>>SINGER: Hi, I’m Steve Singer. I’m the Director of Education and Outreach at the Accreditation Council for Continuing Medical Education.
>>SCHYVE: Hi. I’m Dr. Paul Schyve, I’m the Senior Vice-President at the Joint Commission, which many of you probably still know as the Joint Commission on Accreditation of Health Care Organizations.
>>SINGER: Dr. Schyve, why don’t you tell us about the organization that you work within.
>>SCHYVE: The Joint Commission is an organization that was actually founded in 1951, but it goes back in history all the way back to the founding of the American College of Surgeons. So, it started, an accreditation type process started in 1918 and what happened was there were so many organizations involved that it kind of outstripped the capability of the American College of Surgeons to actually address all the organizations that wanted to be accredited. And that’s why the Joint Commission was formed. And the Joint Commission the reason why the word joint is because it has corporate members who are the American College of Physicians, the American College of Surgeons, the American Hospital Association, the American Medical Association, and the American Dental Association. So, all of them actually appoint members to our board and that’s why it’s the Joint Commission. Originally the Joint Commission on Accreditation of Hospitals, because that’s what was being accredited, but in 1987 the Joint Commission had been accrediting long term care, non-hospital behavioral health, home care, and so, the name was changed to Joint Commission on Accreditation of Health Care Organizations. But, all along our mission, even though, the mission statement has changed from time to time, has been the same. We are a not for profit 501C-3 organization, which means that we’re formed to benefit the public. And so, the ultimate beneficiary of what we do, anything that we do is to be the public, and patients obviously, and patients families and so on. And that mission, though, how we carry it out our latest statement of what that mission is that we carry that out by essentially evaluating health care organizations, collaborating with others to do things like set standards, evaluating organizations, and inspiring them to improve. We literally wanted to use the word inspired because we do quite a few other things besides the accreditation process. We provide education, publications; we have a separate part of the organization literally a separate organization, also a not for profit, which provides consulting, for example. So, we’re trying to essentially help organizations in the interest of benefiting patients with regard to the quality and safety of care. Currently we accredit over, it’s about 18,000 organizations and 4,500 of them are hospitals. The reason why people often think of us primarily in the hospital field is that those hospitals represent 96% of the hospital beds in the United States. So that when we do something in the hospital field it generally means that there’s a change in what happens in hospitals in the United States. And the other things that we accredit like home care and so on, it’s a much smaller portion of those types of organizations.
>>SINGER: I think that the environmental perspective that, that both the Accreditation Council for Continuing Medical Education and the Joint Commission are in is in this environment of improving safety and in improving healthcare delivery and healthcare outcomes. So, within the context of that how has the, you know, the Joint Commission and the ACCME has been at this for a while, how does t the Joint Commission’s viewpoint, or perspectives on the mission and the opportunities and the challenges that are in front of you, how has that evolved over the past several years.
>>SCHYVE: The past several years, in particular past couple years have been under the direction of a new president Dr. Mark Chassin and when Mark came in and I think what he described is, was a very accurate description, he said, You know, Joint Commission has been very influential, made a real change in terms of helping to improve the quality and safety of care. So, we clearly have better care, certainly in the United States today than we did before there was a Joint Commission before there was an accreditation process. But, he said, The problem is that we need to move more quickly. Now, that we’ve recognized, for example, with the IOM report on, on To Err is Human, that we are actually are harming patients in healthcare. Certainly not intentionally, but through errors and things that go wrong, that we actually have to act more quickly. When I use the word ‘we’ there it meant healthcare as a system, the people who deliver healthcare. So, the doctors, the nurses, the healthcare organizations as well as the Joint Commission. How, in fact, do we make changes in improving the safety and quality of care much more rapidly? So, it’s not as if all of a sudden there’s a new switch and well, what do we do? It’s how do we do things more rapidly? And one of the things that we’ve recognized and we had recognized was that, people would learn about, here’s this problem. Let me pick a specific example because I’ll return to it later. Everybody knows that hand washing is important if we’re going to reduce infections. And so, here’s this problem that that everybody also realizes that people aren’t regularly washing their hands. They may have thought they were doing it more often than they really were, but the fact is everybody knew it certainly wasn’t 100%. We could do better in that particular area. So, everybody knew that. It wasn’t like anybody was challenging the scientific basis for why it’s important to wash hands between patients, but it wasn’t being done. So now, the next question was, Well, what can we do say in my specific hospital to try to address that problem? Let’s look around and see what other people have done in order to try to address that problem. We could try that here. And what frequently, probably most of the time happened was that something that was working someplace else when another organization tried to do it, and either they found and often found both of these things, first, that it didn’t work as well for them. Maybe there was some improvement, but they just couldn’t get the kind of improvement that they were looking for. And secondly, even if they had some significant improvement, maybe through the Hawthorne Effect, as well as actual change, that what would happen is it became very hard to sustain that improvement. And the question that Mark Chassin raised when he came to the Joint Commission is, Why is that happening we’re all recognizing that. And that’s really impeding making the kind of rapid changes that we in healthcare now know we need to make. And as this became, these issues became more visible to the public; that the public is demanding that we make in healthcare.
>>SINGER: So, the emergence in the last ten years really, of new methodologies, what were new methodologies ten years ago, new platforms, new tools for collecting data, about health outcomes, healthcare performance, you know, sort of, quality and safety data. We have the conclusions that we draw from those data and we have clear problems as you’ve described, such as, hand washing. And tell me if I’m wrong, but there’s sort of a bifurcation, there’s some aspects of what we’ve learned from our performance data, which have held in relatively rapidly over that ten year period to greatly change
>>SINGER: the behavior and the processes,
>>SINGER: and the resulting outcomes. But, then what you’re saying is that frustration that you have or the desire to continue focusing on this is that there are some things which seem to be resistant to that, sort of, causation/effect approach.
>>SINGER: which to me, not knowing much about this, but to me points to complexity.
>>SINGER: that there’s something else
>>SCHYVE: that’s correct. And actually as you were describing that, one of the differences that appears to, to be meaningful is when we talk about quality versus when we talk about safety. When we talk about quality we’re all often talking about something that we should be doing regularly for a patient. So, we talk about something like when a patient is discharged from a hospital after having had a heart attack, after myocardial infarction that the evidence is clear that it’s useful for the patient to be just discharged on a beat blocker. And so, we can think from a quality point of view, How often, in fact, are we discharging patients on a beta blocker when they’re being discharged after an MI? And that we can measure. And so, over that last decade, or so, we’ve introduced measurement systems, which will accurately measure that and we’ve seen a dramatic improvement in those measures. So, these kind of measures where we’re looking at what should I do for the patient for this particular kind of illness, the measurement and frankly, making public some of that measurement first the feedback to our
>>SINGER: to the pressure
>>SCHYVE: organization, and then also making it public and the public said, Why don’t you do this all the time? That has actually had a significant impact on the quality of care. So, those things that we’ve been measuring, we’ve seen significant changes. Safety is the kind of thing that you don’t want to have happen. And in some ways you don’t want to have it happen, because of the fact that if it happens you’ve got harm to the patient and you’re hoping actually is somewhat rarer. So, you’re trying to avoid something, which isn’t happening all the time anyway as opposed to what you measure saying I want to give a beta blocker to every patient. So, these, the, this problem that I mentioned before about trying to figure out how somebody else does it has been somewhat more successful in looking at the quality issues and improving the performance in individual organizations and then across the organizations. It’s been this issue of: this doesn’t seem to work for us, has been more of a problem in the safety area.
>>SINGER: OK. So, in terms of sort of where that leaves us and I want to sort of talk about the alignment between the Joint Commission as an accreditor of healthcare institutions as you said and the expectations of the public and, and the entities on behalf of the public such as the federal government, who are, who have been partnered with you in these past several years in terms of the evolution of the focus on improving healthcare quality, but sort of where do we stand now, we have the sort of the new vision from, from your CEO and we have certainly on every sort of cover story in the newspaper the focus on healthcare quality, and accountability etcetera, where are those sort of meeting within these examples that you’re , that you gave?
>>SCHYVE: Yeah. We’ve learned, I think, a lot about how to do both of these things. How to use measurement better, in terms of improvement, and what it is we can try to do to improve safety. So, let me first make a comment about the measurement for improvement. It costs. It takes resources to measure and in fact it takes particularly resources that that maybe in the future it won’t take as many resources. What do I mean by that, is that right now most recording of what goes on in healthcare is in written records rather than electronic records it can be more easily searched. And if you look at the kind of data you need for a good measurement system for quality, what it usually means is that you have to invest in looking, having somebody review records. That’s labor intensive and therefore costly. So, in the future it may be we can get some of that data that we need that really important clinical data more easily out of electronic records, but we’re clearly not at that place
>>SINGER: not there yet
>>SCHYVE: yet. So, you’ve got the something, this job you’re trying to do this measuring and doing it either you use poorer data so it’s less useful or if you really want the best data you’ve got this labor kind of intensive process. And the issue is that if you’re going to something which is labor intensive you want to make sure that you’re actually measuring the most important things accurately. And so, recently in the New England Journal, Dr Chassin and Dr Loeb, from the Joint Commission, and a couple others including Dr Bob Wachter from San Francisco have written an article that talked about how we should be thinking about these measures. So, that we’re using measures that and are investing in collecting in using measures that are the ones that will really make the most difference in terms of the quality of the care. And they actually identified four characteristics of a good measure; they called these accountability measures. So, that they might be measures that other people also use for accountability, not just the Organization for Quality Improvement, but it may be used in terms of, of patients, or insurers choosing where people will go for care or they may be used for pay for performance by the government or insurance companies. So, they’re accountability and yes they would be public. And the four criteria were, the first is when you’re talking about a process measure, there has to be really good data, that doing that particular thing
>>SINGER: the process.
>>SCHYVE: the process. Exactly. Will it, in fact, improve the outcomes of care? So, you need to have, it may not be all, you know, double blind studies
>>SCHYVE: they need to be
>>SINGER: so this is a proximal event that
>>SCHYVE: well, that’s actually, that’s actually the second criteria
>>SINGER: oh, OK.
>>SCHYVE: The first criteria is you got studies the evidence that actually doing this will effect the quality of care.
>>SCHYVE: The second criteria is that actually it’s proximal enough that, that doing this process is proximal enough to the outcome that you don’t end up with a whole lot of intervening variables. You may have done this really controlled study that showed if you, if you do this you got a better outcome because you’ve controlled all these other variables; in the real world there’s all kinds of things that intervene. So, the further away the process is from the actual outcome that you’re looking for the more likely that having done the process, is not actually going to result in the real world in a better outcome, because of all these other intervening things and steps that need to occur. A third factor criteria is that this can really be reliably measured. So, to give you an example there’s been a performance measurement that we have used at the Joint Commission, that CMS has also been using, that has to do with providing smoking cessation counseling to patients who have an MI or have heart failure or who have pneumonia. There’s plenty of studies which satisfy the first criteria if you do this
>>SINGER: ensure the benefit of
>>SCHYVE: that’s right. That it’s beneficial if the patient stops smoking. The problem is actually being able to tell whether effective or good counseling was given. And so, if all there is, is a checkmark that says, Yes I provided counseling, you have no idea how good that counseling was. And the real issue is, has good counseling been given? So, you have, you know, you’ve got this evidence based practice, but the measurement of it is simple not good enough to say, oh I can now say, if people, whether or not people are really doing it, whether that’s good for the quality of care.
>>SINGER: Now, is that, that third criterion, is that a reflection of the, or the extent to which the process, the intervention, has sort of been developed and sort of compartmentalized into steps and things that can be recorded, or because, are there accountability measures that sort of fit the criteria that involve communication and those sort of things or are those softer and harder to measure in general?
>>SCHYVE: Well, it’s probably true that the softer something is in terms of being able to measure it. The softer the actual process is
>>SCHYVE: like communication, the more difficult it is to try to measure it. And the reason for that is that you’re really talking about not just whether it was done, but you’re talking about how it was done.
>>SINGER: about the availability of performance
>>SCHYVE: That’s right. Now, in theory you could say well let’s set a whole list of additional measures dealing with the smoking cessation counseling, which would look at that effectiveness, but what you, if you do that you’ve just blown up what currently be one measure
>>SINGER: one check box
>>SCHYVE: that’s right, in a whole bunch of measures requiring more resources to collect the data.
>>SINGER: Right, right.
>>SCHYVE: The fourth criteria is the issue of unintended consequences, we also, actually have an example of that. So, the first is there’s evidence this process matters to the outcome. Second is it’s close enough to the outcome that you’re not wiping out the real world whatever the connection is through the intervening variables. The third is the one that I just mentioned that you can reliably collect this data. And the fourth is that there are not unintended consequences, which oftentimes is as much as you work at it you can’t identify ahead of time. So, here another example that we had: one of the requirements is to do, to give an antibiotic to a patient with pneumonia within, originally it was like, I forgot what the actual hours were, but within X number of hours within the time they come into the hospital. And that was extended by a couple hours, because that was really too tight. But, there’s good evidence that the more quickly you get an antibiotic into a person with pneumonia the better off the outcome. The problem is, is that, that measure incentivized people to give an antibiotic before you actually knew that the patient actually truly had pneumonia. So, it would lead as an unintended consequence. There were actually a couple studies that demonstrated this, that the use of that measure actually led to, what we would now call, overuse of antibiotics. Something that increases the likelihood of the development of, you know, antibiotic resistance and so on. So, there’s a measure that may meet all three of the first criteria, but has an unintended consequence. And as I said a minute ago, sometimes you don’t know that ahead of time, so, you put a measure in place, you need to be watching for that. That, that article, by the way, setting forth those four criteria has been received, been well received in the field, both in the medical field and also, the logic behind it has been, has also been accepted by many of the people in the non-medical field, the consumer representatives and so on, who have said, you know, that makes sense.
>>SINGER: Right, right.
>>SCHYVE: You want to focus on those things that we can tell will make a difference. Those should be accountability measures.
>>SINGER: Right. And, you know, from that theme, there’s a good sort of a linking point for us to segue to talk about the ah, sort of the practical implications for healthcare professionals, you know, you certainly talked about the perspective of the public and the consumer focus groups and insurance and the government, you know, from an accountability standpoint, but it seems that, that this approach with accountability measures gives a clear focus to the hospitals and to healthcare institutions on how to focus their resources on really sort of achieving the best outcomes in the quickest manner, you know, on those areas.
>>SCHYVE: That’s right.
>>SINGER: Can you sort of
>>SCHYVE: I would just interject
>>SCHYVE: and therefore focus attention on those areas, in terms of, of continuing medical education
>>SINGER: yeah, yeah
>>SCHYVE: continuing education for all staff within an organization
>>SINGER: I’m glad you said that. So, let’s, we’ll come back to that in a moment, but what I want to give the people who are watching a perspective on is sort of where this sort of new insight in terms of what you’ve published fits within the perspective of what the hospital administration, you know, the C suite, what those executives are looking for. You know, what are their challenges or what are they looking to do when they think about Joint Commission accreditation, because really what we’re trying to do with the, with these videos are sort of bridge what our leadership and problem solving issues and opportunities for CME professionals, who may work within a hospital or a healthcare institution or may work as a partner, a collaborator, stakeholder, with healthcare institutions and I want to try to dimensionalize the executives perspective on sort of what to do with this. And what are their challenges, what are they trying to address in terms of Joint Commission expectations?
>>SCHYVE: That’s a great question. Let me just, again reiterate that, that it’s useful, I think, to think about where we’re trying to improve quality and where we’re trying to improve safety.
>>SCHYVE: And we’ve just been talking about the quality measurement, the performance measurement, come back because the same question you’ve just asked we clearly need to talk about it in terms of safety issues. I think that, every, that the C Suite, the CEO, the board would agree that one of the things that they want to do is provide high quality care. Also, as we’ll talk about in a minute safe care, but I mean, there’s nobody working within healthcare who says, No that doesn’t matter, it doesn’t matter whether you’ve been trained as a clinician or not if you’ve chosen healthcare as your profession you are saying, Yes, you know, we want to make sure that care is of high quality. That’s an obligation we have to safety and to patients and to society. The second thing is from the point of view of the managers of the organization who are concerned about the financial management increasingly this kind, these accountability measures are being used for the purpose of making decisions about paying. And so, it becomes important, not just from kind of the mission providing high quality care but also from the point of view of the financial viability of the organization to address these issues. And we’re talking here about, it doesn’t matter whether an organization’s for profit or not for profit they’re concerned they’re about the financial viability. So, if you think about it that way, the CEO and other members of the C Suite, it makes sense for them to focus in on those issues that are being measured through the accountability measures, because those are the things people will be looking for not only in terms of are you achieving your mission of quality of care, but also those are the things that people are looking for in terms of are we going to send, are we going to refer our patients here when they’re , or employees here when they’re ill, and also, those are the things people will be looking for in terms of, I’ve got some objective measures here to decide whether I’m going to pay more or pay less to a particular organization. So, it actually it helps to, to, in terms of answering your question it helps the CEO focus on, what are the other things stakeholders are going to be looking at? And what are the things that actually we do have some objective, good measures about that I can focus in on and say, We need to make sure we’re doing this well within our organization.
>>SINGER: And from the standpoint of your criteria for those measures, also, the things for which are could most, I won’t say quickly, because my naiveté about what’s involved with all of this is, I don’t want to sort of bias that, but the things for which the effort they put in could reap them most
>>SCHYVE: yes. benefit
>>SINGER: that’s right in terms of improving outcome
>>SCHYVE: right. You’ve got good return in terms of the outcomes, because you’re focusing on things that have been measured that had to meet that first criteria, the connection is there to the outcomes and I’m suggesting from a business point of view it also has a , should have a better return in terms of, of the
>>SCHYVE: financing of the organization.
This is a transcript of Addressing Quality and Safety Challenges: Joint Commission Perspectives (part 1 of 2).
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