Saturday, July 07, 2007

Who's Minding the Store?

You may have noticed that I haven’t been posting quite as fast lately. I have spent much of my time for the past month or so reviewing Patient Rights Standards of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).

Perhaps it would help to say something about what the JCAHO is, and why it's important to many hospitals. First, it's important to know that health care institutions of all types are subject to review and inspection. Such reviews are sometimes euphemistically called "surveys." They involve onsite inspections for adherence to relevant laws, regulations, and standards. For the institution they are always intense experiences, and can sometimes be quite adversarial. Surveys may come from state authorities, the Centers for Medicare/Medicaid Services (CMS), or any of a number of professional credentialing or certifying organizations.

Part of the reason these surveys can be difficult is that some organizations and some surveyors can get very specific, not only about goals to be accomplished, but also about procedures to accomplish them. The problem with that is a lack of flexibility. Patients should be cared for according to "best practices." However, "best practices" are often subject to debate among professionals. Health care professionals base decisions on published information from various sources reflected against their own clinical experience. But, the published information can change literally weekly, with every publication of an important journal, or with papers presented at important professional conferences or new reports from the National Institutes of Health.

And, each professional's practice is unique. Application of best current information has to be individualized to each patient; and over time that will result in practice patterns individualized to each professional's patient pool and practice environment.

So, with a constant flow of new information, reflected in the specifics of each practice, freedom to adapt and change is important. Regulations and regulators who are too prescriptive and specific may not provide the best care for patients. They can certainly become frustrating for conscientious professionals.

That's how the Joint Commission came to be. A group of physicians, with support from their professional organizations, thought they could offer a better way. They agreed to the need for rigorous goals for patient care. However, they thought that being too prescriptive wasn’t helpful. They brought a different model: they allowed institutions to determine for themselves how they would meet the appropriate goals. The survey would focus on whether the processes an institution chose actually accomplished the goals – were there appropriate policies in place, and appropriate practices to implement them, with staff knowledgeable about them and consistent in applying them? In addition, they chose to encourage ongoing work for performance improvement: how was the institution paying attention, tracking policies and procedures; and how was the institution working constantly to get better? The goal was that surveys would still demonstrate that an institution was offering quality care, but would be less adversarial. Indeed, there was some hope (and some success) that surveys would become educational. Surveyors could share good ideas they had observed in other institutions, and so could help institutions constantly improve.

JCAHO is not the only organization in health care surveying for quality care and practices. However, the JCAHO does have one characteristic that its competitors don’t share: “deemed status.” Under an agreement between JCAHO and CMS a hospital accredited by JCAHO is deemed to have met its CMS requirements for up to three years. Between the less prescriptive, less adversarial survey experience and “deemed status,” JCAHO is a service that hospitals and other health care institutions value highly, and pay well for.

Yes, institutions pay for the privilege of being surveyed by the JCAHO. They don’t have to. They’re not charged for the regular state surveys, or for CMS surveys. On the other hand, those surveys are definitely prescriptive, and all too frequently feel adversarial. Accreditation by an independent organization can be a marketing asset, as well as keeping the institution on its proverbial toes. Add to that the advantage of “deemed status,” so that the hospital experiences a JCAHO survey every three years rather than a CMS survey every year, and it can be well worth the money.

That said, it’s still a lot of work. Some of the work – much of the work, when things are working right – is maintaining daily the best practices and procedures. But, of course, for hospitals, like practitioners, the environment is always changing. In addition to the issues I’ve already mentioned of new information, there are other things going on. There is more and more pressure to provide information about the quality of care and make it available to the general public. Information on a number of quality measures is already available on the website of the Department of Health and Human Services at Hospital Compare. Other information is available from the JCAHO itself at Quality Check. JCAHO has also established a series of National Patient Safety Goals for its accredited institutions, and new measures have been added to that each year since it began. So, with all that in mind, JCAHO Standards change from year to year, and there’s a certain amount of work adjusting to the changes.

And the hospital has to be ready at all times. Surveys are unannounced. That is, we get about 30 minutes notice. We have some approximate idea, knowing that we can expect something at least three years from our last survey. In the past those triennial surveys did have some notice, although not really enough to make significant changes, or even to hide any problems. On the other hand, they have always reserved the right to drop in any time. On top of that, members of Congress raised questions about “deemed status,” and about whether the relationship between JCAHO and its accredited institutions was too chummy. They leaned on CMS, and CMS leaned on JCAHO; and so all surveys became unannounced.

So, the work never stops. And since I am Chapter Leader for the hospital on Patient Rights and Organizational Ethics Standards, now and again I have to commit a block of time to reviewing changes in Standards, and in monitoring our performance. I will admit it can feel pretty tedious; and yet I can see the ethical import of each Standard and the expectations it entails.

That’s part of the work of a chaplain that I didn’t know about at the beginning. Had I known twenty years ago that I’d be so deep in administration, I don’t know that I’d have gone back into full time chaplaincy. However, over the years I’ve learned two things. One is that, dull and removed as the administrative stuff might seem, if it doesn’t get done and done competently nothing else does either. The second is that if I want to reach the greatest number of people, I need to move beyond direct care to shaping the whole culture of health care, so that spiritual care permeates the whole enterprise.

So, if it seems I’ve been a bit behind, and you’ve been wondering who’s minding the blog store, it’s because I’ve been deep into the hospital’s process of who’s minding the store.

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