Monday, October 04, 2010

Joint Commission report

Representatives from the Joint Commission visited us last week for their periodic survey. I post below today's email from me to our staff. As noted, the actual report is available for all to see. We view that as an essential way to make sure all people here can benefit from this appraisal of our clinical quality.

Beyond the report and the email below, I want to mention an important item for your consideration. Many readers here will recall our dedication to transparency about a wrong-side surgery event several years ago. With full staff participation, we then devised a new pre-surgical protocol.

During this survey, this protocol was viewed in actual surgical settings by one of the surveyors, who said, "That is the finest time-out I’ve ever seen." The JC surveyors said they would recommend it as a "best practice" to be shared with other hospitals throughout the country.

I view this as yet another validation of the use of transparency to help obtain process improvement.

Here's the email:


As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients.

As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. There were six surveyors who spent a total of 24 surveyors days with us. In all, they talked with almost 300 of our staff members and visited 49 unique sites on and off campus.

They found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular.

My favorite quotes from them during the week were, “The team is impressive – it’s a privilege to be a witness to the care being provided;” and "They are completely committed to what they do -- inspirational."

Consistent with our practice, we want you to have the advantage of their work product, so we have posted it on our website. Please read it.

With gratitude and appreciation,



Anonymous said...

If I am understanding it correctly, I would take exception to the deficiency regarding the lack of measurement of time of receipt on unit of critical lab values to report of these values to a licensed practitioner. Instead you were measuring time of receipt on unit to time of intervention by the practitioner - a clinically more significant measurement! (Although, do you document a justified non-intervention?) It also encompasses the standard, even if it is not 'direct measurement.' Here's a case of insistence of following the letter of the rule rather than its spirit.

Measuring the time till it's reported to the doc but then not measuring how long it took him/her to do something about it, leaves room for undetected patient harm.

nonlocal MD

Anonymous said...

13 Focus Areas covering 270 standards and nearly 2000 elements of performance were observed during our JC survey. Of these, 1979 were found to be in compliance if not best practice.

I imagine each item of the 270 standards has a history that resulted in its inclusion. As you suggest, there are some things that have a greater or lesser affect on patients.

Anonymous said...

Since you raise the question of historical inclusion, I submit that the standard mandates measurement of time of reporting to a licensed practitioner because that is easier to measure than the way you are doing it. It would appear you have found a way to surpass the standard (perhaps by being an AMC with house staff, and a great IT system), but are being punished for it - a sign of an inflexible system.


David said...

Hi Paul - I just wanted to say I think it's great that we share this report with everyone in medical center.

I joined here about six months ago from another Boston hospital, and they did not do this.

Anonymous said...

"During the review of a medical record of patient care in the emergency department it was noted that the patient was
medicated for menstrual cramps. It was noted that the reassessment of the patients pain level was not documented
according to the policy and the nursing practice guidelines"

*head explodes*
Just reading this document makes my blood pressure go through the roof. The last time the JCAHO idiots rolled through I consistently saw patient care worsen as every bean counter ran around the hospital harassing nurses about having coffee on an impatient ward or whether their re-re-re-re-assessment of a patient before a procedure had been adequately timed. JCAHO literally represents everything that is wrong with American medicine: authoritarian, top down, totally indifferent to cost or time efficiency and above all: fixated on irrelevancies and PAPERWORK. I need to go take some valium.

Engineer on Medicare said...

I'm sure the emphasis of the Joint Commission on the important things will be of enormous value in increasing patient safety. At this very moment every administrator who reads your Blog will have a Fire Safety Engineer going around with a gauge to verify that the space between the edge of the closed fire doors and the frame does not exceed 1/8" by as much as 0.001".

Anonymous said...

Dear Engineer,

I don't think that is quite fair. Beyond the fact that each of the standards has some historical reason for inclusion, we found the surveyors themselves to be extremely well informed and helpful.

It is easy to pick holes in the methodology they must follow if you take the whole thing out of context. As i have said before, if the JC didn't exist, we would want to invent it.

Anonymous said...


I didn't intend to contribute to turning the post into a referendum on the competency of the Joint Commission, rather than a case study of the benefits of transparency.
I agree with you that the JC is necessary,simply because many hospitals, unfortunately, would not meet even inferior standards were that not mandated. Certainly we do not want to wait to check fire doors until a fire, and mandating assessment of pain levels no doubt got in there because pain levels were being ignored.

However, I think the JC can accept feedback on their standards in the same spirit.