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Process improvement, management will see more emphasis

The former executive vice president for excellence in patient care, and professor of health policy and chairman of the Department of Health Policy at Mount Sinai School of Medicine became the new president of The Joint Commission, effective January 1.

During the announcement of his appointment back in early August by the Oakbrook Terrace, IL-based accreditation, certification and performance measurement organization, Chassin was understandably vague about his plans. Instead, he spent much of the brief media teleconference commending Dennis O’Leary, M.D., his now immediate predecessor who serves as president emeritus, and diplomatically scolding the healthcare industry about its lackluster efforts to take safety and quality issues seriously and implementing process change.

Despite the lack of details Chassin did give the industry a glimpse into his philosophy and thinking, foreshadowing where he planned to lead The Joint Commission in 2008 and beyond.

Following an extensive interview with Chassin’s outgoing predecessor Dennis O’Leary, M.D. (published in the November 2007 edition of Healthcare Purchasing News), HPN Senior Editor Rick Dana Barlow spoke at length with Chassin about his latest career move, what his near-term plans are for the agency and what really matters for quality and safety measures among healthcare facilities.

There’s voluntary and there’s ‘voluntary.’ It is voluntary, and particularly choosing an accreditor is voluntary. There are different incentives and different segments of the industry. In the hospital industry Medicare, in order to certify that you are okay to be paid, requires that the demonstration be made that you as a hospital are functioning in concert with its conditions of participation. In effect, every hospital and every nursing home, and in different circumstances every home health agency, has to demonstrate that they are performing in accordance with state licensure regulations and public payment program regulations. The most convenient way to very often do that is through an accreditation process. So there’s voluntary and there’s ‘voluntary.’

There are strong incentives for these institutions to have some outside body certify that they are functioning in accordance with the rules of public payment and licensure programs. In effect, certainly for hospitals, some form of accreditation is as close to mandatory as you could probably get without trying to create a national licensing scheme, which would never happen because it runs afoul of all the processes that have been reserved for the states over many, many years.

I’m not going to characterize any of the other organizations that are out there because frankly I don’t know them well enough to comment in a comparative way. But I think that it’s critically important for The Joint Commission to continue its improvement processes. I’ve been very impressed over the last five years or so with the dramatic and substantial improvement that The Joint Commission has put the accreditation process through and brought the industry, particularly the hospital industry, along. In fact, it’s one of the major reasons I decided that this was a job I was really interested in. I think we always have to keep in the front of our thinking how we can improve safety and quality much more rapidly. The organization can’t rest on those laurels because the safety and quality targets are moving targets. That’s what makes this [so important], particularly in hospitals, which I focus on because that’s where the majority of the risk issues are and where our sickest and most vulnerable patients are, and the greatest hazards to safety and quality are there.

It’s a moving target because we are constantly adding more and more into the system. There are new drugs, new devices, new procedures, new tests, and new processes. In addition, all of the other hazards we deal with in hospitals – like diseases that kill people, new bugs and old bugs with new characteristics that kill people at increasing rates – are also changing. So this is a constantly changing environment and changing in only one direction, which is to increase risk and hazard. The procedures we have in place to manage those risks and hazards need to continually evolve.

I think The Joint Commission has done an incredibly good job in recent years keeping pace with this change. But that’s what it did in recent years. We need to keep that momentum going if we’re really going to get the kind of major and substantial improvements that I think we have to have in safety and quality.

I wouldn’t put so much emphasis on the word ‘discretionary.’ For hospitals, some sort of activity in this area is very close to mandatory. But there are a number of different vendors that provide these services that hospitals can choose from. They may be tempted to try to get the costs down and find a cheaper one. I believe that The Joint Commission needs to add focus on accelerating the rate at which we learn from other organizations in our society that deal with similar kinds of levels of risk, but have figured out how to manage the rate of adverse events to much lower levels than healthcare organizations have.

I’m talking about what are called ‘high-reliability organizations’ – for example, nuclear power plants, aircraft carrier flight decks and chemical factories. We have begun to scratch the surface of the kinds of ways in which those organizations pursue safety and quality, and how that might be translated to healthcare. But we need to make those lessons much more practical and disseminate them much more rapidly within healthcare than we have so far. There are some places that have gotten a little bit of a lead in this area. We need to learn from them. And I think that in addition to accreditation that’s an area in which The Joint Commission can be a leader.

I really can’t comment on whether it should have been done sooner or not. If you look at the last several years and the dramatic improvements that The Joint Commission has introduced into the hospital accreditation survey process, the unannounced survey component is the latest, and perhaps the most dramatic, and essential component.

The other elements of the change were also important and probably needed to be done first. For example, [I’m referring to] the explicit setting of National Patient Safety Goals that transcend the specific and highly detailed standards or elements of performance that are in the hospital accreditation program. The reason that that’s important is that they appropriately focus the attention of the institution on a subset of processes that are particularly critical to producing high levels of safety and quality. We’re going to hold you accountable for demonstrating that you do especially well on these, in addition to complying with all of the other standards.

That shift toward an emphasis on the most key processes with respect to safety and quality was a very important step that started this ball rolling and made the ultimate aim of aligning the accreditation process with easily communicated goals for safety and quality – both to the industry and to the public.

The other important innovation, which I think was much more difficult to pull off, was the change in the way that the survey process is actually conducted, which preceded the unannounced scheduling change. That was the change to this tracer methodology approach.

When I was health commissioner in New York, prior to coming to Mt. Sinai, my predecessor as health commissioner had basically said, ‘we’re not going to accept Joint Commission accreditation for purposes of state licensure because we don’t think it’s a very effective process.’ He created within the Health Department, which had a big inspection unit, a formal survey and certification program [that] he substituted for The Joint Commission. To the hospitals he said, ‘if you want to do Joint Commission, that’s fine, but it’s not going to count for state licensure.’ I saw no reason to change that policy when I became commissioner.

One of the reasons is that the old way hospital surveys were conducted was by having the surveyors scheduled in advance. Then when they got there what they spent most of their time doing was sitting in a big conference room poring over big loose-leaf notebooks that were put together by the hospital staff in advance [containing] things like policies, procedures, committee minutes, and hearing a series of canned presentations that everybody polished assiduously weeks before about how great everything was. They did make some forays out into the world of patient care, but they were very few and far between.

But that’s completely different now with the tracer methodology. Actually having the surveyors spend most of their time on the floors talking to patients, reviewing actual live medical records, talking to nurses, talking to physical therapists, transporters, housekeepers, and tracing what happened to those patients from start to finish was an earthquake – a 9.9-on-the-Richter-scale earthquake in hospitals. Those changes were at least equally important; maybe more important, but certainly equally important.

Making the surveys unannounced has really added another dimension to this whole process. The main effect of this change is not so much to surprise the institution but to create a completely different expectation about what the aim of this survey process is. The aim of the survey process is not to create a test or a hurdle that the institution has to jump over. It now is to create a guide so that institutions can understand how close they are to being a high-quality institution and to be continuously preparing themselves for a survey that might happen any day. That is what the unannounced component did, but the preceding steps that led from a very structured, paper-based process to a much more organic, patient care-focused process were equally important in getting the survey process to where it is now.

I think that they’ve been very, very effective. An interesting problem arises when you then ask the next question, which is, ‘well, how do you know?’ One of the things I’ve done over the years is a lot of research that uses really rigorous, state-of-the-art evaluation methodologies. But you can’t ever apply those research-type methodologies in these kinds of real-world settings. Nobody is going to do a randomized controlled experiment in which different kinds of accreditation processes are randomly assigned to different kinds of institutions and try to figure out which one works best. [Laughter] This is the kind of thing that real-world managers face every day. How do you know what works and how do you know what doesn’t work? You build and extrapolate from really good evidence and apply good common sense management approaches. Then you have some metrics that guide you to see that the things that you hoped would happen really are happening.

Another Joint Commission innovation, in addition to National Patient Safety Goals, tracers and unannounced surveys, is the development of core measures, which are highly evidenced-based measures, typically of processes of care that we also want hospitals and nursing homes to focus their scarce quality improvement resources on. Because we have such good evidence from good research, if we do these processes well patients’ outcomes will improve. That’s what the core measures are about. When we see national data that much higher proportions of appropriate patients with heart attacks are receiving aspirin, beta blockers and ACE inhibitors, we know that The Joint Commission’s core measure initiative is having positive results that can be measured in improved health outcomes. Now Medicare, of course, has picked it up, and private payers have picked it up. But that whole movement was created by The Joint Commission.

Hospitals, in particular, have gotten the message that safety and quality have to improve. Nursing homes are just beginning. There are several barriers to making that happen even more rapidly and more effectively than we’ve seen so far.

One of those is the capacity that I’ve already talked about for robust and sustainable process improvement. The other is that I think we’ve reached the stage in this quest where it would be beneficial to take a broad look at all of the demands that are being placed on the industry, particularly hospitals, and consider pruning some of the ones that may not be as strongly evidence-based as some of the others.

I’m acutely sensitive to the fact that hospitals have very scarce resources for focusing on quality improvement and on process improvement. It is incumbent on all of the organizations that have responsibility for directing that effort in the industry to make sure that the demands that we place really have the greatest likelihood of producing better patient outcomes. If we don’t have a really high assurance that that’s going to occur, then we ought to think twice and three times about making that demand because it runs the risk of distracting effective resources from being deployed in more productive ways. I think we are at that stage and I know The Joint Commission has a standards improvement initiative underway with that as one of its goals. I think all of the organizations with similar responsibilities should address the issue.

If we were to put out of business every hospital in which any error occurred there would be no place to receive care anywhere in the world. If that’s the question, then the answer is no, that’s not a good idea. Mistakes happen every day in every hospital all across the world. Not all of them reach patients, not all of them do harm. Just like they occur in every supermarket, in every barber shop, in every walk of life. Eliminating errors and punishing people for making them is not the way to improve. Some errors deserve discipline, and those need to be punished, but the vast majority do not.