The Joint Commission, the main accreditation body for hospitals, is spreading its wings. The main body that gives accreditation to some 16,000 hospitals is transforming itself from a dictatorship into a caring and helpful father. It's hilarious to watch Happy's hospital transform itself into an obedient child on the day the JC arrives.
I always feel like a grade school child when the speakers proudly proclaim their arrival. Perhaps I'm supposed to straighten my tie? Perhaps I should dump my coffee in the sink? Maybe I should stop and salute? I never know what exactly I'm supposed to do. I once boldly proclaimed my enjoyment with the JC's arrival because all the patient charts are put exactly where they should be. The JC, apparently within ear shot, laughed. At least they have a sense of humor. Because everyone else is running like scared chickens. It's hilarious to watch.
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Other useful information is available at my EHR Resource Center. I've seen my own requirements go from ridiculous to absurd. For example, requiring me to sign a restraint form every 24 hours for patients in the ICU, sedated on a ventilator. For two long and painful years, I would get called at all hours of the day and night to stop what I'm doing and go sign a restraint form because that's what the Joint Commission said needed to be done every 24 hours. It wasn't OK for a nurse, an ICU nurse at that, to make a clinical determination that the patient was comfortably sleeping sedated on a ventilator, with restraints on. No, it needed a doctors signature. So, what happened? I stopped evaluating my patient five floors up and took five minutes out of my day to sign a ridiculous piece of paper that had no clinical relevance.
Somehow, somewhere, in the last two months, I am no longer required to stop what I'm doing and sign a daily restraint form. Nobody seems to be able to tell me why? I really don't care why. It should have never been implemented in the first place. What was wronged is now right.
Or take for example, my requirement to not only sign, but to date and time all verbal orders within 24 hours. I can understand the sign part, but to redate and retime my signature on an order that has already been dated and timed by the nurse? My solution is simple, once the JC is gone for the next two years, I simply wait until the patient is discharged and I sign the order through the EMR. It may take 10 days for the order to make it into the EMR, but at least it will have a date and a time and a signature automatically with the click of a button. Unintended consequences of ridiculous rules that have no consequence on patient care. That's my experience with clinical rules the JC dictates from above.
On another note, I've been involved in Happy's hospital committee's safety initiative to reduce hospital acquired venous thromboembolism. It was one hell of an experience. What the Joint commission did was establish requirements for the accreditation process:
"The hospital must have a way of measuring X"
"The hospital must have a way of responding to Y"
"The hospital must have a way of guaranteeing Z"
It was a series of sometimes vague sometimes specific requirements that had to be met for accreditation purposes. My experience on the VTE prevention committee was an eye opening one. Everything we did had to be approved by
- The pharmacists
- The nurses
- The physicians
- The legal
- The cleaning staff
- The cooks in the kitchen
Our recommendations went to committee X which voted them down sometimes frequently. Back to the drawing board. If it got through committee X, it had to meet the approval of committee Y? No dice? Back to the drawing board. It was too much work for the nurses. It was too much restriction on the doctors. The pharmacists didn't want to be responsible for this or that.
There was always something. I found myself thinking. Wouldn't it be great if there was a validated method out there in hospital land that achieved 90% plus for VTE prophylaxis that we could just bring in and make it work. And we could show the committees that this is what other top hospitals are doing and it works. Wouldn't that be nice? I spent a year on a committee trying to come up with a working order set that could be standardized across the whole hospital. Hundreds of hours in committee time for department heads. That's hundreds of thousands of dollars a year in administrative paper work that doesn't need to happen.
And this one committee of hundreds of committees took A YEAR to implement our process.
I find this absolutely ridiculous that a process to prevent hospital acquired VTE would take a year. Here we have JCAHO telling us what we need to do to be safe? Wouldn't it be nice if they also gave us the tools to implement it?
Well, today is that day. I had an opportunity to listen in as the President of the Joint Commission, Dr Mark Chassin, unveiled The Center For Transforming Health Care. This is not your ordinary JC. This is the new era of socializing the dissemination of Six Sigma processes into the hospital culture.
The first major initiative is hand washing. How do you get everyone that goes in the patient's room to wash their hands? It seems simple enough, doesn't it? I know I make a concerted effort every single time I enter and leave a room to sanitize my hands. But I know even I am not 100%. The goals with the new center are to find ways that work, system processes that can be extrapolated out to the thousands of hospitals across this country.
It turns out this Center will function independently from the accreditation portion of the JC. However, as Dr Chassin commented to my question, the goals are to eventually incorporate best practices learned from the Center's work into the accreditation process.
Bingo.
That means, in my book, it's only a matter of time before having hand washing protocols in place becomes part of the accreditation process. That's fine with me. I would much rather have 16,000 hospitals have access to the tools that work to implement VTE prophylaxis or universal hand washing than I would having 16,000 hospitals trying to develop their own tools from scratch.
My only concern is that the Joint Commission has been accrediting hospitals for years. The same hospitals, which under their watch, are presumably responsible for 100,000 deaths a year. How, I ask, can we have an organization accrediting hospitals as meeting the high standards of patient safety AND have the same hospitals killing 100,000 patients a year, despite the strict safety requirements necessary for JC accreditation. It's a question, I think that should be answered.
My only concern is that IF everything the JC has done up to this point in the accreditation process has been for patient safety, and IF we are still getting 100,000 deaths a year despite their requirements, how can we be sure that eventually implementing the findings of the Center for Transforming Care will change anything? Shall we assume that all the current requirements of the JC are without clinical merit?
My only hope is that the future interventions in the new Center will be strongly validated in outcomes measures. When you know what quality is and you have the tools that are validated to work implemented with ease, you are on your way to a high quality, efficient and low cost solution to hospital acquired complications. I don't want another two years of dropping what I'm doing to sign restraint forms five times a day if there is no clinical outcome to support it. I don't want to spend an hour dating and signing an order that has already been dated and signed. These ridiculous patient safety rules tar the image of the real clinical safety processes that actually save lives.
Will these initiatives reduce the cost of doing business for hospitals? I hope so, because it's only a matter of time before the Medicare National Bank stops paying for readmissions and many government determined hospital acquired disease. If you are a hospital trying to avoid what's coming, you might as well close your doors. Because the push for quality is going full steam ahead. And I think hospitalists are in a perfect position to help hospitals meet safety goals of the new era of quality care.
