Assignment: Accrediting Bodies in Health Care

Assignment: Accrediting Bodies in Health Care ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Accrediting Bodies in Health Care Describe what it is that accrediting bodies in health care do. Assignment: Accrediting Bodies in Health Care Summarize Chassin’s argument in his 2013 article, “Improving the Quality of Health Care: Where Law, Accreditation, and Professionalism Collide,” that these bodies need reform to improve the safety of hospitals and doctors’ offices. In your post, answer the following: What evidence does he present for his main claims? What do you think is the best of his proposals for improving the quality of health care, and why? Is there a proposal he makes that you think would not be effective? Assignment: Accrediting Bodies in Health Care article is attached chassin2013.pdf HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 THE OLIVER C . SCHROEDER, JR. SCHOLAR-IN-RESIDENCE LECTURE IMPROVING THE QUALITY OF HEALTH CARE: WHERE LAW, ACCREDITATION, AND PROFESSIONALISM COLLIDE* Mark R. Chassin^ I want to talk to you about the intersection of law, regulation, accreditation, and professionalism relating to the quality of health care. Maybe at the risk of telling you too much about the quality of health care—more than you wanted to know—I’m going to put it all on the table. Let me start by telling you a little about what the Joint Commission is, because it’s probably not a household name. We are a private, notfor-profit, IRS-classified 501(c)(3). Our roots actually go back to 1917, when the American College of Surgeons created the first program designed to assess quality in hospitals. The Joint Commission was created by five organizations to take over that program in 1951: the American Medical Association, the American Hospital Association, the American College of Surgeons, the American College of Physicians, and the Canadian Medical Association. Later, the Canadian Medical Association withdrew and the American Dental Association joined to create the present-day Joint Commission. Hospitals are not the only organizations that we accredit or certify. Healthcare organizations pay us to come in to see whether they are complying with the standards we create on how to provide quality care. We have competition in all the fields in which we operate. The program started by the American College of Surgeons created certain “minimum standards” for hospitals in 1917. There were five requirements: that (1) hospitals should have medical records for all patients; (2) hospitals should have laboratories and x-ray facilities; (3) hospitals must have a medical staff; (4) medical staffs should be licensed, competent, and “worthy in character”; and (5) medical staffs should review and analyze their clinical experience. On October 24, 1919, College officials announced the first results of the trials applying these standards at a conference in New York City, at the Waldorf Astoria * Edited from the annual Schroeder Scholar-in-Residence Lecture sponsored by the Law-Medicine Center on October 25, 2012, at Case Western Reserve University School of Law. This version has been edited for publishing purposes and does not contain the lecture in its entirety. The full transcript is on file with the editors of Health Matrix. Please direct all inquiries to [email protected] t Mark R. Chassin, M.D., F.A.C.P., M.P.P., M.P.H., President, The Joint Commission and The Joint Commission Center for Transforming Healthcare. 395 HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 Improving the Quality of Health Care hotel. Assignment: Accrediting Bodies in Health Care The night before the conference—before they released the results—they were a little nervous: only 13 percent of the nearly 700 hospitals they surveyed passed the minimum standards. So the officials took the documents that listed the names of the hospitals, went down to the basement of the hotel, put those documents in the furnace, and burned them so they could not be released to the media. That is a true story. Fast forward to 2012, the middle of this year, when we now accredit about 20,000 health care organizations in the United States and almost 600 in fifty-two countries around the world. What we do we actually do, though? We create and continuously update requirements for health care organizations that tell them how to provide safe and high-quality care. Then, in a parallel way that is equally important, we deploy individuals in the field—we call them surveyors or reviewers—to visit these different organizations for a very short period of time. How long depends on the size of the organization and the mix of services they provide; usually a medium-size community hospital would have three folks there for four or five days. During that visit, we are charged with assessing whether the hospital is complying with all of the standai’ds that are in our mandates. That is a very challenging part of the business that we’re in and part of the activity that is not as well-understood as some of the other things we do. We’re constantly working on improving it. We also create and maintain the single most effective system for measuring quality in hospitals. That has been in existence for a little more than a decade. Finally, we are also an improvement organization. Assignment: Accrediting Bodies in Health Care e develop and disseminate interventions to directly improve quality of care; for example, to get rid of hospitalassociated infections, or reduce communication failiu:es when patients move from one healthcare setting to another. So, that is a very brief overview of the critical functions that we perform. When we say a hospital has passed this accreditation test, what does that mean? Let me first say what it’s not. Accreditation is not a guarantee that no errors will occur. It’s not a guarantee that preventable complications will never harm patients. It’s not a guarantee that highquahty care will always be delivered to every patient. It’s no more or less than an attestation that we’ve gone thi’ough our process, we’ve looked at the practices in an organization, and it passed the test. In other words, the organization complied with our standards at the time we went out there. Typically, we will find places where the organization is not in compliance and we point them out. To keep its accreditation, the organization will change what it is doing and then send us evidence that they complied. It’s an ongoing process. Accreditation can’t solve all of our quality problems. You can see evidence of them almost every day in the newspapers or on the Internet. For example, a hospital in Louisiana had to notify 360 patients because it failed to properly decontaminate, clean, and sterilize its gastrointestinal endoscopes, exposing patients to Hepatitis B and C and even HIV infection. A hospital near Pittsburgh had to notify 141 patients that 396 HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 Improving the Quality of Health Care they had had coronary artery stents put in unnecessarily. A few years ago, a patient went into a hospital in Minnesota with cancer in one kidney. The hospital removed the healthy kidney instead. An almost identical event happened in the UK, but a medical student in the operating theater told the surgeon he was operating on the wrong kidney. Assignment: Accrediting Bodies in Health Care The surgeon continued the operation and the diseased kidney was left in. The patient died about five weeks later. And we set fire to patients in our operating rooms: surgical fires occur perhaps as often as 500 times a year in the United States, often producing severe patient injuries. Maybe that is more than you wanted to know about the quality of health care. The healthcare industry has been intensely focused on improving quality of care in a way that is unprecedented in the past ten or twelve years. It is not for lack of effort that we still have these quality problems. It’s fair to say that we are faced with a situation today in which routine safety processes fail rather frequently. So, whether it is our inability to get caregivers to wash their hands every time they should, to get rid of serious medication errors that harm patients, or to prevent other uncommon but completely preventable adverse events, we have a long way to go before we can assure that quality is what we all want it to be in health care. As that headline from the UK reminds me to point out; all of these quality problems are indeed global. There is great diversity among developed countries in how health care is organized, financed, delivered, and structured. But when it comes to quality and safety, there is no such diversity—all developed health care systems struggle with exactly the same quality problems. I’ve given you a little bit of a flavor of what we struggle with in the United States. No system has figured out how to solve these critical problems. In fact, quality failures in all of them are very common. So, if this is a condition of health care in the twenty-first century, but we aspire to higher quality, we have to look outside of health care for models. I’ll talk about that more in a moment. If we put this set of quality problems into the context of all of the oversight that exists, there is obviously a lot of public law and regulation.Assignment: Accrediting Bodies in Health Care First, there’s the federal alphabet soup: the Food and Drug Administration, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, the Nuclear Regulatory Commission, and the Health Resources and Services Administration. There are many others. States have a critical role: they license healthcare organizations and individuals who practice medicine and other health professions. They are responsible for virtually all of the public health protections required to achieve good quality care from a population perspective. Private organizations like the Joint Commission, accrediting bodies in many fields, and other organizations in the private sector devoted to improving and maintaining quality are all over the place. Then there are the delivery system efforts—whether it is inside organizations like the Cleveland Clinic, the Mayo Clinic, or others like Kaiser—that have 397 HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 Improving ihe Quality of Health Care pioneered quality improvement activities. The system of medical malpractice is also supposed to have an influence on the quality of care. It is not for a lack of trying that we still have quality problems. How do all of these systems come together and what are their proper roles? I indicated some of the quality failures we see. Oversight failures also happen with extraordinary frequency. Every single one of the oversight ñmctions I mentioned has flaws. None of them is perfect. I think we need to look outside of health care. There are other models, like occupational safety. For example, if you look within that domain at mine safety, there is a federal Mine Safety and Health Administration that has had notable failures in the United States. Remember the coal mining disasters? But let me tell you the story of Alcoa. Alcoa is a global company with mines in the United States and all over the world. It had one of the worst safety records some years ago. When a new CEO came into office, Paul O’Neill, who later became Secretary of Treasury, he pioneered a complete turnaround at Alcoa. Assignment: Accrediting Bodies in Health Care The laws didn’t change. The technology didn’t change. What changed? Well, he brought to a board meeting a story of a man who was killed in an accident in one of Alcoa’s mines. After he told the story, he looked around at the board members, all of whom were men, and he said, “Gentlemen, we killed this man.” That is what started the turnaround at Alcoa—the governing body of the organization taking responsibility for worker safety. From that moment, a whole series of initiatives carried through from the board to the management that communicated to everyone across the globe in Alcoa that worker safety was not just priority number twenty-five out of fifty. It was the number one priority. Alcoa put a whole raft of innovations in place, including instant communication of the smallest workplace accident to everybody in the organization. They look back after an accident to find out why it happened, look for those flaws, fix them, and then communicate that information across the company around the world, so that every part of the organization can benefit from the learning that occurred at one place. I could go on, but I won’t. That is an example, in a field where worker safety is hugely variable to this day, of an organization that created the best mine safety record in the world. There is food safety, water quality, airline safety, and there is nuclear power. So if we are a httle more systematic than that one story about looking outside of health care for the right interplay of law, regulations, and internal organizational activities, let’s pick some industries that have really gotten it right. There is reseai’ch literature on these organizations. They are called “high reliabihty” organizations because they deal with hazards that are every bit as dangerous and difficult as those we face in health care, but they do it a lot better.Assignment: Accrediting Bodies in Health Care They have adverse event rates that are a thousand, even ten thousand fold, lower than in health care. Some of the usual suspects are air travel and nuclear power. But there are a number of other organizations that have been studied by scholars and practical improvers, and they are pretty far afield. Places 398 HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 Improving the Quality of Health Care like amusement parks have a lot of characteristics that are very similar to the way airlines and nuclear power stay safe. Wildland firefíghting crews and aircraft carrier flight decks are other examples. If you ever want a little bit of a scary experience, Google the TV series called “Carrier.” It was on PBS about ten years ago. Look for the pitching deck episode. This is where they practice landing on an aircraft carrier in high seas at night. The deck is pitching up and down, so that the instant before the jet fighter lands, it looks to the pilot like he is going to crash into the underside of the deck. Then it flattens out and he iands. They have a vanishingly small adverse event rate. Why is that? What do all of these organizations have in common? To simplify it a little bit, in addition to a passionate devotion to safety like I described Paul O’Neill had, they have incredibly effective tools to improve the processes that they have to complete in order to be safe. They also have a safety culture that wraps around those nearly perfect processes and keeps them working at very high levels of performance for long periods of time. That safety culture is critically driven mostly by the expectations of the workers on the liront line. I’ll talk more about that. That really distinguishes these organizations the most from health care. In health care, we are most often in the situation of experiencing— whether we’re a hospital, ambulatory surgery center, or a nursing home—an event in which a patient was harmed, and then we do something. Fifteen or twenty years ago, the Joint Commission introduced root cause analysis: figure out why that harmful event happened so we can start teaching folks how to correct the problem so that it doesn’t happen again. But that is not how high reliability organizations stay safe. The way they stay safe is by everybody on that aircraft carrier deck, for example, always looking for the smallest thing that might go wrong. On an aircraft carrier, one of those things is a foreign object on the deck.Assignment: Accrediting Bodies in Health Care If something as simple as a screwdriver gets left on the deck as one of these Jets is landing, it can get sucked into the jet engine and blow it up. Everyone on the deck looks for the smallest thing that is wrong so that it can be identified before it poses a risk, way upstream from harm, when it’s actually much easier to fix than after it’s been allowed to mushroom into a very risky problem. They fix those things right away, using those highly effective tools. That leads to more reports of small things that are even further upstream from harm. We’re nowhere near that capacity or that situation in health care. To describe this theme called “safety culture,” which I’ve said is so important to making a really safe organization, I will borrow firom the work of James Reason. He pointed out that if you look inside these organizations, there are three imperatives that link all of them together: trust, report, and improve. Each of them is tied to the others. So in order to find the small things that are wrong, every worker needs to trust his or her peers, because finding something that is wrong usually means uncovering mistakes that were made. Say a safety procedure isn’t 399 HEALTH MATRIX • VOLUME 23 -.ISSUE 2 • 2013 Improving the Quality of Health Care constructed quite right, so people have to take a shortcut and violate protocol in order to get the work done. That is an unsafe condition. Revealing it means that somebody is going to have the opportunity to blame the people that took the shortcuts. High reliability organizations greatly value that reporting, so they don’t “shoot the messengers.” Once a worker identifies and reports the unsafe conditions, he or she also has to trust that management will take that report seriously, fix the problem, and communicate that improvement back so that the worker’s initial trust is justified. Assignment: Accrediting Bodies in Health Care That reinforces trust. You get more reports further upstream from harm. It turns into a very positively reinforcing culture that keeps these organizations safe. In a room filled with healthcare professionals, typically in hospitals, I’ll ask them to think about the place in the hospital where medical instruments for sui’gery are cleaned, decontaminated, and sterilized in preparation for the next group of surgical procedures. Think about the busiest time, usually mid-morning, after the first round of surgical cases has been completed and the instruments are being reprocessed. Think about a sterile processing technician who was just hired about thi-ee or four months ago. He sees a problem with one part of the cleaning and decontamination process. Then I ask the audience: How many of you are certain in your hospital that that technician would do the right thing and tell his supervisor right away that there is a problem with that part of the decontamination process? And how many of you ai’e certain that the supervisor would do the right thing and stop the sterilization process, retrieve all those instruments that were improperly cleaned and decontaminated until the problem was corrected? I have asked this question all ai’ound the world, whether it’s in the United States, Europe, the Middle East, or Asia Pacific. What would you guess is the percentage of hands that go up in answer to the question, “Are you certain?” Five percent; one in twenty. Then I say, that’s the gap—between the 5 percent and 100 percent that you would get at a meeting of aircraft carrier flight deck engineers or amusement park engineers, or anybody in the high reliability industries like nuclear power and commercial aviation—that is the gap that health care has to traverse in order to get to be highly reliable. Let me also show you a positive side of this. I had mentioned that airhnes are really safe. From 1990 to 2001, on US air carriers, there were 129 deaths per year on average and 9.3 million flights per year. That is a rate of 13.9 deaths per million flights. At that time, the US airline industry was the safest in the world. But in just the next decade, from 2002 to 2010, the number of deaths fell to 18 per year for 10.6 million flights per year. Assignment: Accrediting Bodies in Health Care That is a rate of 1.74 deaths per million flights. Moving from 13.9 to 1.74 is a drop of 87 percent in the death rate in US airlines. That’s unbehevable in an industry that was already the safest on the planet. That is another characteristic of high reliability industries: they keep pushing the envelope further on safety. 400 HEALTH MATRIX • VOLUME 23 • ISSUE 2 • 2013 fmproving the Quality of Health Care How did air travel get that safe? First of all: progressively safer equipment. That was true from the 1940s through the 1970s. But when NASA looked at a series of air crashes in the 1970s, they found that the landscape had completely changed. Eighty percent of those crashes had nothing to do with equipment failure. They all had to do with failures of communication in the cockpit between two or three people about problems. Those failures involved things like the junior co-pilot saying, “I think there is a funny thing going on with this gauge.” The captain would often reply, “Shut up and do your job!” So, long story short, that finding led … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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