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Tag: JCAHO

The Joint Commission Pain Standards: Five Misconceptions

Baker_David_275In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.

The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain. The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.

Our foundational standards are quite simple. They are:

  • The hospital educates all licensed independent practitioners on assessing and managing pain.
  • The hospital respects the patient’s right to pain management.
  • The hospital assesses and manages the patient’s pain.

Requirements for what should be addressed in organizations’ policies include: 

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Germs. The Pseudoscience of Quality Improvement

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No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

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What JCAHO Knows

flying cadeuciiHere’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).Continue reading…

Why Do Academic Medical Centers Do Poorly on Quality Report Cards?

In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut.  Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’”

The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21stcentury.

The most pressing challenge for American medicine has been summarized in the triple aim:  how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.

Can we expect academic medical centers to lead the country in meeting the challenge?  If history is any guide, the answer may be no.  In a 2001 article titled “Improving the Quality of Health Care:  Who Will Lead?” the authors write:

“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education.  They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years:  tobacco control, health care cost containment, and universal access.”

Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research.  While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.

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Hospital Quality Under Scrutiny

Last week’s New York Times article on cardiac care at some HCA-owned hospitals yielded a chorus of comments from readers who argued that for-profit hospital care is inherently low-quality care. As it happened, in working on a history of the investor-owned hospital sector, I had just been crunching data that might either support or refute that assertion. The results are surprising, if far from decisive.

Last September, the Joint Commission released the first of what it said would be annual lists recognizing “Top Performers on Key Quality Measures™” among the nation’s accredited hospitals. The all-star roster is based on “core measure performance data” that hospitals report to the Commission. The data cover adherence to “accountability measures ” established as best practice in the eyes of the Commission – making sure to prescribe beta-blockers for heart attack patients at discharge, for example, or to discontinue prophylactic antibiotics within 24 hours after surgery.

Unlike hospital quality measures that look at results – death rates and other outcomes – this one looks at processes. In theory, then, it ought to be more fair to hospitals that tend to serve sicker or more compromised patients, such as government-run hospitals in inner cities.

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Time to Make Joint Commission Surveys Public

Can anyone doubt that the recent kerfuffle faced by Parkland Memorial Hospital in Dallas would have had a greater chance of being avoided if earlier reviews by the CMS-designee, the Joint Commission, would have been made public?  Yet, JC surveys are held in confidence.  This is a matter of federal law.

Currently, the results of hospital accreditation surveys cannot be accessed by the public under Section 1865 [42 U.S.C. 1395bb] (b) of the Social Security Act, which reads as follows:

“(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by[615] the American Osteopathic Association[616] or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.”

When I was CEO of a hospital, we voluntarily made our JC surveys public, posting them on our corporate website.  We felt that it was important for all staff in the hospital to have the chance to review the findings and act on them, and we also felt that public confidence in our hospital would be enhanced by this kind of transparency.  While this practice has spread somewhat, most hospitals still do not make their surveys public.

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Joint Commission Apes Newt, Takes on IHI

Not content with handing out demerits for bad behavior, the Joint Commission has launched an effort to help those who misbehave change their ways.

As detailed in the Wall Street Journal’s Health Blog, the mission of the Joint Commission’s new Center for Transforming Healthcare will be, in the Journal’s words, “to work on new collaborative programs with leading hospitals and health care systems to find a cause of the most deadly breakdowns in patient care, and put a stop to them.”If the name of the new group sounds familiar, you could be confusing it with Newt Gingrich’s Center for Health Transformation. That center was launched by the former House Speaker to tout the benefits of health information technology and a changed reimbursement system and then show how those benefits could work in practice through demonstration projects. Of course, with the advent of the Obama administration, the for-profit center has changed its mission just a tad from Newt-the-Wonk’s, “Paper Kills” to Newt-the-Republican-Attack-Dog’s “Democrats kill.”  Visitors to the Center’s site can now find helpful op-eds with titles like “Healthcare Rationing” and “Listen to Barney Frank or listen to America?”

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