Joint Commission still sees room for improvement

Latest survey shows how, where hospitals fall short

While U.S. hospitals continue to demonstrate overall improvement in quality and safety, they still have a long way to go in several key areas, according to Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007.

The report released several other key findings:

  • Requiring hospitals to follow a standard process for continual quality measurement, reporting, and improvement has contributed significantly to this improvement.
  • There is great variability in performance by state, as well as between the highest- and lowest-performing facilities.

Specifically, the quality of care for heart attack, heart failure, pneumonia, and surgical care patients improved based on 2006 performance data provided by accredited facilities. In addition, they achieved 90% compliance or greater on most of the 2006 Joint Commission National Patient Safety Goals.

"In terms of quality data, this is consistent with what we have seen in a variety of quality-related reports," notes Jerod M. Loeb, PhD, executive vice president, quality measurement and research for The Joint Commission.

One of the keys behind the continued improvement, he asserts, is that "things that get measured get managed," but he is quick to add that it is "also abundantly clear these processes are not ingrained in facilities and systems and process redesign so that in all encounters all the right things happen."

What The Joint Commission measures, he continues, is basically processes. "We have seen a tremendous increase in the use of ACE inhibitors and smoking cessation programs for acute MI [myocardial infarction], but not everyone is at perfection. The same goes for heart failure and pneumonia," he observes.

Where hospitals fall short

Even when it comes to the National Patient Safety Goals, Loeb notes, there is room for improvement, despite the 90% compliance rate. "If you look at these goals, we have requirements, and the data suggest a fair number of things where we continue to see non-compliance — such as time-outs between surgery, use of abbreviations that are known to cause problems, reporting critical tests results, and medication reconciliation. It's very difficult for hospitals to do these and to remain compliant," he notes.

There are a variety of reasons for this difficulty, Loeb adds. "When you've seen one hospital, it doesn't mean you've seen them all," he explains. "Not all hospitals have the same electronic infrastructure and databases, or ways to accomplish things."

Even something that at face value seems simple, such as giving aspirin within 24 hours of admission for acute MI, can have its difficulties, he continues. "Between the point the medicine is thought about and ordered and the point at which it is actually placed into the patient's mouth, 100 different steps need to be followed. They can break down — and often do," says Loeb. "Health care is a uniquely human endeavor."

One of the keys to sustaining improvement, says Loeb, is to constantly think about the process in question. "Even when you change from 20% to 95% compliance, if you do not continue to measure and to emphasize the process, it will drop," he warns.

Compliance still lags on four measures introduced five years ago, according to the report:

  • discharge instructions for heart failure patients: 17.7% of respondents are not performing it consistently;
  • pneumococcal screening for pneumonia patients: 22.7% of respondents are not performing it consistently;
  • ACE inhibitor prescribed at discharge for heart failure patients: 36.1% of respondents are not performing it consistently;
  • ACE inhibitor prescribed at discharge for heart attack patients: 43.6% of respondents are not performing it consistently.

"The discharge instruction measure has different pieces," notes Loeb. "I'm not sure providing any med is more difficult than providing any other, but many times it's a matter of disparity between what the evidence suggests and what people think in their minds."

Unfortunately, he notes, not everyone practices evidence-based medicine. "ACE inhibitors are newer meds, and it's entirely within the realm of reason that they are not on the daily radar screen of all doctors in terms of prescribing them," he says. "We have knowledge base deficits as well. "

Standardization is key

The authors of the report attribute improvements in part to requiring that hospitals follow a process to measure and report quality advances. "What we've done," Loeb says, "is to identify a series of standard processes of care we know have good linkage to outcomes, and have developed standardized measurement tools so all hospitals can look at the same clinical cases the same way.

"So, for example, if a patient is allergic to aspirin or had a recent GI bleed, even though the literature says to get aspirin on board, it may not be a good thing to do," says Loeb. "We look at a clinical condition with all its complexity."

"We state explicitly what to look for, and where it should be found in the medical records," adds Stephen Schmaltz, associate director of The Joint Commission's Center for Data Management and Analysis.

The Joint Commission also hopes to make its performance measurement and reporting requirements "increasingly relevant," states the report. "These are clinical conditions that represent the bedrock of American medicine — the most common DRGs," Loeb explains. "We try to focus on very specific practices that are associated with better outcomes."

The Joint Commission also plans to continue collaboration with groups such as the Centers for Medicare & Medicaid Services, the National Quality Forum, and the Hospital Quality Alliance.

"In today's world of performance measurement, we hope to coalesce with others," Loeb explains, but is quick to add that the development of one single measurement standard is "the Nirvana state — it will not exist today or tomorrow."

The closest we can come, he says, "is to be sure all data are collected once at the point of care and streamed then at that point. Then, let those who ultimately have need of it utilize it in whatever way they need to in order to meet their specific demands."

"That's why our focus has been on the standardization of the reporting," adds Schmaltz.

[For more information, contact:

Jerod M. Loeb, PhD, Executive Vice President, Quality Measurement and Research, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.]