Safety profiles delayed by JCAHO but coming soon

The "patient safety management profile" proposed by the Joint Commission on Accreditation of Healthcare Organizations is under fire from health care providers who say it will create unfair comparisons and increase liability exposure, but a lead player in the plan says you will be subject to some sort of safety rating before long.

When the plan was reviewed by the Joint Commission’s board of directors recently, health care providers flooded the board with objections and concerns, says Ken Shull, FACHE, president of the South Carolina Hospital Association in West Columbia. The board was considering whether to go forward with a plan that would score hospitals and other providers according to how well they complied with certain standards and best practices considered key to providing a safe environment for patients.

Shull tells Hospital Peer Review that the board felt the heat from providers and decided to send the plan back for another look. The Joint Commission staff then sent the plan to the Accreditation Process Improvement Implementation Task Force, which Shull chairs. The committee has met once to consider the plan and is likely to meet once more on the same topic. "They wanted field input to make the plan worthwhile, meaningful, doable, and not have it lead into more liability than necessary," Shull says. "It’s considered a very important issue, and it’s on a fast time frame."

Shull says his committee hopes to present its recommendations to the Joint Commission board in November and the plan might be implemented soon after. According to Shull, even though the proposal has generated criticism, the Joint Commission is determined to enact some version of it without delay. He acknowledges that much of the concern is legitimate and says he hopes his committee’s work will overcome some of the problems. "Disclosure of anything is a touchy issue for health care," he says. "Concern about liability is a top priority. I think the general feeling is that we need some release of data, but we have to be careful . . . and make sure they’re accurate, fair, and presented in a way that people can understand — a way that is relevant to how people obtain health care."

What data to gather and how to report them

The committee is considering two main issues: what information should be included in the profile and how to report that information publicly. As proposed, the patient safety management profile would be part of the Joint Commission survey process, with each organization getting a report card on how it manages hospital safety. Each hospital would receive a score, with quantitative numbers that theoretically could be used to compare providers. That is one of the biggest concerns. "The information would be live and in color on the web, accessible to anyone. There’s no easy way to display data like that and make sure people understand them in the way you intended," Shull says.

"I don’t care how many disclaimers you have on something; if there is a graph, chart, or picture, people are going to look at that and forget all the words. They will make assumptions that you may not have intended and that may not be an accurate assumption," he adds.

The committee is reassessing one of the original proposals to use the Joint Commission’s Sentinel Event Alerts as a way to calculate the hospital’s patient safety management score. The Sentinel Event Alerts are published periodically by the Joint Commission as a way of highlighting sentinel events and bringing attention to the types of dangers involved, plus the lessons learned by health care providers.

The original idea was for the alerts to be used as criteria for determining how well a hospital has addressed patient safety, in effect considering each one a lesson and then seeing how accredited hospitals have put those lessons to use, Shull explains. But there has been criticism that the plan to use the alerts is too complex.

Karen Reeves, vice president of professional services with the South Carolina Hospital Association, has been monitoring the situation since the Joint Commission first proposed the plan. Though Shull is her boss, Reeves says she is not shy about voicing her opinion of the project he’s trying to improve. "Thank God that didn’t fly," she says. "The Joint Commission wants to develop a methodology for a grid that would show a numerical score like 90%, with that number used as an indicator of patient safety. But it’s a black box methodology. It’s not been disclosed how you would calculate that numerical score, so there’s no reason to think it’s valid or reliable."

Alerts could be a lot to comply with

The plan to use the Sentinel Event Alerts as a measure of patient safety causes particular concern for Reeves. She is concerned that the Joint Commission would throw too many of the alerts at hospitals and not realize how much work is required to comply with them.

"They wanted to tell hospitals in October of each year that you have to show compliance with these 10 alerts for next year. But if you tell me in October that you’re focusing on these 10 things, there is no way that in January I can have a good process in place for doing that," she says. "It would be much better for them to say, Here are 20 alerts, and you need to pick a couple that involved concerns at your hospital, implement them, and then explain to the surveyor why you chose those.’"

Shull has heard similar concerns from many other health care providers and observers. He says that, despite some serious misgivings by different parties, the patient safety management profile will be a reality within a matter of months. The actual implementation date may come after the grace period built into most new Joint Commission standards and procedures. "We’re going to have to click this together pretty quickly," Shull says. "It’s on a fast track because it’s important. The public, employers, and insurers are all looking for information like this. It’s all part of the increased awareness and emphasis on medical errors and patient safety."

Standards Review Task Force making progress

Shull also chairs the Joint Commission’s Standards Review Task Force, which is conducting a sweeping review of nearly all the Joint Commission standards and requirements for demonstrating compliance with standards, with the goal of making them less burdensome and more realistic for health care providers.

The 18-member task force will pinpoint which accreditation standards are most relevant to the safety and quality of patient care, and target for elimination or modification those standards that do not contribute to good patient outcomes. In addition, the task force will identify "redundant and overly burdensome" documentation requirements with an eye toward streamlining and identifying areas that need more attention. Only a few recently established standards, such as new requirements regarding pain management, patient safety, and restraint and seclusion are exempt from scrutiny.

Shull tells HPR that the process is going well. The committee has met twice and gone through three chapters, he says. It will be a yearlong process through the end of June 2002. Shull says the specifics of the committee recommendations cannot be released yet, but he is pleased with its progress. "So far we’ve pointed out some redundancies and that seems to be well-received by the senior [Joint Commission] staff," he says. "We’ve said others were not necessary, and that also was well received. And we’ve confirmed that some were good, that they needed to be there."

Shull says he is most pleased by the reaction of the Joint Commission staff, who he says seem serious about the plans to cull the standards of unnecessary and unreasonable requirements. "The book ought to be thinner when we’re done," he says.