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Here are some of the concerns expressed in the Illinois Hospital and HealthSystems Association’s (IHHA’s) letter criticizing the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) plan for the patient safety management profile:
• Providers need to know what standards comprise the different categories as well as the methodology being proposed for weighting of categories. Providers will need to have their individual scores on each standard and the aggregation into new categories as a subject of discussion during survey and as part of the final preliminary report at the conclusion of each survey.
• In order for the graphs to be of any value to the consumer and accurately reflect a hospital’s performance, in addition to the above criteria, the graphs need to be properly scaled and displayed with data that reflect a level of confidence (which may involve usage of ranges and standard deviation techniques). It needs to be made clear to the public that these are process and structure standard and do not directly measure the safety of the hospital or the care it delivers.
• The IHHA is concerned that there will be significant inconsistency in surveyors’ assessment of hospital compliance. As Sentinel Event Alerts now are routinely issued monthly, JCAHO needs to develop a plan to train the surveyors with each new Sentinel Event Alert as well as assess the reliability of the surveyor training and surveyor assessment skills.
• If compliance with alerts is scored in this fashion, the result will look and feel like a Type I Recommendation. Thus, similar to Type I Recommendations, JCAHO needs to establish a process for correction and reassessment on areas that are deemed incomplete or noncompliant. JCAHO also needs to update its reports to the public upon assessment.
• JCAHO needs to establish an expert panel to select targeted areas so that the energies of hospitals are devoted to sentinel event issues that are truly of highest priority for patient safety if these alerts are going to be driven by general themes rather than JCAHO experience with the sentinel event reporting policy and database.
• JCAHO needs to establish an expert panel (or a series of panels unique to each issue) to identify recommendations of best practices for each Sentinel Event Alert. Recommendations need to be thoroughly discussed in the Sentinel Event Alerts, with appropriate literature citations, and examples need to be provided of different approaches. If these recommendations are to be scored and publicly disclosed, then a review process must occur as it does with new standards.