological AssociationAssoc of American Medical CollegesAssoc of PeriOperative Reg NursesAssoc of Surgical TechnologistsFederated Ambulatory Surgery Assoc.Federation of Amer
45、ican HospitalsMedical Group Management Assoc.National Assoc.of Medical Staff ServicesNorth American Spine SocietyRadiological Society of North AmericaSociety of Thoracic Surgeons,Joint Commissions Safety Initiatives,1996-The Sentinel Event Policy is established requiring RCA,action plan and measurem
46、ent2001-New standards that focus directly on patient safety and medical error reduction are in 2002-Establishes the National Patient Safety Goals2002-JCAHO&CMS launch Speak Up Campaign2003-Intensive analysis,FMEA standards introduced2003 Universal protocol for prevention of wrong site surgery2004-Pa
47、tient and Family Notification2004-QualityCheckR,ENHANCING PATIENT SAFETY,“Are unapproved abbreviations just unapproved,or are they really dangerous abbreviations?”“That issue has never been a problem at our hospital”“Is a time out before surgery an unnecessary use of 60 seconds?”,DO NOT USE ABBREVIA
48、TIONS,uIUqdqodLeading decimal point(always use a leading zero)Trailing zeroMSMSO4MgSO4,DANGEROUS ABBREVIATIONS,WEVE NEVER HAD A BAD PATIENT OUTCOME AT OUR FACILITY DUE TO.,We can learn from the limited reported mistakes of othersWe dont have to wait for the adverse outcome to be replicated at every
49、hospital.IOM report calls for national patient safety center and nationwide reporting so we can learn from the incidents occurring elsewhere,CREATING A CULTURE OF SAFETY,How is care provided?How are errors perceived?How are the reporters of errors perceived?Are they rewarded or punished?What are the
50、 barriers to reporting?How does the environment allow errors to occur?,CHANGING CULTURE,Make the safest thing to do,the easiest thing to doLessons from aviationDishonorable not to reportNeutral party reportingSeparate from performance reviewLeadership involvement and commitment,“WHAT CAN JCAHO DO TO
