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The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) made significant strides last year in widening the scope of the organization’s reach across health care settings and refining the tools it uses to measure the quality of care provided, says Dennis O’Leary, president of JCAHO. But, he quickly adds, those accomplishments pale in comparison to the challenges that lie ahead.
For starters, O’Leary says, even the estimate of 98,000 deaths from medical errors, which was well-publicized in a report by the Institute of Medicine (IOM) last year, is probably understated. Not only are most of these studies based on old data, they rely on incidents recorded in the patient records, he contends. In addition, many incidents that occur in ambulatory care settings are not even known or analyzed, he adds.
"We are not lightening in our movement forward," O’Leary says. In fact, despite the spotlight the IOM report put on this problem last year, not much has actually happened. "This is in essence a hand grenade with the pin out," he warns. "It is potentially a very explosive issue unless we are able to make some significant progress."
According to O’Leary, a second major challenge closely related to patient safety is "the progressive disappearance of health care professionals," which includes nurses and pharmacists. The reasons for this differ across disciplines, he says. "But it is time for some deep soul-searching about how we are going to address this problem." The good news on this front is that the health care industry has previously demonstrated that it can refill this pipeline, O’Leary says. But until a "fundamental redesign" takes place, the system will continue to hemorrhage, he adds. "In all candor, to provide care as a nurse in an inpatient setting is getting close to being one of the worst jobs in America."
According to O’Leary, many hospitals are successfully addressing this problem already. Those hospitals are implementing strategies such as delegated authority, career ladders, shift modifications, and infrastructure development. "There are probably some good lessons to be learned there," he argues. "The fact of the matter is that good salaries can do wonders for retention, too."
The third major quality of care issue confronting hospitals is the public’s increasing demand for more information about performance, even though most hospitals lack the information technology infrastructure to support the consistent gathering of those performance data, O’Leary says. "We have a bunch of policy-makers who believe we are going to start coughing up a lot of performance data in hospitals and everywhere else and [people] will use that to make intelligent decisions about where they go for care." However, O’Leary says, that is a "a cruel illusion" because the infrastructure needed to do that does not exist, and neither does the money to establish it. "We are going to come face to face with this issue in the very near term."
Another major problem confronting hospitals in this area is that "the business case for investment" in these systems has not been made, he points out. "I think those cases have to be made at the leadership level of our health care organizations and they have to be made in business terms. If you spend $1 on patient safety, you will get $2 back," he contends. "But if you don’t believe that, I will not have your attention. The CEO is the leader in patient safety, and you have to walk the talk. If you are not taking this on as your mantra, then people who provide services in your organization simply are not going to believe you."
From JCAHO’s perspective, O’Leary says, there are some even more chilling environmental trends. Topping that list is the current price-driven environment. "In 15 years with the Joint Commission, I have never met anybody who was against quality, but I also have not met a lot of people willing to put their money where their mouths are in business decisions."
O’Leary says those decisions are driven by price, and when a monetary focus is combined with the tenuous financial condition of many provider organizations today, accreditation will be more likely to be viewed as optional or at best a "funds-availability issue."
According to O’Leary, there are serious problems surrounding the drive to implement the use of performance measures. "This is an expensive proposition, and there is nothing cheap about gathering and transmitting and analyzing performance data," he explains.
Before long, people will start questioning the value of performance measures, he says. One question is whether the health care industry can demonstrate that there have been substantive improvements in quality care as a consequence of the expenditures. "I would say that the states are not able to really demonstrate that on a large scale," he maintains.
Another issue is whether there is evidence that the performance data made available to the public are in a form the public understands and whether these data are "actionable information" people are interested in, O’Leary says. "The evidence is simply not there, and that scenario will not sustain a performance measurement improvement program for a long time."
The Health Care Financing Administration (HCFA), according the O’Leary, has promised to implement core measures for hospitals if JCAHO is not interested in doing so. But, he adds, not much had been done on certain specifications for those measures, especially the cost analysis. Most of the measures related to cardiovascular disease and community-acquired pneumonia required medical record abstractions, which is the most expensive way to gather data, he explains.
The challenges don’t stop there, O’Leary says. JCAHO now is facing many state agencies with fat coffers, and in some states, that is translating into perceived opportunities for regulatory oversight. "This is very real," he warns. "There are states that are creating new oversight programs as we speak."