Saturday, March 17, 2007

If Jayco didn't exist, we would want to invent it

The Joint Commission (previously known as the Joint Commission on Accreditation of Healthcare Organizations, and still informally called "JCAHO" or "Jayco") has for years assessed quality and safety in hospitals. Previously conducting a somewhat bureaucratic review of files and written rules, Jayco recently enhanced its survey procedures to complete much more thorough investigations of actual clinical procedures and the medical staff's understanding of patient care guidelines.

Also, the Joint Commission now does unannounced surveys, in contrast to the previously scheduled visits. So, a team shows up on a Monday morning and spends the week in your hospital conducting an extensive and intensive review. If they find things wrong, they issue "requirements for improvement", and the hospital must show a detailed plan for making the improvements in a set period of time. If they find enough things wrong, the ultimate sanction is a loss of accreditation, which is bad in many respects, not limited to losing the right to be paid by Medicare.

This is all to the good. Notwithstanding great intentions by well-meaning medical staff and effective supervision by a board of trustees, independent external reviews are helpful in many respects. Our slogan is, "If Jayco didn't exist, we would want to invent it." That is not to say that a visit doesn't make us sweat, and that the prospect of their unannounced arrival doesn't keep people awake each Sunday night. It does.

One of the medical standards currently being enforced by the Joint Commission is something called "medicine reconciliation". Part of this standard means that we are supposed to to discuss with all patients the medications they were taking before entering the hospital, and review their medications again upon discharge. This is supposed to apply to both inpatients and outpatients.

This makes tremendous sense, of course. How can you give thorough and proper care to patients without knowing what medicines they are already taking? But, frankly, it is not always carried out to the full extent. Things happen: A busy clinic, a confused patient, a missing note from the referring physician. But clearly, the goal is full compliance.

This is just one example. It would be the truly extraordinary hospital that gets a perfect score from a Jayco surprise visit on the wide range of patient care standards. But that's just the point, isn't it? Even the finest institutions can improve, and sometimes we all need an objective outside observer to tell us where we should focus our efforts.

The job of hospital management is to use those findings as positive challenges for the institution and help it achieve ever better results for the public. Having talked with my colleagues in the other Harvard hospitals and in the other Boston-based hospitals, I know they share that view. The public should feel good about that shared perspective -- while still holding us accountable for better and better performance.

18 comments:

Anonymous said...

Good timing.

Today's Boston Globe, "Surprise check faults MGH quality of care", gives me cause for greater concern as to the safety of a hospital experience.

The article included a "memo" from Peter Slavin, President of MGH. (http://www.boston.com/yourlife/health/other/articles/2007/03/17/memo)

After pumping up the caregivers, Slavin offered these handy tips. For emphasis as you read, utter "A-DUHHH" after each:

# Wash your hands and/or use Cal Stat before and after every contact with patients and equipment - no exceptions;
# Put the date and time of every entry into the clinical record;
# Wear your hospital ID in a visible place at all times when at the MGH or any of its satellites;
# Conduct and document the universal protocol - "time out" - for all procedures in the OR, office, ICUs and other patient care areas;
# Do not use any unapproved - and dangerous - abbreviations in clinical documentation;
# Ensure that every patient has an appropriate and up-to-date history and physical in the chart before any interventional procedure;
# Understand that medication reconciliation is not an option, it is a requirement;
# Document pain assessment, especially after any interventions to control pain;
# Document whether patients have signed an advance directive; and
# Store all medications properly and safely.

Considering the care that we apply in our kitchen when preparing a meal, basic stuff like washing hands are habitually routine. We keep medications in a chest, with lock caps, and inaccessible to children. When our twins were sick, we kept meticulous records of their temperature, I and O, and other notes that might help our pediatrician should their condition worsen. We're parents, not doctors, yet manage to do it properly.

Slavin's little note causes me to shudder - it's inexcusable that any hospital need reinforce these basics.

And these are just simple things.

What else are our hospitals missing?

To have JAYCO then offer accreditation is beyond understanding, except when I consider the money and politic which winds around the great profession of medicine. This situation requires immediate and firm action by the hospital and a non-accreditation action until their medical act is cleaned up.

Where's our Department of Public Health? Asleep?

Paul Levy said...

Hi anon,

Look, as I think you all know by now, I am never going to offer excuses for bad care or poor habits. I know, too, how inconceivable it is to us non-doctors that any trained medical person should need reminders about this stuff.

But, please remember that these hospitals are VERY, VERY busy places where people are intimately engaged in doing highly complex things to save people's lives or cure them. There are hundreds of things that doctors and nurses have to remember to do, and often to do quickly and in real time.

As people in industry will tell you, even people working in repetitive and regimented industrial processes need to be reminded over and over again about basic safety procedures. In hospitals, it is not regimented and repetitive: Each patient gets individual attention, so the medical staff needs to focus their judgment and experience on those needs hundreds of times per day. I am no expert on this kind of process question, but perhaps that is why bad habits sometimes slip back in.

And so, yes, whether it is Peter or me or any other hospital CEO, you will see us send out reminders of the sort he did. Rather than being critical of him, I think it is praiseworthy that he as CEO personally takes an interest in this and reinforces the message.

mr.healingman said...

Paul, also a lot of things can get lost in translation. (Not intended as a dig to interpretor services) but non English speaking patients who are sick can be a real challange and throw in a third person to relay the info - it does cause some confusion.

Anonymous said...

Anon will offer understanding for the fact that hospitals are busy (distractive) places (part of the deal) and caregivers engage in real-time decision-making (trained for that) and challenged communications with patients who may not speak the native tongue (resources for that)...

All these (reasons as much as excuses) have little to do with basic hand washing and documentation, two prominent items that stick out like sore thumbs in Slavin's memo and most surely can translate into disaster. These issues (and others) have nothing to do with patient communications (with the exception of pain assessment which ought to be done and documented at each routine staff visit). Instead, these items have everything to do with personal hygine and professional practice.

I have some knowledge and strong interest in risks by way of automation and the human/machine interaction and would suggest that the learnings in this area apply equally to hospital procedures.

The famous crash of a DC-10 that had its entire flight surface hydraulics disabled due to a catastrophic engine failure was the result of a tiny manufacturing defect in a high-rpm fan disk. The defect was not detected due to improper testing. The airplane flew fine for thousands of hours until the disk finally gave way. This ordinarily would not be unrecoverable, but designers failed to account for the possibility that three independent hydraulic circuits could all fail. Well, they should not, except for this instance where in the one point the designers failed to keep routing of the lines separated (instead bringing them close together in the center tail section of the airplane) the flying metal pieces tore through all three.

It was, in the classic statement of one of the surviving crew, a case where little failures snowballed into much larger ones, leaving a nearly helpless flight crew with a very small set of options.

A similar situation, much more fatal, led to the largest loss of life at the time when a rear pressure bulkhead of a Japan Airlines 747 gave way due to a long-ago improper repair, again shredding all of the hydraulics and rendering the plane uncontrollable. It eventually bounced off the top of one mountain and impaled itself in the side of another.

I bet a slip of the tongue in communications; an assumption; a hasty and incorrect calculation; overtired staff; a failure to work together on a problem; a failure to triage the issues and avoid the fog of war have all played a part in avoidable medical disaster too, let alone the little things that are encountered every day which can easily and quickly end up as very big trouble such as Slavin outlined.

With heaps of respect for the hard work and the science I'd suggest that hospital staff focus on doing the foundational things well first.

I take this quite seriously. I have seen another person suffer (and intervened to prevent other issues) by way of several of the items pointed out on Slavin's list.

Attention to detail == quality == safety == patient confidence == good outcomes == staff pride.

If Slavin's list is boiled down I bet one will find that there are strong cultural roots that get in the way of improvement. I would single out Boston in this because it's my native land, but am certain that there's an element of it throughout our culture.

The DC-10 crew member left some words which I will never forget, and I believe would be well inscribed on every caregiver's brain: "Your attitude determines your altitude. If you think you can't, you won't".

Paul Levy said...

Lots to agree with there.

Please see my posting below, entitled "These Things Happen", for some similar themes.

(almost) dr. jess said...

in my limited experience with JCAHO, the Monday they visit is a surprise, but the cat is out of the bag pretty quickly. for the rest of the week, it seems that everyone in the hospital knows exactly where JCAHO is, and parts of the hospital come to a screaming halt or at least slow to a snail's pace.

what amazes me is how different things are when JCAHO is around. the general attitude of the staff is that JCAHO is a pain, and they can't wait until they leave so they can go back to doing things the way they were before. this attitude saddens me. in many ways a JCAHO visit can be educational as we are reminded of the rules we should be following; however, those lessons are quickly forgotten in an unmotivated workforce.

Anonymous said...

It is interesting that anon cites the aviation industry as analogous to that of health care , because that's precisely the analogy many in the health care field are making in order to bolster their pleas for performance improvement. I well remember the chair of my former hospital's Performance Improvement Council making the statement that, if the aviation industry performed as poorly as hospitals, there would be 250 major airplane crashes per year.
I hate to say it, but every issue mentioned in Slavin's memo is familiar to me as a former medical staff and PI Council member. They seem so simple but, it is true, they require a huge culture change for every staff member (to say nothing of physicians, we are the worst offenders) to comply.
A major reason is that most see documentation as taking up valuable time that could be used caring for patients instead, not seeing the big picture. (Handwashing I cannot defend in any way, but lack thereof is the #1 cause of hospital acquired infection, I think I am correct in saying.) I think training programs could do a lot to help with this cultural change. As Paul points out, strong leadership by the CEO (as well as the medical staff President) is also critical - not just lip service while JCAHO is around. I've seen a lot of the latter.

Paul Levy said...

I think the aviation field has some useful lessons, but it also does not provide all the answers. For example, we learned a lot from them in our team training efforts -- much of which derived from experience in hierarchical cockpits. See http://runningahospital.blogspot.com/2007/01/what-works-part-5.html.

But much of what happens in a hospital requires constant reinforcement for individual action in an unstructured and unsupervised setting. Tonight, I met a very fine doctor from another hospital who pointed out that handwashing with Calstat among the younger MDs (i.e., fellows) is automatic and embedded in their lives. For the older MDs, though, it was not part of their training. This 50-year-old MD remembered being a resident inserting central lines, without gloves and without handwashing.

So different approaches might be needed among different groups.

And, Dr. Jess, I understand what you mean. We really try at our place to approach things in a very different way. Maybe if you matched at the "right" hospital, you will see things done better!

Anonymous said...

I think the intent of the Joint Comission - to monitor hospitals and improve healthcare is noble. However in actuality, the standards they set are so far removed from the actual running of a hospital that they wind up being counterproductive at best and harmful at worst.

Take medication reconciliation for example: it sounds brilliant in theory. At every medical encounter, every patient should have a complete list of their medications recorded, and at the end of the encounter they should get back a new list of exactly what to take. Why is that not a great idea?

Because many patients don't know all of their medications and doses. If they have a podiatry appointment, they might not think to bring along the list of their heart medicines. If it was an urgent visit, maybe they didn't have time to bring the list.

Since the JC doesn't fund additional staff to collect this information, you will have an overtaxed clinical staff compiling the list as best they can with the resources they have. Then the patient will go home with an "official" list of their medications, that is most likely wrong.

Hospital-based electronic medical records alone can't solve this, since patients are often seen by doctors from different systems that can't share records.

If the JC wants to help improve care, their mandates should be linked to increased reimbursement to provide the resources to perform these tasks, and/or legislative changes and financial support to lower the barriers to electronic medical record sharing.

BC said...

When a patient acquires an infection (other than central line), I wonder how much analysis is done to try to determine the cause and what process improvements are needed to reduce future events. What happens if infection analyses point to a specific doctor, nurse or other provider as the cause of a disproportionate number of incidents? Are there adverse consequences or is it only the patient that suffers? If there are consequences for the provider(s), what are they?

Paul Levy said...

Dear BC,
Let me start with an incomplete answer, and then others can jump in:

Unlike the central line infections, where we know which individual or team inserted and maintained the catheters, other types of hospital-created infections can be harder to track.

So, on the specific question you ask, it is usually very difficult to monitor a specific doctor's or nurse's performance to the degree that you can attribute specific infections to that person. But there is usually sufficient oversight of medical staff to detect lower-then-expected clinical performance in general. I say "usually" because many provider-to-patient interactions occur in private.

Of course, an extreme safeguard of sorts is provided by noting the number and nature of malpractice claims against a provider. But that is unsatisfactory because these are usually well after the fact and also because there are relatively few cases ever pursued by patients and families and also because malpractice claims are often not justified.

David said...

Paul --

I hope that if we had to invent JCAHO, we'd create a better one than the current version.

As far as I can tell, JCAHO becomes focused on odd things and creates mandates without evidence that these mandates actually improve care.

My first experience with JCAHO at the BI was as a Fellow working in our outpatient clinic. We learned that patients who were in bathrooms had to have a way to alert providers if there was an emergency. Seems like a resonable enough requirement, but we were in a clinical space that did not have the standard emergency pull alarms in the bathrooms.

Not to worry. It turned out that it was sufficient for JCAHO for us to post a sign (in English) in the bathrooms that said "In case of emergency, shout for help" and up went the signs, handwritten on paper. I kid you not.

Then they decided that chairs in a back waiting area were a potential obstruction that could compromise safety (probably related to the clinic being attached to a hospital). This was despite a large area with plenty of room for movement of people and stretchers. At the time of every JCAHO audit, the chairs would be removed and patients forced to stand or else be kept far from their providers in a front waiting room. When the audit was over, the chairs were so clearly needed (and so clearly harmless) that they would be replaced.

Then JCAHO decided that the CLIA regulations meant that hospital clinics should not be allowed to perform certain tests, even though the actual regulations deal only with billing for those tests. As a result, residents no longer learn to perform Gram stains (still probably the best way to diagnose gonorrhea), urine microscopy, or many other simple tests. This action of JCAHO has clearly compromised both care and education.

More recently, JCAHO declared that "pain is the fifth vital sign" and must be routinely measured and recorded. Are there published data showing that this is an effective way to control pain in patients on an inpatient medical service? If not, how do they know this is really the right strategy?

And now they are focused on medication reconciliation. As another poster pointed out, this sounds good, but may distract from more important actions at a visit, or may frequently just not be possible. Again, is there published evidence that such medication reconciliation actually reduces patient medication errors or did the people at JCAHO just intuit that it was a good idea?

In most of medicine, we are pushing harder and harder for evidence based medicine -- demanding evidence and practicing according to that evidence whenever possible. As far as I can tell, though, JCAHO seems to act based on its own internal beliefs about benefit.

None of this is to suggest that hospitals are not filled with dangerous practices and behaviors. I completely favor external audits that focus on clear dangers and evidence-based solutions.

But if we do decide to invent JCAHO, let's invent one that makes demands of itself to look for evidence before it demands change of others.

Anonymous said...

Let's also invent a JCAHO that informs a patient/family of the findings of their investigations. They withhold data that could be life saving for other family members.

Anonymous said...

Paul! As saddened as I am to be defined in your group of "older MDs" (over 50) your 50-year-old MD who "remembers putting in central lines without gloves" needs a STAT psych consult! OF COURSE central lines were always put in with sterile gloves! (and by "always" I mean at least back to 1979 when I started training.) He's right that handwashing was not as emphasized and that CalStat didn't exist, but he's getting a little carried away. . .we did know about the germ theory, after all, and we did understand about transferring germs from patient to patient, although we thought about things like stethoscopes more than hands.

Anonymous said...

Jayco is in the process of auditing a clinic in Houston TX ( Continuum Healthcare LLC). I currently am employed there. There are many many issues existing at this PHP. We have several ex-felons employed there one is even a supervisor over the transportation Dept. Several elderly patients have took bone jarring falls. One was even picked up dusted off and carried to a waiting van and sent home. We should as tax paying citizens watch very closely how Jayco rules on this one. It seems as though no one else cares about these poor individuals. Let's see if Jayco allow these abusers to continue to fly under the radar.

Neutron Jerk said...

I've been reading some of your posts thanks to the Lean blogs that linked to you.

I'm floored that you say, above:

"I am never going to offer excuses for bad care or poor habits."

And then you go ahead and do just that. You offer excuses that you're complex and excuses that factories aren't perfect either. This is supposed to create a good impression about your hospital that you would write such things???

I could care less how busy or complex your environments are, as a patient. How much of that system complexity is of your own design (or lack of design)? I want you people to use safe practices 100% of the time if I'm coming into your hospital. The excuses don't seem to cut it, to this observer (and someone who has been in west coast hospitals, not Boston or yours).

Paul Levy said...

NJ,

Those are not excuses. They are descriptions of the problems. If you don't first identify them, you can't solve them.

you are right that, as a patient, you shouldn't care how complex the environment is. As a systems analyst, though, you sure had better care.

I clearly cannot convince you that we are trying to do exactly what you advocate. In fact, I think I am enhancing our likelihood of doing it by being transparent with our actual clinical results and putting ourselves on the line publicly.

Neutron Jerk said...

Without discussion of how you plan on fixing things), the list comes across as excuses. It really does. Seriously.

Definition -- Excuse: "excuse, overlook, or make allowances for; be lenient with; "excuse someone's behavior"; "She condoned her husband's occasional infidelities""

Unless you can report progress in:

1) improving the system so people can do "simpler" things compared to "highly complex"

2) not making people remember all of their tasks -- the book "To Err Is Human" (which yes, I've actually read) makes this a major point, to NOT force reliance on memory

3) improving the system so people are not "VERY, VERY BUSY"

those sound like excuses. You want us to view your hospital's less-than-perfect performance with lenient eyes because it's complex and you're working hard.

I'd respect your views more if you simply just said, "We're not perfect, that's not acceptable. But, we're human and we're doing everything we can to fix the problems."

Detroit is full of excuse making CEO's also.

I certainly wish you luck (and other hospitals) luck in your journey. Sorry for dumping on you. I do respect you for posting the critical comments (I did a google search on you and saw you wanted critical comments... so here you are).