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The Role of the Joint Commission in Health Care Quality. Dennis S. O’Leary, M.D. President Joint Commission on Accreditation of Healthcare Organizations.

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the role of the joint commission in health care quality

The Role of the Joint Commission in Health Care Quality

Dennis S. O’Leary, M.D.

President

Joint Commission on Accreditation

of Healthcare Organizations

joint commission origins
…of Ernest Amory Codman, concerns about the quality of care in America’s hospitals, and the great debate over outcomes measures versus standardsJoint Commission Origins

Joint Commission

on Accreditation of Healthcare Organizations

mission statement
The mission of the Joint Commission on Accreditation of Healthcare Organizations is 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.Mission Statement

Joint Commission

on Accreditation of Healthcare Organizations

scope of work
Evaluation: the core competency

Performance improvement support

In the mainstream

International spread

Scope of Work

Joint Commission

on Accreditation of Healthcare Organizations

deemed status
Definition

Significance

Basic requirements

Associated baggage

The balance of interests

Deemed Status

Joint Commission

on Accreditation of Healthcare Organizations

facilitative joint commission roles
As convenor

As collaborator

As listener

Facilitative Joint Commission Roles

Joint Commission

on Accreditation of Healthcare Organizations

the modern joint commission efforts in service of its mission
Accreditation and certification

Patient safety

Performance measurement

Information dissemination

Public policy initiatives

The Modern Joint Commission: Efforts in Service of Its Mission

Joint Commission

on Accreditation of Healthcare Organizations

the accreditation art form
Standards development

Evaluation against the standards

Accreditation decision-making

The Accreditation Art Form

Joint Commission

on Accreditation of Healthcare Organizations

goals of the new accreditation process
Continuous standards compliance

Adoption as a management tool

Organization ownership

Goals of the New Accreditation Process

Joint Commission

on Accreditation of Healthcare Organizations

elements of the new accreditation process
Periodic performance review

Priority focus process

Tracer methodology

Surveyor development

Elements of the New Accreditation Process

Joint Commission

on Accreditation of Healthcare Organizations

current accreditation focus areas
Medication management

Infection control

Emergency preparedness

Data usage for improvement purposes

Current Accreditation Focus Areas

Joint Commission

on Accreditation of Healthcare Organizations

current accreditation initiatives
Intensified Life Safety Code compliance review

Unannounced surveys

Random validation surveys

Data-based intra-cycle monitoring

Current Accreditation Initiatives

Joint Commission

on Accreditation of Healthcare Organizations

standards development priorities
Credentialing and privileging

Leadership responsibilities

Enhanced emergency preparedness expectations

HIT-related expectations

Standards Development Priorities

Joint Commission

on Accreditation of Healthcare Organizations

patient safety linkages
The nature of accreditation

Standards issues

Dealing with sentinel events

Patient Safety Linkages

Joint Commission

on Accreditation of Healthcare Organizations

creating a reporting for learning model
State database legacy

Sentinel event database

Sentinel Event Alerts

National Patient Safety Goals

Creating a “Reporting for Learning” Model

Joint Commission

on Accreditation of Healthcare Organizations

national patient safety goals
Goals vis-à-vis Requirements

Philosophy

Expert support

Old Goals never die…

Issues on the horizon

National Patient Safety Goals

Joint Commission

on Accreditation of Healthcare Organizations

national patient safety goal wins an losses
Wins

Removal of concentrated KCL from in-patient units

Re-design of infusion pumps

Losses

Do-not-use abbreviations

Universal Protocol for preventing wrong site surgery

Hand-washing

National Patient Safety GoalWins an Losses

Joint Commission

on Accreditation of Healthcare Organizations

wins and losses cont
“Not-there-yet”

Patient identification

Reporting of critical test results

Medication reconciliation

Wins and Losses (cont.)

Joint Commission

on Accreditation of Healthcare Organizations

other patient safety beachheads
Patient Safety Events Taxonomy

Speak Up campaign

Patient safety legislation

International Center for Patient Safety

Other Patient Safety Beachheads

Joint Commission

on Accreditation of Healthcare Organizations

performance measurement linkages
Ties to quality improvement

Ties to accreditation

Measure sets: creating “portraits of performance”

Evidence-bases for measures…and standards

Performance Measurement Linkages

Joint Commission

on Accreditation of Healthcare Organizations

setting a high bar for performance measures
Expert panel analysis

Measure set identification

Measure data element specification

Field testing for reliability and validity

External validation

Setting a High Bar for Performance Measures

Joint Commission

on Accreditation of Healthcare Organizations

the measurement players
Federal agencies (CMS, AHRQ)

The accreditors (NCQA, Joint Commission)

National Quality Forum

The states

Pay-for-performance programs (purchasers, payors)

The Measurement Players

Joint Commission

on Accreditation of Healthcare Organizations

perennial measurement issues
Low bar to entry

Standardization needs

Data collection burden

Multiple data demands

Priorities among structure, process and outcome measures

Clarification of measure uses

Perennial Measurement Issues

Joint Commission

on Accreditation of Healthcare Organizations

emerging measurement issues
Volume of measures

Absence of National Quality Goals

Measurement of patient safety performance

Data quality

Data flow

Embedding measures in electronic records

Emerging Measurement Issues

Joint Commission

on Accreditation of Healthcare Organizations

information dissemination linkages
Quality improvement stimulus

Meeting public accountability expectations

For accredited organizations

For the Joint Commission

Information Dissemination Linkages

Joint Commission

on Accreditation of Healthcare Organizations

evolution of joint commission policy
From a Confidentiality Policy to a Public Information Policy

The troubled launch of Performance Reports

The transition to Quality Check

Evolution to current Data Use Policy

Evolution of Joint Commission Policy

Joint Commission

on Accreditation of Healthcare Organizations

the quality check evolution
Basic content

Accreditation status information

National Patient Safety Goal compliance

Comparative performance measurement information

“Merit badges”

Addition of quarterly measure data points

Inclusion of non-accredited organizations

The Quality Check Evolution

Joint Commission

on Accreditation of Healthcare Organizations

public policy linkages
Underlying rationale for Public Policy Initiatives

Basis in mission: “…and related activities”

Joint Commission assets as a public policy player

Convenor role

Purity of purpose

Public Policy Linkages

Joint Commission

on Accreditation of Healthcare Organizations

public policy development process
Roundtable analysis

National summit

Issuance of white paper

Determination of follow-up strategies

Public Policy Development Process

Joint Commission

on Accreditation of Healthcare Organizations

white papers issued health care at the crossroads series
“Strategies for Addressing the Evolving Nursing Crisis”

“Strategies for Creating and Sustaining Community-Wide Emergency Preparedness Systems”

“Strategies for Narrowing the Organ Donation Gap and Protecting Patients”

“Strategies for Improving the Medical Liability System and Preventing Patient Injury”

White Papers Issued“Health Care at the Crossroads” Series

Joint Commission

on Accreditation of Healthcare Organizations

in the public policy pipeline
Emergency Department Overcrowding

Health Professions Education Reform

Linkages Between Health Literacy and Patient Safety

The Hospital of the Future

Developing a National Data Management Strategy

The Efficiency Dilemma: Identifying Opportunities for Waste Reduction in Health Care

In the Public Policy Pipeline

Joint Commission

on Accreditation of Healthcare Organizations

slide32
What Will It Take to Succeed?

Joint Commission

on Accreditation of Healthcare Organizations

culture defined
A culture is defined by the customary beliefs, values, an behaviors – including traditions – shared by members of a group.Culture Defined

Joint Commission

on Accreditation of Healthcare Organizations

barriers to making it happen
Board and professional cultures

Payment system design

Medical liability system

Health professions education design

Professional shortages

Barriers to Making It Happen

Joint Commission

on Accreditation of Healthcare Organizations

pushing the culture change envelope
Patient safety as “the” priority, not “a” priority

Leadership engagement

Transparency at all levels

Systems re-design competency

“Back to the basics” education

Pushing the Culture Change Envelope

Joint Commission

on Accreditation of Healthcare Organizations

culture change envelope cont
Focus on microsystems

Patient engagement in reporting and problem-solving

Investments in staff retention and recruitment

Getting ahead of the power curve

Culture Change Envelope (cont.)

Joint Commission

on Accreditation of Healthcare Organizations