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The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is getting mostly positive reviews on its recently approved standards focused on patient safety and medical error reduction in hospitals. But experts warn that integrating these new standards into existing safety protocols will be no easy task.
The new standards augment the nearly 50% of current Joint Commission standards related to patient safety. Requirements for establishing ongoing patient safety programs in organizations accredited under the Comprehensive Accreditation Manual for Hospitals will be added in the areas of leadership, management of information, and other functions. The anticipated implementation date for the standards is July 2001.
Michael Millenson, a principal with William J. Mercer, a consulting firm in Chicago, compares JCAHO’s action to a politician chasing an issue. But he says that is a positive development, not a negative one. "The Joint Commission helps to validate the patient safety movement and give it stature, and for that reason, it is very important," he explains. "Nevertheless, they are validating the patient safety movement rather than leading it." In fact, Millenson argues that there is no technological reason that everything included in the new standards couldn’t have been accomplished a decade ago.
"What this represents is another step in how the leadership of the health care field has started to react to public pressure to take meaningful steps to improve patient safety," he adds. "That should signal hospitals that this isn’t going to go away, and for that reason, I think it is very important."
Sally Trombly is director of regulatory services for the Risk Management Foundation of the Harvard Medical Institutions, in Cambridge, MA, and chair of the 2001 advocacy task force for the American Society for Healthcare Risk Management of the American Hospital Association. She credits the Joint Commission with taking much of the advice of outside parties who commented on the draft standards even though JCAHO and other regulators sometimes are criticized for not listening to practitioners. "I think the Joint Commission, at least for this group of standards, tried to involve the industry."
One important change Trombly points to in the final standard is recognition that no single individual should be accountable. While the draft called for at least one individual to manage the organizationwide safety program, Trombly says JCAHO recognized in the final version that it requires a team concept or a multidisciplinary group to make this work within an organization. According to Trombly, there must be a change in the culture of the health care environment in order for everyone to become vested in patient safety. "You have to educate the staff and providers to understand the value of this," she adds. "You can’t just say, Tomorrow, we are going to have a safe institution.’"
According to Ken Applebee of the University of Michigan Health System (UMHS) in Ann Arbor, most health care systems already are doing most of what the Joint Commission has set forth in these new standards in one form or another. For example, JCAHO’s leadership chapter requires an integrated patient safety program with qualified individuals and interdisciplinary groups, as well as an organizationwide patient safety program. "Many organizations are already doing that," he reports.
Applebee says different hospitals call it different things, and the membership structure may vary. But that is an important distinction, he adds. "This is a better structure or at least a more formal structure, and it may help meet some of the goals that everybody has been striving for, such as standardization of terminology." Similarly, he says some organizations perceive an error to be a patient given the wrong medication. "We look at it on a broader scope." That means looking at hospital-acquired infections and complications from procedures that may not be defined as an error but have an impact on the outcome to the patient, he explains.
According to Applebee, the new standards require health care organizations to have an integrated safety management program and collect and aggregate data not only from a reactive but a proactive basis. That includes not only medical errors that result in injury but also errors that don’t result in injuries, such as "near misses" and "hazardous conditions," he says.
While there are many similarities in what organizations are doing already, Applebee says the differences lie in going beyond collecting and analyzing the data. "Some organizations are looking very closely at the research component of patient safety and expanding the definition of what some people perceive an error to be."
Applebee says that one of the more ambiguous standards that JCAHO established is eliminating the barriers to effective communication among caregivers, which falls under the Management of Information Standard. He reports that UMHS currently is addressing this area by surveying its nursing staff to determine what they see as the main barriers to reporting problems.
According to Millenson, one potentially important item included in the new standards is the requirement that patients and their families be informed of the results of care, including unanticipated outcomes. "That is a fascinating statement, and it marks a significant shift," he asserts. Millenson says this represents an extension of informed consent. "First hospitals told patients what the risks were, and now they are telling them that if something bad happens it was not just because they were sick. In a sense, this is a call on hospitals to rid themselves of the age-old attitude that the operation was a success, but the patient died."
Trombly says one important portion of the new standards that will pose a challenge to hospitals is JCAHO’s intention to increase involvement of patients and their families. She says there has been considerable discussion in the industry about how to get patients involved in the patient safety movement without creating barriers between patients and clinicians. According to Trombly, efforts to provide more education upfront can be a very positive development. "If you then have better patient expectations because patients are informed in advance about what areas can become problems, you are going to have fewer unanticipated outcomes, whether there is a good outcome or a bad outcome."
But Trombly says the issue of informing patients can represent a major challenge to hospitals because the populations served by institutions vary culturally as well as by their level of understanding of medical care. There also is variation between patients coming in for elective procedures vs. emergency situations. "This is a huge challenge that is going to call for a lot of creative methods of getting information out to people," she asserts.
Trombly says she also was encouraged because the standards give patients not only rights but responsibilities. "I took that to mean, for example, that part of the patients’ role in all of this is to understand that it is important to talk to their caregivers about what medications they take."
According to Trombly, that includes not only what they take by prescription but also what they take as over-the-counter medications. Many people do not yet consider aspirin, nutritional supplements, or herbal preparations to be medication. "All of those things are becoming more important for the clinician treating the patient, who may not have access to that information unless the patient tells them," she warns.
In short, Trombly says the issue of how to involve patients goes beyond asking patients if they are allergic to certain medications. "I think this is going to be the wave of the future as we go forward," she predicts. "Trying to build that bond between the patient and the caregiver is not an easy task with all the built-in impediments to good communications."
Trombly also points out that JCAHO is not the only group playing a role in this area. While the organization is approaching patient safety from an accreditation perspective, a number of states have legislative initiatives looking at these issues as well. "You may have some state regulators who come out with their own set of standards that may or may not match what the Joint Commission has come out with," she cautions. "And who knows what may come out of Congress."