Radical revision is under way at Joint Commission

Striving for clinical relevance, physician buy-in

With a keen awareness of the increasing pressure for improved patient safety, the Joint Commission on Accreditation of Healthcare Organizations is radically revamping its oversight of hospitals. Slated for implementation in 2004 — giving health care facilities a full year to grasp the depth of the changes — the new Shared Vision/New Pathways strategy is aimed at making the survey process more clinically relevant and increasing physician involvement.

"[We have] evaluated how accreditation could be strengthened and remade, so it could bridge any gaps between where we are and where we wanted to be in improving quality of care during these times of tremendous change," says John Noble, MD, Joint Commission board chairman. "We agreed on one basic premise: Now is the time for the Joint Commission to take bold action," he adds.

The critical elements of the new accreditation process include a major consolidation of existing Joint Commission standards; the introduction of a self-assessment process; use of data from multiple sources (including the self-assessment) to guide the on-site accreditation survey; and reviewing actual patient experiences during the on-site evaluation.

The self-assessment will occur at the approximate midpoint of the three-year accreditation cycle, making the accreditation process more continuous and reducing the "ramp-up" efforts that many organizations undertake before surveys, says Dennis O’Leary, MD, Joint Commission president. "It will also shift the basic ownership of the evaluation process from the Joint Commission to the organization," he says. "Experience with both self-assessment by others and the Joint Commission pilot tests have found that organizations themselves are at least as effective as accreditors in identifying significant performance issues."

The self-assessment may lead to a "plan of correction," which will be reviewed and finalized by telephone with a Joint Commission staff member. The plan of correction will not affect the organization’s current accreditation status. The organization’s success in executing its plan of correction, together with assessment of compliance with other randomly selected standards, will be evaluated at the on-site survey approximately 18 months after the self-assessment. The self-assessment process will be supported by newly developed computer software.

Tracing the care of a single patient

"In the future, we’ll get at the same information, but in a different way," says Russell Massaro, MD, Joint Commission executive vice president. "[For example], we’re going to choose at random, from open records, a patient who just had surgery. And we’re going to trace that patient’s course through the organization."

Thus, if a patient with a fractured hip came into the emergency department, the surveyor may start there and assess initial treatment. Then the survey would follow the admission process and talk to the operating room staff if surgery was necessary on that patient, he adds.

"And all the questions are coming from the chart of a patient who actually received the care," Massaro says. "Because every patient who goes through a hospital is actually touched by every one of our standards. That’s not always obvious when we ask questions of the organization about how they comply with standards; but it now becomes quite obvious when we ask about what actually occurred to a patient, and we interpret those responses in terms of our standards. That’s really the difference in this approach."

As part of the new process, Joint Commission surveyors will undergo special training and have to pass a certification test. Surveyors who fail the exam cannot be the surveyor of record in any organization, and must undergo a remedial program of study until they successfully complete the exam. Another key aspect of the new accreditation process is heightened physician involvement, something the Joint Commission says is critical to making the survey more clinically relevant. "It has not necessarily been apparent to physicians that when we survey and when we accredit an organization that we’re looking directly at patient care," Massaro says. "This new process exposes that very precisely and makes the connection real clear for them."

Physicians have been receptive and more involved during pilot testing, particularly due to the approach of tracking the care of a single patient. "It gave the surveyors a more realistic assessment of our day-to-day hospital operations," says Chuck Young, administrator of Shriners Hospital for Children in Spokane, WA, one of the pilot-testing sites. "The surveyors went through and followed, using tracer methodology, an actual patient experience. Our staff, especially our physicians, were very enthusiastic about the process because they were able to be involved with it."

All well and good, but the real question is whether the new accreditation approach will accomplish what the Joint Commission is ultimately seeking — improved patient safety. "I definitely think that it will," says William T. Richardson, CEO of Tift (GA) Regional Medical Center, another pilot-test site. "There’s going to be more buy-in. It’s much more personal to us, much more palpable. And I think that just by virtue of it being more meaningful to us that there has to be something good to flow from it. I think that it will compel us all to do a better job," he says.