Wednesday, April 11, 2012

How to alter the flow of the Mississippi

A very thoughtful commenter on a post below, noting the slow pace of change in hospitals with regard to quality and safety improvement, said, 

For all the talk of disruption, isn't it time that we actually witnessed a little?

So, who will break this dam between knowledge and candor? It isn’t that we don’t know what to do. We just won’t do it. It will require: (1) a centralized, protected anonymous log of harm and near misses observed, experienced, and performed; (2) visual social penalties to the very highest (rather than next in line, middle or lowest) in the priesthood for poor reporting; and, (3) elevation of substantial contributions to institutional safety performance as requisite to all levels of physician and managerial promotion.

One of these would alter the flow of the Mississippi. Two would alter the tides. Three would be an entirely different universe of patient care.

These are excellent thoughts, and let me add a possible input into how these steps might be accomplished, a more rigorous accreditation process that included the elements above as part of the standard of hospital operations -- accompanied by unvarnished transparency in that accreditation process.  Elements of the first part exist, but need bold expansion and refinement.  The Joint Commission offers a framework of expert and peer review of hospitals as it conducts periodic surveys of institutions.  While many of the metrics used by The Joint Commission are based on archaic and misplaced CMS requirements imposed upon it, The JC has tried to do better than that over the years and has focused more and more on processes, procedures, and standards that make sense.  That transformation is not over, but at least the capability exists -- if the will is there -- to include items likes those mentioned by my commenter as part of the accreditation requirements.

But the Joint Commission fails mightily on the issue of transparency, both in its actions and in its role as advocate for quality improvement.  In terms of actions, I have been and remain highly critical of The Joint Commission's failure to make widely available its library of best practices -- and of CMS' failure to force this to occur.  These are stories of quality and safety successes from the nation's hospital's, accumulated by The Joint Commission during its survey activities.  Those survey activities are carried out in its role as a designated agency of CMS.  In essence, they result from a public function.  Yet, the Joint Commission persists in holding those useful stories close to the vest, precluding their view by thousands of clinicians and administrators throughout the country, and also from patients and families who might want to engage in collaboration --or activism -- with hospitals to encourage adoption of these best practices.

A recent position taken by The Joint Commission is even more reflective of a terrible misunderstanding of the role of transparency in nudging along quality and safety improvements.  Last September, I reported on an effort by Dr. Kevin T. Kavanagh and many others to change the federal law to make public the content of accreditation surveys.  This was opposed by The Joint Commission.  As explained in a letter to Kevin, President Mark Chassin said: 

I would like to point out that there is no prohibition on hospitals releasing Joint Commission accreditation reports to whomever they decide is appropriate. Nonetheless, The Joint Commission does not itself provide survey reports directly to the public for the critical reason that we want to maintain an open and honest dialogue with hospitals in the various stages of review over survey findings.  Under our relatively new process, hospitals which are found to be out of compliance with accreditation requirements that rise to the level of an accreditation citation must generally come back into compliance within 45 days of the end of the survey or they will start moving down a path toward non-accreditation.  During this time, The Joint Commission works with hospitals to ensure an appropriate plan of correction and enters into dialogue with the hospitals over the nature and scope of the cited areas. We believe strongly that this ability to engage hospital leadership in the early stages of review should be protected and kept confidential.  By establishing a safe environment for give and take, we promote the attainment of higher levels of quality improvement and faster resolution of any deficiencies found at the time of survey. This philosophy of having a protected dialogue is consonant with similar arguments made by many diverse stakeholders, including some consumer advocates, that there should be a safe environment for health care organizations to report and vet issues about adverse events.  In fact, this broadly held concept led to the enactment of the Patient Safety Organization Act of 2005 which encourages protected reporting of patient safety events.

The Joint Commission is not subject to the Freedom of Information Act (FOIA) because the Act does not apply to non-governmental agencies. We do not support opening the FOIA to accrediting bodies simply because their evaluations are recognized by the government. A critical difference exists between the roles of a governmental body only performing certification activities and an accrediting organization which also seeks to help organizations succeed in achieving compliance with ever increasing levels of quality for the services and care they deliver. To that end, The Joint Commission has many additional standards, safety goals, and requirements beyond those of CMS. But most importantly, such a change to FOIA could have very broad implications well beyond accrediting bodies. 

Dr. Chassin unfortunately misses the point.  He confuses (appropriate) peer review protections for adverse events with (inappropriate) secrecy concerning accreditation results.  He obfuscates by focusing on release of interim survey findings compared with release of final findings.

Further, relying on FOIA as an argument misses the point that the proposed bill would allow the Department of Health and Human Services to release the survey results.   As Kevin noted to me, "This requires repeal of a portion of the social security act.  Also, we asked for modification of the Freedom of Information act to allow TJC (and other accrediting agencies) as a Governmental contractor to be subject to it."

Dr. Chassin's use of existing law to argue against a change in existing law reminds me of a true story from my days in Arkansas, when the Legislature was considering a bill to establish a state lottery.  One legislator pronounced that he was against the proposition because "gambling is illegal in Arkansas."


Joel said...

Caregivers see the world through self-interested filters that prevent them from seeing most of what should be reported. Even when they do something terribly wrong, most of the time they find ways to believe that they didn't. The proposals to increase reporting invariably are oblivious to this core problem. When nothing is seen as being wrong, nothing is seen as needing to be reported.

All of the proposals trying to increase reporting imagine that the people on the front line are selfless and objective. They are neither. They are brokers with vested interests who see the world through self-interested lenses. Honest information never can be collected by them.

Fortunately, for sources for the information, they are not the only choice. Unfortunately, they are the only ones being chosen.

e-Patient Dave said...

How distressingly familiar: "We don't have to tell you what we're doing - we don't have to show ANYONE - but it's good."

Totally reminds me of the hospitals in certain regions that have dominant market position but refuse to disclose their quality and safety statistics: "We don't have to tell you, and you can't make us. But it's good."

I might point out that this reminds me of the Detroit executives who told Congress decades ago that they were making the safest, highest quality car possible. "Trust us - this is our industry - we know." Then Japan came along.

Leah Binder said...

Bravo! People entrust their lives and treasure in hospitals and transparency is the least they should expect in return.

But I like Dr. Chassin's challenge in the meantime. Perhaps we should ask hospitals to voluntarily release their acceditation findings. Leapfrog could ask that on our survey....

Anonymous said...

Being a patient advocate for a patient who received multiple HAI's
and was not told nor treated and the Health & Senior Serv. dept. responding that this is standard medical treatment, our family feels that the Law needs to respond to this medical matter which is med. abuse. Priests abused children for years and the law stepped in because the Catholic church could not police themselves which is no different for hospitals. Jail time for doctors or administrators should be the medication used and then they would comply and clean up.