New old chapter in TJC manual
For the first time, it’s open to the public
There’s nothing new in The Joint Commission’s first chapter of the 2015 Comprehensive Accreditation Manual Hospitals, and yet, everything about it is new. The chapter includes more than two dozen standards, all of which appear in other chapters, all having to do with patient safety systems, creating a learning organization, and fostering a culture of quality. Those standards will still appear in the chapters from which they were culled. But for the first time, the chapter in its entirety is being published on The Joint Commission’s publicly accessible website so that anyone, whether they are accredited hospitals or not, can see it.
"Why should we limit this to accredited organizations?" asks Ron Wyatt, MD, MHA, the medical director of The Joint Commission’s Division on Healthcare Improvement. "If everyone can see this, then everyone will know what patient safety is," he says. "You can’t assume that people know that. Even leadership may not have a clear answer."
In addition, seeing this chapter will help patients and their families to understand that there is a minimum standard that hospitals should meet, Wyatt says, and they will have greater awareness of patient safety.
The process of creating this chapter — and Wyatt emphasizes that it is the first chapter in the manual, not something buried in the middle or as an appendix — started 18 months ago after several stakeholders suggested revising the sentinel events chapter. Wyatt and his team suggested rather than being reactionary, why not create a proactive, prospective method of dealing with the issues that lead to sentinel events.
He wrote a chapter, "but the first draft was 200 pages long," he says with a laugh. It was promptly turned down by commission leadership. He brought in risk managers, quality improvement staff and corporate liaisons — a total of 40 people. They suggested that he speak to the issue of patient safety. That was addressed in the manual, but throughout different chapters. So they went through it and brought a group of standards together that seemed to address Wyatt’s dream of being proactive and prospective about sentinel events through enhanced patient safety and a supportive leadership and organizational culture.
"It’s a road map to safety and to activating patients," he says. "It gives us free lessons of unsafe conditions and how to respond to them. It helps us learn how to use data for improvement and pushes us to become learning organizations."
The idea to publish this on publicly accessible Web pages wasn’t Wyatt’s, but still: "I was thrilled that no one said don’t do this," he says. So far, the response from the wider public as well as hospitals accredited through TJC has been positive, but he is anxiously awaiting the initial feedback from consumers, for whom this chapter was designed. While some may say the chapter is too transparent to share with everyone, he thinks it’s a stroke of genius. "I say go for it."
For more information on this topic, contact Ron Wyatt, MD, MHA, Medical Director, Division of Healthcare Improvement, Joint Commission, Oakbrook Terrace, IL. Email: [email protected].