Wednesday, November 19, 2008

At the Joint Commission

I'm currently in Chicago, having been invited to speak at the Joint Commission's annual conference on quality and safety, "Safety and Quality Solutions: Driving Sustained Improvements." My talk is about to follow that given by Mark Chassin, President of the Joint Commission (shown in picture). As I sit here waiting, I am summarizing what he is saying for those of you not in attendance. (Apologies in advance if I do not do a completely thorough or accurate job. Please excuse typographical errors, too, as it is tricky to listen, synthesize, and type at the same time.)

Mark described the environment within which the Joint Commission finds itself in the quality field and what kind of improvements are needed. "Despite our best efforts, we still have serious quality and safety problems in all of the domains we try to work in." In addition to the usual areas, there is a particular new focus on overuse, an essential problem to solve if the issue of affordability in the health care system is to be addressed.

But there are models of success, which serve as learning opportunities. Core measures have improved since their introduction in 2002. For example, the average for compliance with acute MI metrics (e.g., aspirin on arrival) is over 70%, with about 95 percent of hospitals having performance over 90% in two key metrics. So it is possible to have success in carrying out important metrics that lead to improved outcomes.

But the value of other metrics is problematic, in terms of achieving actual clinical results. For some, the measure we use doesn't really assess the process that we want to assess (e.g., smoking cessation counseling advice.) For some, the process that is assessed is far removed from the outcome we want to achieve (e.g., oxygenation of left ventricular function assessment). For some, the measure is susceptible to workarounds, more than encouraging the process we want have happen (e.g., heart failure discharge instructions). For some, measures lead to adverse effects (e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis).

"We should start withdrawing measures like this that are not excellent," that have these problems. But Medicare needs to do the same thing. It can't just be the Joint Commission's decision.

But let's look beyond the particular measures and find out "where's the beef" in real improvement so we can focus on the most important things. Unfortunately, there is a scarcity of evidence as to what those are, both in the hospital setting and other settings. As health care assimilates new drugs, devices, procedures, and equipment, "the goal posts keep moving" because of the increased complexity of the care system. And, in a time of scarce resources, we need to be cognizant that the Joint Commission itself influences how those resources of used. If we don't have the highest confidence that a measure is excellent, we shouldn't ask you do to it. "We have an obligation to maximize the health benefits of our measures and standards."

There has been a balance between the roles of the government and the private sector in overseeing quality in health care. Two related forces are affecting that balance: (1) bad things are happening even in Joint Commission accredited hospitals, and (2) routine safety process break down routinely and visibly. "Our public stakeholders are losing patient with us." Unless we get better at things, this will lead to a change in the balance between the government and private sector roles.

The expectation of our public stakeholders is that major adverse events, like wrong side surgeries, should diminish in frequency and be eliminated. If that does not happen, we should expect legislators to pass new laws. The nature of the legislative process is that new laws can often be heavy handed and not recognize the subtleties of these issues. Unfortunately, laws are not the best way to achieve the right results, but it is easy to see why they are passed.

So, how do we got a lot better quickly and document that improvement, to help maintain the appropriate balance between governmental supervision and private sector responsibilities? The first major barrier to this is lack of capacity in the health care system to execute robust process improvement. Secondly, we have not truly adopted a true safety culture.

We need to learn from other industries -- high reliability organizations -- and apply those lessons in the health care system. Those organizations have a commonality in their methods of achieving their excellent results. (My comment: See similar points by Steven Spear.) Mark quoted Karl Weick: "Safety is a dynamic non-event." Mark then went into details on this point, which I will not summarize, as regular readers have seen lots of this topic on this blog.

The Joint Commission wants to work with health care institutions to help them adopt these methods. But, he is also doing this to achieve internal improvements within the Joint Commission. He wants to improve its own customer service, to reduce costs, and to be more effective in carrying out its mission.

On the issue of safety culture, Mark noted that there are three imperatives of a safety culture: trust, improve, and report. On the trust point, the aim is not a blame-free culture, in that there is a difference between small errors (for learning) and egregious errors (for discipline, equitably applied). My note, please review this post for more on this topic.

Learning begins with reporting, especially near misses. "They are free lessons", an opportunity to fix a system before it breaks. A bureaucratic culture celebrates near misses rather than learning from them. High performance organizations react to near misses exactly the same way you would react to an adverse event.

Finally, on the Joint Commission itself, Mark cited improvements over the past five years, but firmly said, "We need to continue the aggressive improvement of our own processes." "We must increase confidence by pruning the measures that don't help, by focusing on and enhancing the ones that do," and by helping to provide useful process improvement tools to the the industry.


Bo... said...

Love this blog. Always wanted to know what the CEO was thinking....

Anonymous said...

I think the Joint Commission both has an impossible job and, even in that context, is not doing its job very well. Most of us within the system know that the entire system of delivery of health care to the patient must be radically transformed. Anyone working in health care can cite its numerous failings - lack of communication, excessive fragmentation, poor IT systems and/or clumsy use of those systems, lack of aligned goals between hospitals and physicians, on and on. Until the system of care is completely redesigned - and many have spoken and written about how that should be done - quality and safety problems are largely out of JC's control.
But second, I do not think they do their job very well. Concentrating on metrics instead of outcomes is one example. Having too infrequent inspections and lack of continuous monitoring is another. Quality of inspectors, at least from my experience with the physician inspectors, is yet another. Instead of tweaking incrementally at the margins, they need to sit down with enlightened CEO's like yourself, physicians who understand quality and safety (and this is a pretty small group), and a wide variety workers in the field and figure out how to redesign what they do and how they do it.
And that doesn't even address the quality and safety issues in the outpatient care system......
Pardon the rant, but time is getting short. We don't need Congress telling us how to improve care.

nonlocal MD

Anonymous said...

I think he was pretty honest about their good and bad points and would truly like to do as you say. Not easy.

Unknown said...

"For some, the measure is susceptible to workarounds, more than encouraging the process we want have happen (e.g., heart failure discharge instructions)."

This cracked my whole department up, because it's something we struggle to comply with and get angry because we know other hospitals skip the steps that we are extra thorough on.