ED Accreditation Update

Physicians, medical staff may report safety concerns without fear of disciplinary action

In a Sept. 5, 2007, revision of its accreditation participation requirement for concerns about hospital safety and quality of care, The Joint Commission specifically stated that physicians and medical staff members who have such concerns "may report those concerns with the understanding that retaliatory disciplinary action is prohibited."

The revised requirement, which are targeted to be effective Jan. 1, 2008, means that accredited hospitals must educate staff and medical staff that any employee or any physician who has concerns about the safety or quality of care provided in the hospital may report these concerns to The Joint Commission. In addition, "The Joint Commission policy forbids accredited organizations from taking retaliatory actions against those who report quality of care concerns because it is the obligation of everyone in an organization to make patient well-being the priority," said William E. Jacott, MD, special advisor for professional relations at The Joint Commission, in a prepared statement.

According to The Joint Commission, the accreditation participation requirement previously referred generally to hospital staff, but it has always been intended that physicians and medical staff be included as part of 'Good Faith Participation' in the accreditation policy.

ED managers responded to the announcement with a mixture of understanding and concern. "In concept there's everything good about a check-and-balance system that allows people to register concerns without fear of retaliation," says Randy Pilgrim, MD, president and chief medical officer for The Schumacher Group, an emergency physician group in Lafayette, LA. "It stands for the basic principle of continually improving patient care and safety."

Will policy succeed? Here are keys

The key to success for this policy is what The Joint Commission will do with the information and how it will be translated by the hospital into safety and quality improvement, he says. "The other key is how hospitals and EDs continuously engage in improvements that don't require reporting to external entities," he says. "It's very important to have a good culture of patient safety, quality of care, and good teamwork." When that doesn't work, he says, external reporting and methods of improvement should be available, "But it's important to work well with the team that, hour by hour and day by day, must continuously be about quality improvement."

Michael D. Bishop, MD, president and CEO of Unity Physician Group in Bloomington, IN, is concerned that this policy is vulnerable to abuse. "I understand theoretically why [The Joint Commission] would do something like this; it's good to be open and honest and report properly, and that if people see something going on they should feel free to report it," he says. "But from an ED physician's standpoint, this a real concern, because occasionally we have instances where nonphysician staff or other physicians will play the 'gotcha!' game."

A nonphysician staff member may have a beef with a physician, he explains. "Then, three months later, the doc does something and all of a sudden we have a call in to The Joint Commission, no names, no documentation, and they will be here looking for 'the problem' — which may or may not exist."

Finding the balance

Striking a balance between complying with policy while protecting against abuse is difficult, Bishop admits, "but the manager and their team need to do a great deal of education with the staff that this is not just a 'gripe' thing," he says. "If a doctor or nurse is not nice to you, let's deal with that. That's not a Joint Commission type of issue."

In other words, he says, the ED manager may have to be very clear to his or her staff as to exactly what kinds of events, activities, or actions or behaviors need to be reported to The Joint Commission. If there is a single event of concern, he explains, there are procedures and mechanisms in every hospital for dealing with those kinds of issues. "One of the things the ED management has to do is inform people they are not to just feel free to pick up the phone and say 'I saw this person go into a room and not wash their hands," he notes. "It needs to be big issues, or repetitive issues that the department or system is unable to deal with through regular channels, and of course whoever reports this should not get retaliated against."

ED management "needs to explain to their staff that the first option if you have issues is to go to your supervisor or manager and try to get it solved that way, as opposed to taking it to the Supreme Court before it's ever been tried in a lower court," Bishop says. He is not advocating that issues should never be reported to a higher authority, "but in the grand scheme of things, you need to start at the basic level first." If the staff member feels ED management and hospital management are not dealing with the issue, "then that would be the time to say this is a terrible patient safety and quality issue and we've got to get somebody [on the outside] to deal with it."

As for educating your staff about the policy itself, says Pilgrim, "You should put it in the context of your greater vision and mission for patient care." In other words, he says, "Emphasize that we care most about the patient right in front of us, and we want to embrace any opportunity to provide quality and safety to them."

The discussion should be framed by adding that the department staff should also care about their team members and work well with them, embracing openness, Pilgrim says. "Any improvement to process or comment that can improve care is important," he notes. "Then, let the staff know that we also embrace processes that go beyond our department that will assist us with a view of ourselves that we may not have, and that we are committed to that. We encourage it."

Assure your staff that you will care about what is reported and quickly act on it "if it is in indeed in the best interests of our patients, for that is our primary commitment," Pilgrim says.

Start with department meetings

How can such messages best be communicated to staff? Pilgrim says that departmental meetings are a good starting point, with continual reinforcement in quarterly or annual meetings, new employee orientation, and employee evaluation. "It's easy for this to go hand in hand with corporate compliance processes that work very similarly — that is, most of them have a hotline for anonymous reporting without retaliation," he says. "It's also easy to fold into an entire culture of quality improvement and openness on behalf of your patients."

These regular activities also will make it simple to document the fact that you are complying with The Joint Commission requirements. "If it is discussed in departmental or staff meetings, the minutes will assist you [in documentation]," Pilgrim says. "If it is discussed in the context of new employee orientation or evaluation, part of the standard form you use could include these acknowledgements and discussions."


For more information on The Joint Commission's accreditation participation requirement for concerns about hospital safety and quality of care, contact:

  • Michael Bishop, MD, President and CEO, Unity Physician Group, Bloomington, IN. Phone: (812) 333-2731. E-mail: mbishop@unitypg.com.
  • Randy Pilgrim, MD, President and Chief Medical officer, The Schumacher Group, 200 Corporate Blvd., Suite 201, Lafayette, LA 70508. Phone: (800) 893-9698.