JCAHO will want evidence that physicians are involved in safety

Surveyors will expect to see continuous involvement

If a Joint Commission surveyor asked a physician at your organization about patient safety initiatives or recently performed root cause analyses, would the surveyor get a detailed, enthusiastic response or a blank look?

To increase physician involvement with the accreditation process and patient safety initiatives, JCAHO has established a Physician Engagement Advisory Group and will be looking closely at this during 2006 surveys, says William Jacott, MD, special advisor for professional relations, who acts as an interface between physicians and JCAHO. "Physicians need continuous involvement in quality activities and patient safety, not just during the survey," he emphasizes.

When JCAHO’s board of commissioners underwent a strategic planning process several years ago, one of the goals that kept coming up was engaging physicians in patient safety, and this became a strategic objective of the Joint Commission, says Jacott.

"Physicians play a major role in our accredited programs, and they really ought to be part of the team that works on the quality activities," says Jacott.

Although the Joint Commission has had advisory groups for nursing, business, and the public, there has never been a physician advisory group. During a December 2005 meeting, the 20 physician committee members gave feedback on the new accreditation process and educational programs.

"Some had no exposure to JCAHO, and others are playing the role of chief medical officer and are very involved," says Jacott. "We will be getting their input about performance measurement and the use of core measures."

One example of a way to ensure physicians are involved in safety is by having an interdisciplinary safety and quality council with a significant number of physician members, says Jacott.

Every organization has its patient safety "champions" in the physician ranks, adds Jacott. "It’s important that these individuals are put in a position to advance activities in safety and quality," he says. "Often, this is the chief medical officer, but not necessarily — it could also be the chair of the quality council."

Physicians are an untapped resource in many organizations, says Jacott. "Many look at JCAHO accreditation and quality issues as a nursing or administrative task, and they think that physicians don’t need to be involved. They hear that the JCAHO is coming and say So what?’"

This is especially true for community hospitals where physicians are independent practitioners instead of employees, adds Jacott. "The fault is on both sides. Physicians need to become more involved, and the organization also has to recognize that they need to engage the physicians."

Jacott suggests tapping physicians in charge of various departments, such as pediatrics, family medicine, and internal medicine and surgery. "It’s up to them to gather their group together and review the performance measures," he says. "I have attended a lot of those meetings at various hospitals. And when a physician starts getting data on his or her own practice — for instance, if a pediatrician has the lowest immunization rate of their group — it really gets their attention."

Few JCAHO standards specifically require physician involvement, other than requirements that physicians be on the hospital bylaws and credentialing committees, notes Jacott. However, surveyors will be looking closely to see whether physicians are involved in patient safety initiatives on an ongoing basis.

"There is nothing that says a physician must be present when you trace the patient during a survey," says Jacott. "However, several surveyors have told me that they never pass up a physician when they see one during a patient tracer — they will always stop to chat with them."

During a recent JCAHO survey at St. Jude Medical Center in Fullerton, CA, surveyors frequently questioned physicians during tracers. "Whichever unit the surveyor happened to go to, they would approach physicians and query them about the care of the patient," says Pat Wardell, RN, vice president for quality management and patient safety officer.

For example, a surveyor asked an anesthesiologist if a preoperative evaluation was done, if patient consent was obtained, and if a reevaluation was done.

"Basically, a lot of the questions they used to ask during a scheduled meeting that you would prepare the physicians for, are now asked out on the floor," says Wardell. "In the past we spent a lot of time scripting the physicians. The beauty of this was that the surveyors came, the questions were asked, the physicians answered them and were great on their own."

At St. Jude, JCAHO surveyors were impressed by a strong showing from medical staff members at the medical staff leadership conference on the first day of the survey.

The physicians were given very short notice and were alerted at 9:00 a.m. about the 5:30 p.m. meeting that same day.

"Of 38 members, about 30 members showed up. The surveyors were floored that with less than 12 hours notice, we could get that many physicians there," says Wardell. "We expected a possible problem and didn’t know how many would be able to attend. But our physicians always step up to the plate when we need them, and this particular Monday evening at 5:30, they were there."

Wardell recommends giving physicians a "heads-up" about the importance of attending this meeting well in advance. "We talk about JCAHO readiness on a routine basis with our medical executive committee, and that was one of the things we talked about," she says.

Surveyors also want to see the organization’s chief medical officer interact directly with them, adds Jacott. "In some cases, the chief medical officer is now being named by the organization as the chief contact person with JCAHO. That is direct contact with physician leadership and sends a strong message," he says.

At Spectrum Health in Grand Rapids, MI, more than 20 part-time physician medical directors have patient safety projects as a key responsibility, with specific clinical and quality improvement goals connected with JCAHO accreditation standards.

"They have a quarter or half of their time set aside for patient safety work," says John Byrnes, MD, the organization’s senior vice president of system quality. "Every year I sit down with them, and we develop a list of projects they are going to tackle for that year. For that project list, we also attach quality metrics and set goals for those measures."

The medical directors get an annual performance evaluation, which includes evaluation of their success in working with colleagues to get various safety projects implemented throughout the organization.

"We have hardwired’ physician involvement with quality and safety initiatives, just as we would any administrative director, manager, supervisor, or staff member in our hospital," says Byrnes. "During our next JCAHO survey, all of our medical directors will make themselves readily available. They have taken ownership of these projects and will be proud to talk about them."

For example, compliance with JCAHO requirements to mark the surgical site before surgery and holding a "time-out" before an incision is made was assigned to the perioperative medical director, who is paired with an administrative nursing director counterpart. Both are accountable to make sure the protocol is fully implemented with 100% compliance by the end of the year.

For every project, the medical director is supported by a QI specialist, a data analyst, and additional quality staff as needed. "They are fully backed up by staff from my department, who are there to help the medical and nursing director drive the project to completion," says Byrnes.

Data collection is automated as much as possible, but some manual chart reviews are done, with data updated on a monthly basis. In addition, the organization also has three part-time medical directors assigned to the quality department.

"We call them our quality medical directors. They are also available to help the specialty medical directors if they come up against barriers or need help negotiating with colleagues," says Byrnes. "So that pool of expertise is there as well. The medical directors are backed up by multiple levels of support."

If capital expenditures or major policy changes are needed, Byrnes works with the director of quality to appropriate needed resources. A recent example involved an investment in systems to automate data collection from the existing administrative databases and financial and medical records systems.

"The software allows us to report on how we are doing on our 30 high-volume medical and surgical procedures," says Byrnes. "With that capability in place, we are improving care for at least 80% of our patient population. When we back that up with chart review, there is probably not a single patient who comes through that hasn’t been touched by our quality or safety initiatives."

Most organizations have medical directors but haven’t put in an organized structure in place to ensure their involvement in patient safety, says Byrnes. "Formalizing the job descriptions is pretty rare. I think of it as a small army to drive quality and safety throughout the organization," he says.

The key is to "hardwire" patient safety into overall hospital operations with accountability, says Byrnes. "Every administrative director is accountable for the budget and how they performed at the end of the year. This is essentially the same thing put into place, except their budget’ is made up of quality metrics," he says.

[For more information, contact:

John Byrnes, MD, Senior Vice President, System Quality, Spectrum Health System, 100 Michigan Street NE, MC 060, Grand Rapids, MI 49503. E-mail: john.byrnes@spectrum-health.org

Pat Wardell, RN, Vice President, Quality Management and Patient Safety Officer, St. Jude Medical Center. 101 E. Valencia Mesa Dr., Fullerton, CA 92835. Telephone: (714) 992-3000, ext. 3763. E-mail: pwardell@stjoe.org.]