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Accreditation agency chief prepares to shift into emeritus role

In January, O’Leary becomes president emeritus of the Oakbrook Terrace, IL-based accreditation, certification and performance measurement organization, handing off the baton to successor Mark Chassin, M.D. O’Leary, 70, an internist and hematologist, announced on May 31, 2006, his intention to retire at the end of 2007.

O’Leary’s contributions to improved quality and safety measures within healthcare facilities while leading the nation’s oldest and largest certification and standards-setting organization span 21 years. But he deflects any credit to his colleagues and peers, including staff members. Under O’Leary’s watch, The Joint Commission embarked on unannounced inspections and surveys, explored medical error prevention and emergency planning in the context of healthcare crises and promoted more interactivity between patients and clinicians as a safety improvement strategy. In addition, The Joint Commission shortened and simplified its brand name from the Joint Commission on Accreditation of Healthcare Organizations, effectively dropping the popular JCAHO acronym.

Healthcare Purchasing News Senior Editor Rick Dana Barlow recently spoke with O’Leary about his career highs and lows atop the accrediting agency as well as what’s next for quality and safety measures among healthcare facilities.

O’LEARY: You need to be careful not to take what I said out of context. And that was two years ago also. What I was trying to point out is that sometimes there are externalities that you don’t have any control over. The major cause of the shrinkage was the fallout from the Balanced Budget Amendment of 1997. A number of organizations that we accredited saw an immediate impact. We also saw before that and continuing after that the progressive consolidation of organizations where organizations didn’t go out of existence but two or three became one. For the purposes of our accounting, that’s a decrease. You can’t control those. I didn’t create the boom that got us up to 20,000 and I wasn’t the one who caused it to go down. My successor is one person who is not going to determine those things either.

We’ve had a strategy here for some time that’s built on a thesis that accreditation has to be of value for organizations that decide to seek it, and we do a whole variety of things to make it more valuable. That had much of the desired impact, and it varies across the field. In the hospital field a good example is that in all of the time I’ve been here, except for one year, we have had more hospitals seek accreditation than we have had hospitals leave. During that time we have lost 20 percent of our book of business. Now why is that? Closures and mergers. And hospitals were really not affected by the Balanced Budget Act Amendment itself. What we lost as a consequence of that and some of the environmental fragilities were largely home care and long-term care facilities. Those have now bottomed out and we’re pretty much flat so whatever is coming in looks the same as going out. But tomorrow’s another day. The environment may become more favorable or less favorable.

We have the Medicare Modification Amendment that requires durable medical equipment suppliers to be accredited. That’s potentially a boon for us and for other healthcare accreditors but there also seems to be an agenda at the government level to discourage durable medical equipment suppliers from qualifying for Medicare payment, and they’re making them jump through lots of hoops and they’re making the accreditors jump through lots of hoops, too, so I don’t know how we’re going to do in the end. I think we’ll see a net increase in accredited durable medical equipment suppliers. We’ll have a big chunk of that. But how big it’s going to be is hard to gauge.

We’ve been accrediting DME suppliers since 1988 and we’ve been accrediting ambulatory surgery centers since the 1970s and imaging centers we’ve done for a long time. We offer a full range of accreditation services across the mainstream healthcare delivery system. There are theoretically growth opportunities, but the question is what is going to be an incentive for these facilities to seek accreditation. In the long-term care field they are so tightly regulated by the state and the federal governments they don’t really, in their eyes, see a need for still another evaluation – even if it might be of some value to them. They just want to go do their work.

In the hospital field, we’re accrediting about 92 percent of what’s out there, and that accounts for probably 97 percent of all the inpatient beds. There are a certain number of small hospitals and there are some – I’ll say renegade – hospitals because we don’t accredit them, but there are some decent people who want to do their own thing. So there’s not a lot of growth opportunity there. There is maybe some growth opportunity among critical access hospitals where we’ve gotten a larger market share than I would have guessed, but these are small resource-poor organizations. I think if you look at the unaccredited [facilities] across all these fields you’re talking about small organizations and a lot of them buy the accreditation manual and try to meet the standards but stop short of seeking accreditation. They do what they can do.

He’s not going to be able to do that by himself. There is a whole set of strategies for demonstrating the value of accreditation. I don’t think he’d just go and tell them it’s important. You have to make it valuable to them. Those things are already in process. He’ll take that over and lead the organization in ways to elaborate that. We’re going to make a smooth handoff and he’ll go forward. I don’t think that either he or the board is envisioning radical changes to the whole field but new ideas.

First of all, we love competition. Not all organizations like competition, but frankly where we have had strong competitors to our programs is where we tended to do our best job. I don’t think we ever take anything for granted in terms of market share in any of these accreditation areas. Whatever you’ve done today you’re going to have to do something better tomorrow. That’s how people work at The Joint Commission, I feel.

We actually held a press conference in the mid 1990s urging the creation of more competitors of our hospital program. It didn’t happen, but we tried. It was in the midst of some expressions of concern by the American Hospital Association as
to whether we were doing our job. We thought we were doing fine. So we challenged them to create something else if they didn’t think we were doing our job. They didn’t, and we still did our jobs the best way that we could. But I think that there will be new accreditors in the hospital accreditation business, and we wish them well and will compete with them.

Well, I’ve certainly had a good time. I think that the original challenge was getting The Joint Commission on the map and making sure that it was centrally involved in public policy discussions and debates and issues related to quality and safety. I think it’s safe to say that we’ve succeeded in doing that. A lot of the challenge now is to manage the complexity of this environment because there are so many things going on in patient safety, quality management, accreditation, public reporting and public policy issues that affect us that we have to hustle to keep all of those bases covered effectively.

In any one of those arenas there are conflicting points of view, and because we are what I sometimes describe as an effecter – in other words, people have ideas on things that should be done but we’re supposed to do them – we get pressures from various points to do this or to do that and then there are others who would rather we not do something. We are constantly managing conflict and trying to reach syntheses that are acceptable to everybody – the public and the organizations that we accredit. Everybody’s got their own slice of the world and they want to be taken care of in that slice.

You’d have to ask him that.

This is an environment of constant change so change management and responding to an environment of change is necessary. It’s anticipating the environment and its speed and staying in front of issues. It’s been a challenge for us and it will be a continuing challenge for him and The Joint Commission. I think he’s able to meet the challenge. The only thing I did here was bring together an excellent staff, and that staff is still here. He will add a great deal to it.

I wouldn’t do anything differently. Basically, we have been and we will continue to be bold. People look for us to be the ones out on the cutting edge. If you do that you will make some mistakes, but I would say that if you’re not making mistakes you’re not being bold enough. Even those things that didn’t work out I don’t apologize for. I think they were important learning experiences for the healthcare field and for The Joint Commission.

I wouldn’t single out any one in particular.

Bringing a great staff together. That’s all I did. They did all the rest.

It’s all timing. We had just gone through the creation of the new accreditation process and one of the major goals entrusted to that process was to create the mindset in accredited organizations and the reality that accreditation is a continuous process. It’s not something that happens every three years. I think that really started to resonate with people, particularly in the hospital field, but it was more than that. Some said if that’s true why don’t you come anytime? So the recommendation to transition to unannounced surveys actually came from accredited organizations. That wouldn’t have happened five years before. It is timing. When we brought it to the board they basically approved it without much debate.

Because I don’t think that’s where people’s heads were. We implemented it at the beginning of 2006 and we have not had a single incident around unannounced surveys with a hospital. It’s been extremely smooth. People not only find it acceptable but they find it useful to them to be looked at as close to being unprepared because they should be doing and providing good care every day.

Our surveys represent just one variable. There are a lot of things going on in the environment. If you look at the number of requirements for improvement coming out of the typical hospital today under unannounced surveys vs. before we started them that number is up a little bit. But it may be up also because we have more national patient safety goals and requirements, and the surveyors are becoming more sophisticated in the survey process. So I don’t know whether that’s related to unannounced surveys or something else. But I think the level of acceptance of the unannounced surveys is important because the organizations are agreeing that they should be in compliance with the standards all of the time. That’s, to me, very telling in this regard.

If we didn’t exist we would be created because there’s always going to be a need for external or third-party oversight of healthcare organizations, just like there is for physicians. What the state does is minimal in that regard, so it should be something that’s a cut above. For organizations that’s called accreditation. For physicians that’s called board certification. This need for external validation is an inherent professional need and it’s a need of the public as well. The number of accrediting bodies over time has not gone down but has gone up. People keep creating them where they think there’s some additional need.

Well, they have that authority right now. It’s up to them whether they wish to enter into public sector or private sector relationships or set up partnerships. In most cases they’ve decided they like to do [partnerships]. The one instance where that has not happened is in long-term care, which has been kept tightly under the wraps of the federal and state governments, largely at the driving of AARP and the National Citizens Coalition for Nursing Home Reform. That just happens to be their opinion, and no one wants to take them on. The annual Government Accountability Office report castigates the government for the effectiveness of its oversight of nursing homes. The federal government and state governments do not have a good track record for executing quality oversight activities. That’s a matter of record. I think the conventional wisdom within the government and the private sector is that these public sector and private sector partnerships are a win-win situation for everybody.

Everybody is pretty cynical about CMS or even Congress for that matter because they just see them as bailing out of their support for healthcare. And any time policymakers cloak this in quality and patient safety people kind of roll their eyes, like give me a break. I think that has pretty limited value. I think you need a patient system that does not create disincentives to pursue safety and quality. That’s one of the problems that we have.

Our public policy makers probably do more things to make it hard for hospitals and physicians to focus on safety and quality. In simple terms if they would just get out of the way most people will do what you want them to do. Look at the design of pay-for-performance initiatives that are being piloted by CMS and the hundreds out there by the private sector. No one starts by asking what to me is the most obvious question and that is, if you’re talking to hospitals or doctors, what do you want them to do? No one has asked that question. Instead, they come up with convoluted schema about how they’re going to punish people, which is not going to get you where you want to go. Frankly, by many indications the level of interest by the Democrats at least in pay-for-performance is modest compared to the way the Republicans look at it.

That’s a fairly stupid idea. The basic problem is that almost everything we do in healthcare – for all of our care delivery processes, organizations just went out and did them. No one told them not to do it that way. There was no engineering competency when this was done. The design of care processes is really an art form. I think it is really only now starting to dawn on people that one of the major things that you have to bring into healthcare organizations is engineering competency. That generally means hiring systems engineers. If you look at a Mayo Clinic they’ve got a bunch of these people up there, but your typical hospital doesn’t have any.

We do no training of doctors, nurses, pharmacists or healthcare administrators in their basic professional training about systems thinking, care process redesign, human factors and communications, all of which we know as being fundamental. So what we need to do is fix our professional education system and we need to start leveraging the introduction of care process redesign competency into our organizations. That’s how you start fixing the problem. If you want to close everybody who’s making medical errors or take their accreditation away that will close everybody. Now where are we? It is really necessary to engage the brain before you make suggestions like that.

That is the DRA [Deficit Reduction Act] and some of the other stuff. That is the Congress’ version of pay-for-performance, and it has mandated a value-based purchasing program for hospitals by 2010. CMS is busy working on that. It’s not a hearty menu. It leaves a lot to be desired. This is going to be part of that philosophical debate between the Congress and between the Democrats and the Republicans as to whether there’s even going to be any follow-through on this.

I think what we’re seeing is that when you take these pay-for-performance or value-based purchasing programs and you get down into the weeds, [you’ll see] these are enormously complex. There is very little understanding about the critical importance of high-quality measures or metrics. If you don’t have good measures you’re dead. A lot of the programs out there right now are using measures that have not been validated, tested, shown to have any evidence-based [justifications]. To me, the level of understanding about what is needed if you’re going to go down this road is so lacking that it makes you feel helpless. Those scenarios that we’ve tended to see over time is that when this happens these things just die under their own weight before they even get off the ground. Maybe a miracle will happen this time.

We tell everybody that everybody has a role in making it better. Something as basic as process redesign – and supply chain management is a process – you just need to remember that however you’re doing things today there’s no good reason for it. Somebody just decided they were going to do it that way one day, so the opportunities for improving safety and quality are everywhere. You only need to start moving to become part of the solution.

Let’s get serious about what is or is not on the radar screen in healthcare for these guys. This is a healthcare coverage issue. This is about universal coverage, access to care and that’s the beginning and end of it. It’s started to [attract] a little bit of interest in quality measurements and there is a little bit of interest in comparative effectiveness. But patient safety is not on anybody’s screen, to my horror. It is amazing to me that in this country people accept the fact that when they go into a hospital or any healthcare setting it’s dangerous. No one seems to be bothered by that. But they should be because of things that they could do and things that should be done.

Measuring improvements in patient safety is itself very difficult. If you look at some of these measures being bandied about for patient safety, when you measure the impact of patient safety you are measuring that in terms of bad things that didn’t happen. It’s hard to measure. It doesn’t mean there are not ways you can work around it. We’re actually engaged in some of that work, but it is, like a lot of things, much more complicated than it seemed at the beginning.

We’ve actually been pretty heavily involved in this. Our Quality Check Web site is the most visited free report card site in the industry and one of the frustrations is keeping the information at a level that is comprehensible to your average person and keeping it modest enough in scope so that it is comprehensible because most of us can only keep track of so much data in our head at a particular point in time. I may think it is wonderful to put out 22 hospital measures or 65 HEDIS measures, but if you think somebody is using that to become an informed consumer that’s silly.

The other issue is that even if you are a genius or you can figure out a computer program to make you informed your leverage as an individual consumer is fairly modest. I hear purchasers complaining about their lack of leverage, so at most you’re going to be able to vote with your feet and make reasonably good choices, you hope. Having access to patient charges and pricing is kind of sexy, but no one knows what it means because patient charges do not equal costs. What the hospital gets paid is not what it charged. It is just a smoke-and-mirrors kind of thing that we’ve created in this country. Now we want to make it transparent. Well, okay, but good luck in interpreting what that means.

The interesting thing is that if you had eight hospitals in a community that are all doing the same procedure and they all have agreed on the way in which the charges for that procedure will be portrayed and they’re all over the map, the ones that are on the high end are probably going to start thinking about why they are high and whether they should fix that. Whether they will be smart enough to translate that into process redesign so the resulting internal savings will make it possible to have lower prices is anybody’s guess. I’d like to believe that’s going to happen but I don’t think most of them know how to do that.

We’ll at least be helping them develop that capability.