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The Role of the Joint Commission in Health Care Quality

The Role of the Joint Commission in Health Care Quality. Dennis S. O’Leary, M.D. President Joint Commission on Accreditation of Healthcare Organizations.

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The Role of the Joint Commission in Health Care Quality

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  1. The Role of the Joint Commission in Health Care Quality Dennis S. O’Leary, M.D. President Joint Commission on Accreditation of Healthcare Organizations

  2. …of Ernest Amory Codman, concerns about the quality of care in America’s hospitals, and the great debate over outcomes measures versus standards Joint Commission Origins Joint Commission on Accreditation of Healthcare Organizations

  3. The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. Mission Statement Joint Commission on Accreditation of Healthcare Organizations

  4. Evaluation: the core competency Performance improvement support In the mainstream International spread Scope of Work Joint Commission on Accreditation of Healthcare Organizations

  5. Definition Significance Basic requirements Associated baggage The balance of interests Deemed Status Joint Commission on Accreditation of Healthcare Organizations

  6. As convenor As collaborator As listener Facilitative Joint Commission Roles Joint Commission on Accreditation of Healthcare Organizations

  7. Accreditation and certification Patient safety Performance measurement Information dissemination Public policy initiatives The Modern Joint Commission: Efforts in Service of Its Mission Joint Commission on Accreditation of Healthcare Organizations

  8. Standards development Evaluation against the standards Accreditation decision-making The Accreditation Art Form Joint Commission on Accreditation of Healthcare Organizations

  9. Continuous standards compliance Adoption as a management tool Organization ownership Goals of the New Accreditation Process Joint Commission on Accreditation of Healthcare Organizations

  10. Periodic performance review Priority focus process Tracer methodology Surveyor development Elements of the New Accreditation Process Joint Commission on Accreditation of Healthcare Organizations

  11. Medication management Infection control Emergency preparedness Data usage for improvement purposes Current Accreditation Focus Areas Joint Commission on Accreditation of Healthcare Organizations

  12. Intensified Life Safety Code compliance review Unannounced surveys Random validation surveys Data-based intra-cycle monitoring Current Accreditation Initiatives Joint Commission on Accreditation of Healthcare Organizations

  13. Credentialing and privileging Leadership responsibilities Enhanced emergency preparedness expectations HIT-related expectations Standards Development Priorities Joint Commission on Accreditation of Healthcare Organizations

  14. The nature of accreditation Standards issues Dealing with sentinel events Patient Safety Linkages Joint Commission on Accreditation of Healthcare Organizations

  15. State database legacy Sentinel event database Sentinel Event Alerts National Patient Safety Goals Creating a “Reporting for Learning” Model Joint Commission on Accreditation of Healthcare Organizations

  16. Goals vis-à-vis Requirements Philosophy Expert support Old Goals never die… Issues on the horizon National Patient Safety Goals Joint Commission on Accreditation of Healthcare Organizations

  17. Wins Removal of concentrated KCL from in-patient units Re-design of infusion pumps Losses Do-not-use abbreviations Universal Protocol for preventing wrong site surgery Hand-washing National Patient Safety GoalWins an Losses Joint Commission on Accreditation of Healthcare Organizations

  18. “Not-there-yet” Patient identification Reporting of critical test results Medication reconciliation Wins and Losses (cont.) Joint Commission on Accreditation of Healthcare Organizations

  19. Patient Safety Events Taxonomy Speak Up campaign Patient safety legislation International Center for Patient Safety Other Patient Safety Beachheads Joint Commission on Accreditation of Healthcare Organizations

  20. Ties to quality improvement Ties to accreditation Measure sets: creating “portraits of performance” Evidence-bases for measures…and standards Performance Measurement Linkages Joint Commission on Accreditation of Healthcare Organizations

  21. Expert panel analysis Measure set identification Measure data element specification Field testing for reliability and validity External validation Setting a High Bar for Performance Measures Joint Commission on Accreditation of Healthcare Organizations

  22. Federal agencies (CMS, AHRQ) The accreditors (NCQA, Joint Commission) National Quality Forum The states Pay-for-performance programs (purchasers, payors) The Measurement Players Joint Commission on Accreditation of Healthcare Organizations

  23. Low bar to entry Standardization needs Data collection burden Multiple data demands Priorities among structure, process and outcome measures Clarification of measure uses Perennial Measurement Issues Joint Commission on Accreditation of Healthcare Organizations

  24. Volume of measures Absence of National Quality Goals Measurement of patient safety performance Data quality Data flow Embedding measures in electronic records Emerging Measurement Issues Joint Commission on Accreditation of Healthcare Organizations

  25. Quality improvement stimulus Meeting public accountability expectations For accredited organizations For the Joint Commission Information Dissemination Linkages Joint Commission on Accreditation of Healthcare Organizations

  26. From a Confidentiality Policy to a Public Information Policy The troubled launch of Performance Reports The transition to Quality Check Evolution to current Data Use Policy Evolution of Joint Commission Policy Joint Commission on Accreditation of Healthcare Organizations

  27. Basic content Accreditation status information National Patient Safety Goal compliance Comparative performance measurement information “Merit badges” Addition of quarterly measure data points Inclusion of non-accredited organizations The Quality Check Evolution Joint Commission on Accreditation of Healthcare Organizations

  28. Underlying rationale for Public Policy Initiatives Basis in mission: “…and related activities” Joint Commission assets as a public policy player Convenor role Purity of purpose Public Policy Linkages Joint Commission on Accreditation of Healthcare Organizations

  29. Roundtable analysis National summit Issuance of white paper Determination of follow-up strategies Public Policy Development Process Joint Commission on Accreditation of Healthcare Organizations

  30. “Strategies for Addressing the Evolving Nursing Crisis” “Strategies for Creating and Sustaining Community-Wide Emergency Preparedness Systems” “Strategies for Narrowing the Organ Donation Gap and Protecting Patients” “Strategies for Improving the Medical Liability System and Preventing Patient Injury” White Papers Issued“Health Care at the Crossroads” Series Joint Commission on Accreditation of Healthcare Organizations

  31. Emergency Department Overcrowding Health Professions Education Reform Linkages Between Health Literacy and Patient Safety The Hospital of the Future Developing a National Data Management Strategy The Efficiency Dilemma: Identifying Opportunities for Waste Reduction in Health Care In the Public Policy Pipeline Joint Commission on Accreditation of Healthcare Organizations

  32. What Will It Take to Succeed? Joint Commission on Accreditation of Healthcare Organizations

  33. A culture is defined by the customary beliefs, values, an behaviors – including traditions – shared by members of a group. Culture Defined Joint Commission on Accreditation of Healthcare Organizations

  34. Board and professional cultures Payment system design Medical liability system Health professions education design Professional shortages Barriers to Making It Happen Joint Commission on Accreditation of Healthcare Organizations

  35. Patient safety as “the” priority, not “a” priority Leadership engagement Transparency at all levels Systems re-design competency “Back to the basics” education Pushing the Culture Change Envelope Joint Commission on Accreditation of Healthcare Organizations

  36. Focus on microsystems Patient engagement in reporting and problem-solving Investments in staff retention and recruitment Getting ahead of the power curve Culture Change Envelope (cont.) Joint Commission on Accreditation of Healthcare Organizations

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