Patient Safety and the Joint Commission

Two of my local hospitals just invested $3 – $4 million dollars in preparation for an inspection of the facilities by the Joint Commission on Accreditation of Hospitals (JCAHO). The cost of the inspection runs in the $10 million dollar range after the preparation costs. The inspection is a high stress situation for the administration because if you fail, or lose your accreditation, the private insurers will void their contract with you and you won’t get paid for the work done.

Medicare through the Center for Medicare Services (CMS) is preferential to JCAHO so much so that they perform 80% of the inspections of hospitals in America. When JCAHO was initially formed it was in response to poor care in small private hospitals in non-urban nonacademic centers. They cleaned that up.

The current version uses up a great deal of money, creating a legion of hospital administrators running around with clipboards and computer tablets without making any meaningful dent in mistakes and outcome results. In a recent study published in the British Medical Journal the outcomes and re-admissions rate for the same problem within 30 days of discharge were compared at hospitals which rely on state surveys of quality and safety as opposed to the JCAHO ten million dollar survey. They found that there was no statistically significant difference.

In a related report hosted by the journal Health Affairs, a review of the 1999 report of the National Academies of Sciences, Engineering and Medicine entitled, “To Err is Human, Building a Safer Health System” was discussed. That controversial report claimed that 44,000 to 98,000 deaths per year occur due to medical errors. They discussed the work of Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. Her research looked at safety at 535 hospitals in four large states between 2005 and 2016. She called the results disappointing noting improvement based on suggestions in the 1999 report in only 21% of the hospitals surveyed and worsening in 7%. Most of her work involved the staffing and role of nurses which is critical to the quality of the care an institution provides.

Staffing or the ratio of patients cared for per nurse per shift is a critical component of safe patient care. Once a nurse on a non-critical care unit is asked to care for more than four patients the time spent at the bedside nursing diminishes. You cannot recognize problems, complications or changes in your patient’s condition if you are not spending time with them.

It seems to me as a clinician caring for patients in the outpatient and inpatient setting for 40 years that the more time nurses get to spend with patients the better the patients do. Maybe it’s time for government to separate the insurer’s ability to pay hospitals and JCAHO accreditation. Maybe the millions of dollars spent per inspection would be better spent on hiring more nurses per shift plus giving them the clerical and technical support they need to spend more time and care for their patients?

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