Cover Story
It's not just about accreditation anymore, it's about partnering with hospitals to create a 'high reliability' health care system
Mark Chassin, M.D., became president of the Joint Commission in January 2008 with an ambitious goal: to make the organization an active partner with hospitals so that together they could transform health care into a "high reliability" enterprise‚ maintaining the best quality and safest performance possible over long periods of time. In the process, theJoint Commission has adjusted how it conducts surveys in some subtle and not-so-subtle ways.
Hospitals & Health Networks asked several health care leaders and Chassin himself how the Joint Commission has changed in the two years since his appointment, how it will continue to evolve, and how all of that will impact hospitals.
Before coming to the Joint Commission, Chassin spent five years spearheading patient care improvement at New York's Mount Sinai Medical Center. So he understands how hospitals can respond to the commission's edicts.
"I can talk to hospital quality folks and say things like, 'Look at the core measure that
requires you to counsel patients with pneumonia about smoking cessation before they leave the hospital,' " Chassin says. "Does that measure assess the effectiveness, the thoroughness, the competency of that smoking cessation counseling? No. In fact, it is a test of how clever you are in coming up with a discharge planning sheet with smoking cessation information on the back and a checkbox on the front. It's a workaround.
"They sort of laugh a little nervously," Chassin observes, "and I say, 'Look, I was doing this myself two-and-a-half years ago; I know what's going on out there.' "
Needless to say, pressing front-line hospital staff to invent clever workarounds instead of effective improvements is hardly the Joint Commission's goal. That its requirements and accreditation process have often generated that kind of work-to-rule response suggests the organization is not as effective as it needs to be.
Chassin is out to change that. He has implemented a "robust process improvement" program that trains Joint Commission employees in Six Sigma statistical tools and lean management. The goal is to focus the entire organization on creating value for customers and improving efficiency both in its own operations and for the the hospitals and health systems that must meet its requirements. "It's all wrapped together with a formal approach to change management," he says. "We are aggressively adopting it to change our culture so that we don't just write reports about quality improvement, we make it the way we work. We are singularly devoted to increasing the value of all the services we provide."
But the ultimate goal goes much further: health care with high reliability in quality and safety. The aviation and nuclear power industries are often cited as models, and although skeptics claim there's no comparing those businesses with health care, in the two years since Chassin's appointment, improving quality of care and patient safety has become a high-profile priority for government, payers and providers themselves.
Chassin says hospitals and other providers must adopt process improvement programs similar to the Joint Commission's. That will help make care more effective, more efficient and less vulnerable to failure. To sustain that "quality culture," executives and trustees will have to step up and accountability systems will need to be established.
Chassin believes that the Joint Commission's reach and influence uniquely position it to lead the effort by example.
"High reliability is incredibly important for the future of health care," says James B. Conway, senior vice president of the Institute for Healthcare Improvement in Cambridge, Mass. "Even if you get it right 99 percent of the time, there is a huge amount of pain and suffering and expense in that 1 percent gap. What Mark is doing is moving the organization so that gap will narrow and narrow and narrow. The Joint Commission can't make everyone do it, but they can set the expectation that it needs to be done."
Last year the Joint Commission revised its vision and mission statements to reflect the goal. "Our newly defined mission is to improve the safety and effectiveness of health care by evaluating health care organizations and inspiring them to excel," Chassin says.
"No matter how good the standards are, if the organizations we work with hate us and don't like the requirements we are bringing them, we don't get any impact because we don't provide health care directly," Chassin says. "We have to inspire change to be effective."
The new approach is already being felt in Joint Commission requirements that are intended to be less burdensome but more effective. Examples from the past year include clarifying the staffing effectiveness standard, adopting more realistic requirements for meeting the medication reconciliation national patient safety goal, and streamlining the universal protocol on wrong-site, wrong-procedure, wrong-patient surgery to make it easier to implement in diverse organizations. The recent revision of the medical staff governance standards in response to confusion in the field also reflects the Joint Commission's commitment to workable, effective requirements, Conway says.
"We started with some of the most problematic requirements and now we are looking at all requirements to get rid of those that do not contribute to improved safety and quality and that cause unproductive work," Chassin says. "If we can't be sure from strong scientific evidence or an iron-clad rationale how a requirement improves patient care, we are questioning why it is in there."
The accreditation decision-making process is also changing. "They are getting away from the old 'a standard is a standard is a standard' approach in which if you didn't click on any of them you were in trouble," says Richard J. Umbdenstock, president and CEO of the American Hospital Association.
Immediate accreditation decisions are now based mainly on the one-third or so of requirements that directly affect patient safety and care, such as managing high-risk medications, Chassin notes. Hospitals will be required to remediate issues with indirect standards, like staffing levels, but they are not likely to lose accreditation over them. "Now hospitals know that the requirements that have a significant potential for harming patient care are being weighted a lot more heavily," Umbdenstock says.
Surveyors also have more latitude. "We can flexibly accommodate emerging or current threats by deploying surveyors on tracers to observe things like sterile processing," Chassin notes. "All of this is to focus our contacts on identifying things that are the most important safety and quality risks." In addition, the rigorous training and experience that surveyors now receive in applying quality improvement tools makes them much more capable of assisting hospitals in developing solutions to any problems found.
These changes build on the Joint Commission's shift from its historic emphasis on structure, staffing and policy toward measuring critical care processes and outcomes begun under Chassin's predecessor Dennis S. O'Leary, M.D. And they have greatly improved the survey experience, according to James Dwyer, D.O., executive vice president for physician services at Virtua, a four-hospital system based in Marlton, N.J.
"The survey we just went through was the most educational and collaborative of the seven I have been through; it is the first time it was actually an enjoyable experience," Dwyer says. "There was a tangible difference in the engagement of the surveyors in both learning from and teaching the staff. If this is a result of the rigor Dr. Chassin has applied to the survey process, I would say they are setting a great example."
The AHA's experience seems to bear out Dwyer's assessment, Umbdenstock says. "When I started at the AHA in mid-2006, the new, more educational approach to accreditation was just being rolled out and we were still hearing a lot of complaints. I get virtually no complaints today."
These changes have taken disseminating evidence-based best practices and how to implement them to a new level. The Joint Commission's new Center for Transforming Healthcare goes a step further. It brings together small groups of hospitals to develop rigorous, sustainable solutions for some of the most critical and intractable patient safety issues they face.
The first project is hand hygiene. Eight hospitals—including, Cedars-Sinai in Los Angeles, Johns Hopkins in Baltimore and Wake Forest North Carolina Baptist Hospital—are involved. Most thought their staffs were doing pretty well meeting hand hygiene protocols—until they started using secret observers to collect valid compliance data.
Process mapping and root cause analysis were used to identify common factors driving noncompliance. They ranged from lack of training of housekeeping personnel to inconveniently placed hand-washing stations to lack of space to put down dinner trays or other objects carried into a patient room so that people can wash their hands.
The project has revealed significant and unexpected obstacles. For instance, says Michael L. Langberg, M.D., chief medical officer at Cedars-Sinai, deploying observers throughout a hospital would be prohibitively expensive. So the project is working with technology vendors on a system for hand-washing stations that would detect radio ID cards as hospital workers enter rooms, beep if they didn't wash hands within a set period of time, and record compliance. Collecting data like that, then doing a statistical performance analysis, is at the heart of process improvement.
Local regulations are another issue. For example, alcohol-based hand sanitizers are flammable, so their placement and density are subject to local fire codes. At Cedars-Sinai, that makes it difficult to place hand-washing stations conveniently in the workflow patterns in some units, Langberg says.
"For us, it has been a real eye-opener," says William D. Petasnick, president and CEO of Froedtert Hospital and Froedtert Community Health System in Milwaukee. "From the public's perspective, it is a simple compliance issue. But as we delved into it, we found it is not so simple as it appears."
A second project, on streamlining patient handoffs, is under way. If best practices emerge from these and future projects at the Center for Transforming Healthcare, they may become Joint Commission standards. But projects are already influencing certain requirements. For example, because of the eye-opening results of the hand hygiene pilot, hospitals will be required to develop rigorous measurement systems for compliance, a shift away from the current unmeasurable 90 percent compliance target.
While these projects are narrowly focused, Petasnick believes they will yield significant benefits to the broader field, which will spur interest in developing additional rigorous quality systems. "The Joint Commission is a bully pulpit. They are using this as a change strategy as well."
Perhaps the biggest challenge in implementing process improvement systems at the 90 percent or so of hospitals that lack them is creating a culture of quality to sustain them. That requires leadership, Conway says. "One principle of lean is if you don't have governance and executive leadership defining a very clear mission, you won't get there. You have to set the expectation and then optimize the design to reach it."
Over the past few years, the Joint Commission has encouraged hospital boards and executives to take an active role in creating a quality culture. In addition to standards that require leaders to set quality goals and review performance, a sentinel event alert in August recommended that hospitals make safety performance a key, measurable element of the evaluation of CEO and all leadership performance.
Still, making such a shift is difficult and takes time, Langberg points out. "I would ask that regulatory and accrediting agencies appreciate the fact that there is a ceiling to how much change can occur in a time period. If it is not managed correctly, it can have unintended consequences for patient care. Taking care of human beings is one of the most complex undertakings there is. We do not want to interfere with the things that are working well as we feel pressure to change culture."
Chassin acknowledges that implementing process improvement or even semistandardized processes for addressing specific safety issues, like hand hygiene, across thousands of extremely diverse organizations is a huge challenge. For one thing, the organizations have to want to change. For another, they need to approach the process as a change management issue.
"Companies have tried lean alone or Six Sigma or even lean Six Sigma without a formal change management component and a lot of times they fail," Chassin says. "They move on to the next flavor of the month or maybe they end up with a small group of quality experts. You send them in like paratroopers, but you don't get the full benefit because the tools are not disseminated throughout the organization. Hospitals will find that [the change management] approach gets them furthest on the road to high reliability."
Chassin believes the seeds he is planting with the Center for Transforming Healthcare—nurtured by improved accreditation requirements and processes—will shift health care toward high reliability because it will produce improvements that patients and care purchasers demand. It will also help hospitals cope with contracting health care payments.
Process improvement "not only has huge quality and safety benefits, it also produces dramatic cost reductions," Chassin notes. "It gets the waste out of processes, improves cycle time, builds process throughput. These are the kinds of things that every hospital is struggling with today, and we can help."
| A Circular Century - The Joint Commission's renewed emphasis on evidence-based quality initiatives echoes Ernest Codman's 1910 calls for an "end result" system. |
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This article 1st appeared in the March 2010 issue of HHN Magazine.
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