February 2004
Volume 28 • No. 2

JCAHO process changes:

'Real world' benefits can flow from 'real time'
licensure visit in April

The joint commission is coming, and preparations this year are evolving - along with medical practice generally - toward a "real time" demonstration of patient safety, explained the physician most directly responsible for getting Stanford Hospital ready for the April visit.

An inspection team from the Joint Commission on Accreditation of Healthcare Organizations and the Institute for Medical Quality are scheduled to visit Stanford April 13 - 16. The state Department of Health Services inspection is expected to visit later. "In the not so distant past, the triennial visit was an effort by the hospital's medical and administrative elite to reassure joint commission and state inspectors that the hospital was well organized, fundamentally safe from gross hazards and malpractice, and run by articulate and responsible individuals," explained Joseph Hopkins, associate chief of staff and chair of the Quality Improvement and Patient Safety Committee. "Of course we must demonstrate these points, but the emphasis now is on genuine quality and comprehensive safety," he added.

Hopkins said the effort a decade or so ago was far more stylized and structured than today.

"Physicians who were involved a decade or so ago may recall the drill: a group of physicians, nurses and other hospital professionals was heavily briefed for a month or two before the visit. At a scheduled time, the group would be ensconced in a conference room, the review team would be escorted inside, and the hospital leaders would present flip charts, diagrams and a stack of carefully reviewed charts. Then the inspectors might ask predictable questions.

"Things have changed," Hopkins noted wryly. Hopkins said JCAHO is now using the "tracer method". The reviewers will select several patients currently in the hospital and back track through every test, procedure and treatment that the patient has received, walking the path the patient took. Along the way they will randomly query personnel around the hospital to see if they understand the principles and practices expected of caregivers and other hospital personnel.

Physicians, nurses and other caregivers can expect to be stopped in the hallways or on the units, "and asked questions appropriate to their level of responsibility and role in a patient's care," Hopkins said.

"We as physicians are all expected to know such things as unapproved abbreviations [see president's column this month], the procedure we require to ensure correct identification of patients, and what steps we take to avoid wrong site surgeries. In addition - on an appropriate level depending on our responsibilities - inspectors will also expect us to know how to use such tools as failure mode and effects analysis (FMEA) or root cause analysis (RCA) if we are to continue our accreditation. More importantly, knowledge of these principles, quite simply, will help us practice better medicine."

For example, FMEA is an approach to analyze possible problems in health delivery - such as wrong site surgery or medication errors - before they occur. It also looks at what the effects of these errors will be. Most importantly, it serves as a template for establishing procedures that will minimize errors. Root Cause Analysis (RCA) looks at the entire process surrounding a specific event with a goal to minimizing risk in the future. RCA creates the building blocks for the action plan, said Hopkins.

"For me, looking at the components of potentially key dangers - sentinel events - is much like the rigors of scientific method that I as all physicians learned in medical school. It's humbling, because it takes me way beyond thinking, 'I'm smart, I can figure this out', to a higher level, where I sit down and analyze what could go wrong, what the consequences will be, and how can we fix the problem - using real data, real statistics.

"We are currently looking at lists of quality indicators (QI) - each team headed by a physician - to seek improvements. Over the past year or two we have used hospital administrative closed chart abstraction data to highlight potential quality concerns, identify areas that need further study and investigation and track changes over time. [See this month's new Quality Corner column].

"These QI areas, which will take the process beyond chart abstraction to professional clinical analysis, include such topics as 'accidental puncture and laceration', headed by Edward J. Damrose, assistant professor of surgery and director of the Stanford Voice Center; and 'postoperative pulmonary embolism or deep vein thrombosis', lead by David Spain head of trauma surgery.

Other QI areas are more general, such as a task force expected to begin this year looking at complications of anesthesia.

"All of these topics are focused on improving patient care and involve areas where standards of practice and the requirements of safety are well defined. They are also areas where the outcome can be expected to be positive if processes are completed successfully," Hopkins said.

FMEA is used in many highly sophisticated industries, such as in airline safety, he said.

"When the joint commission and state inspectors arrive, they will look closely at our quality indicators. And crucial to that process is that all of us responsible for quality are familiar with the process," he said. All physicians will be expected to know about the quality improvement activities that are related to their own service.

For further information: contact the Quality Improvement Department, (650) 723-7258.

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