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MBA 590 Patient Safety and Accreditation

Professor Matt Spurgeon

Summer 2020

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Today’s Agenda

 Introduction to the Course

 Looking back at the history of patient safety and the evolution of accreditation

 The current state of quality

 Overview of Joint Commission International

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Let’s look back about 170 years…

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Early Signals: 1846

 Ignaz Semmelweis OB, Maternity Clinic Vienna – discovered hand washing reduces “childbed fever”

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Medical Education

 American Medical Association established in 1847 – Tougher standards for medical education

 Abraham Flexner – 1910 The Flexner Report: – Dramatic changes to medical education in the U.S.

and Canada

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Early Signals: 1854

 Florence Nightingale: Crimean War, Barrack Hospital, Istanbul; – Hand washing, sanitize surgical tools, change linen

– Mortality went from 60% to 1%

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The Plague of 1910

 Fall 1910: epidemic breaks out in a small town and quickly spreads to Harbin.

 Four months later, 60,000 people are lost.

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Dr. Wu Lien-Teh (Goh Lean Tuck in Hokkien transliteration)

 First Chinese doctor nominated for Nobel Prize in Medicine

 China’s Chief Medical Officer

 Rushes to Harbin

 Performs the first postmortem exam in China on a Japanese woman who died from the epidemic.

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Dr. Wu Lien-Teh

 Discovered that the epidemic was the pneumonic plague— transmitted by breath or sputum.

 The scientific community largely dismissed this finding.

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The First Surgical Mask

 Dr. Wu invented the first simple surgical mask.

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Dr. Girard Mesny

 Girard Mesny, prominent French doctor with experience fighting bubonic plague in India, arrived just after Dr. Wu.

 Disputed Wu’s initial findings, with racial undertones.

 Mesny believed that the illness was transmitted through flea bites.

 Rejected Dr. Wu’s advice. Refused to wear a mask.

 Mesny contracted the disease and died in January 1911.

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Actions Are Taken…..

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….And Social Behaviors Change…

Woman: “Dear, why are you wearing a face mask today? Is it for epidemic prevention?” Man: “No! It’s for preventing your constant kisses.” Found in “Manhua Jie漫画界” magazine, published in 1936. From Shanghai Library

During the 1918 flu pandemic, a streetcar conductor in Seattle refuses a person who attempts to board without wearing a mask.

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…For a time.

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 Surgeon, 1869-1940

 Proposed the “end result” theory for evaluating surgeon competence (1910):

"Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.”

Dr. Ernest Amory Codman

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The First Hospital Standards

 1910 - Dr. Codman creates the “End Result System of Hospitalization Standardization”, a 3 Step Approach: 1. Determine if it is a patient,

hospital system or physician problem

2. Quantify the quality issue

3. Determine a means to prevent in the future

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Dr. Ernest Amory Codman

 Started his own hospital based

upon this theory  This theory underpins all modern healthcare risk reduction  The theory became the stated objective of the new American College of Surgeons-a founding member of TJC.

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American College of Surgeons

 1912: American College of Surgeons formed

 1917: American College of Surgeons develops a set of minimum standards for hospitals based on the work of Codman

 1918: American College of Surgeons uses standards to inspect 692 hospitals, only 89 passed the inspection

 They burned the report!

 1950: 3,200 hospitals approved

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The Next Three Decades

 1921 U.S. Congress enacts Sheppard-Towner Act proving funds for maternity and child health

 1935 Social Security Act includes funds for pediatric primary care in underserved areas

 1946 Hill-Burton Act capital financing to build hospitals

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Joint Commission of Hospitals (JCAH)

 1951 JCAH is formed with “corporate members”

 American College of Surgeons, American College of Physicians, American Hospital Association, American Medical and he Canadian Medical Association Association, were the founding corporate members to create JCAH

 1959: The Canadians depart

 1979: American Dental Association was added

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Donabedian

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Avedis Donabedian

 1966: Evaluating the Quality of Medical Care

 Proposes a three elements required for quality

 Major impact on the Joint Commission’s standards

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Donabedian’s Structure/Process/Outcome Model

Donabedian's Structure, Process, Outcome Model Definitions

and examples adopted from (Kurowski and Shaughnessy 1982)

Structure The capacity of the

provider to respond to patient needs

Process Activities performed to

meet patient needs

Outcomes Observed consequences

of provider activities. Changes in the physical, functional, and psycho-

social status of the patient

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Other Influencers

 1945: Deming and Juran – Early quality improvement work in industry; Toyota

 1970: Institute of Medicine is founded – 1999 To Err is Human: Building a Safer Health

System

– 2001 Crossing the Chasm: A New Health System for the 21st Century

 1979 Joint Commission moves away from audit to systemic process approach

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Joint Commission History, cont’d

 1986: Joint Commission Resources established

 1987: JCAH changes name to Joint Commission on Accreditation of Healthcare Organizations

 1987: Agenda for Change, to emphasize actual organization performance

 1994: First organization-specific performance reports released to US public

 1994: Joint Commission launches new survey process that uses system wide, cross-department orientation

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Lucien Leape Influence

 1991: NEJM article highlights that adverse events occur in nearly 4% of hospitalizations, with 14% being fatal –

 1994: JAMA article looks at systems based approach to addressing errors in medicine

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Joint Commission History, cont’d

 1994: Joint Commission International is formed to accredit health care providers around the globe

 1996: Sentinel Event Policy is established in response to 1991 New England Journal of Medicine article on adverse events in accredited hospitals

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Joint Commission History, cont’d

 1997: Joint Commission integrates the use of outcomes and other performance measures into accreditation process

 1998: Sentinel Event Policy revised to encourage self reporting of errors and root cause analyses

 1999: JCI publishes First Edition of the International Hospital Accreditation Standards and accredits first hospital

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Joint Commission History, cont’d

 1999: Institute of Medicine releases To Err is Human, which details number and severity of medical errors in hospitals – report places spotlight on patient safety

 1999: First JCI hospital accredited – Albert Einstein Hospital, San Paulo, Brazil

 2003: Joint Commission launches first National Patient Safety Goals

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Joint Commission History, cont’d

 2004: JCI opens first international branch office

 2004: Joint Commission launches Shared Visions-New Pathways to focus on care processes and organizational systems critical to safety and quality of patient care

 2006: Joint Commission begins conducting unannounced onsite surveys

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Joint Commission History, cont’d

 2006: JCI launches tracer methodology in onsite surveys in which surveyors trace a patient’s care experience through a hospital and also trace key clinical and managerial systems and processes

 2007: JCI first accredited by ISQua

 2009: Joint Commission launches The Center for Transforming Healthcare

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Joint Commission History, cont’d

 2011 – JCI launches first set of International Patient Safety Goals

 2016 –Joint Commission launches Project REFRESH, transformative approach for identifying and communicating risk levels of deficiencies identified during surveys

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Looking Forward

 Accreditation is a very strong foundation

 Things would be much worse without it

 Current new work at the Joint Commission Enterprise: – GETTING TO ZERO HARM

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The State of Quality and Patient Safety

 Routine safety processes fail routinely – Hand hygiene

– Medication administration

– Patient identification

– Communication in transitions of care

 Uncommon, preventable adverse events – Surgery on wrong patient or body part

– Fires in ORs, retained foreign objects

– Infant abductions, inpatient suicides

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3000 patients over 6 years

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Patient Safety Data

 Up to 98,000 patients die annually in hospitals due to medical errors (likely higher)

 Adverse medication events cause more than 770,000 injuries and deaths each year at a cost as high as $5.6 billion annually

 An estimated $19.5 billion dollars in health care costs are attributable to medical errors (2008 estimate)

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How Does Healthcare Compare?

Aviation

1 : 1 million

Healthcare

1 : 300

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Good News

 Barcoding has been shown to reduce

medication administration errors (Poon et al. 2010)

 Team training in surgery has been shown to reduce mortality by 50% compared with control sites (Neily et al. 2010).

 A handoff communications process reduced medical errors by 23% and preventable adverse events by 30% (both P<0.001) (Starmer et al. 2014).

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Recent Data from AHRQ

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Patients Awareness in China

 Study Jan. 2009-Dec. 2010; 1,000 surveys distributed, 96% response rate

 58% not aware of what a medical error is

 65% wanted full disclosure

 187 experienced an error; 83% legal action

 52% understood hospital infection but 28% not aware infection could occur in hospitals

 Only 14% knew the side effects of their medications

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To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services.

Mission of Joint Commission International

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The Joint Commission Enterprise

Transforming patient safety and quality of

care

• Leading accrediting body for health care institutions in the US

• Founded in 1951 • >20,000 accredited institutions

The Joint Commission

Joint Commission International (JCI)

• JCI is the international arm of the Joint Commission • Improving the quality and safety of patient care and

achieve peak performance in the international community • Work with health care orgs, NGOs, and governments • 900+ JCI accredited organizations • Offices in Chicago area, Dubai, and Singapore, with a joint

venture in China

• Non-profit affiliate of TJC • US Accreditation assistance • Quality and safety innovations • Founded in 1986

Joint Commission Resources (JCR)

• Helps develop adaptable and robust improvement practices for healthcare’s most persistent problems.

The Center for Transforming Healthcare

JCI Accredited Hospitals

1,000-plus organizations spread throughout the world.

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4 1 10

JCIA Accreditation and Certifications (1 July 2019)

CCPC = Certifications

JCIA - China

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JCI Joint Venture in China

 JCI-CRHG Academy of Hospital Management – See more on WeChat

 Our publisher, education and consultant services partner

 Partner is China Resources Health Group

 JCI accreditation in not part of the JV – New Beijing office handles accreditation

– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes.

Accreditation – A Definition

– Usually a voluntary process– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions

– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards

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What is Accreditation?

 At its best, accreditation involves two closely integrated processes: – Evidence-based requirements that increase the

likelihood of improved health outcomes for patients

– Effective methods to evaluate how well individual organizations are complying with the requirements

 The Joint Commission has conducted and improved these processes for 60+ years

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What Accreditation is Not

 Accreditation is not a guarantee that:

– No errors will occur

– Preventable adverse events will never harm patients

– High quality care will always be delivered to every patient

 Accreditation is not a panacea that can solve all our quality problems

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Core Strengths

1. Create “optimally achievable” safety and quality standards

2. Continuously update standards to reflect changing science and practice

3. Develop and deploy most effective methods for onsite evaluation

4. Apply highly effective process improvement to create, disseminate interventions to solve quality problems

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JCI Standards

 JCI standards are rooted in what we know about what characterizes organizations with excellent quality programs and results

 Leadership is vital to all aspects of quality

 Standards assign accountability for quality and safety to highest levels of leadership – Governing body, management, MDs, RNs

– Program, resources, improvement agenda

– Reporting, communication, safety culture

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Development Process for 7th Edition

 International Standards Advisory Panel, stakeholders

- What new practices in health care need to be addressed?

- What standards need clarification?

- Are there issues to be addressed for which there are no standards?

- Standards that could/should be eliminated

 Field reviews conducted on proposed standards

 Final approval by JCR Accreditation Committee and JCR Board of Directors