High-level disinfection, sterilization, and hand hygiene: What do accreditation surveyors want to see?

Health care organizations accredited by the Joint Commission should follow a standardized approach to the development of infection prevention and control-related processes, policies, and protocols. This approach should start with applicable regulatory requirements and may incorporate evidence-based guidelines and consensus documents chosen by the Health care organizations. Surveyors follow this approach when assessing compliance.

Home Health Agency Patient Experience Measures and Their Relationship to Joint Commission Accreditation

BACKGROUND

Health care accreditation is a widely accepted mechanism for improving the quality of care and promoting patient safety. An integral dimension of health care quality is the patient experience of care. However, the influence of accreditation on the patient experience is unclear. The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey is the standard for collecting patient care experience data in the home health setting. The aim of this study was to examine the association of Joint Commission accreditation on patients' experience of care by comparing HHCAHPS ratings from Joint Commission-accredited and non-Joint Commission-accredited home health agencies (HHAs).

METHODS

This multiyear observational study used 2015-2019 HHCAHPS data obtained from the Centers for Medicare & Medicaid Services (CMS) website and Joint Commission databases. The data set included 1,454 (23.8%) Joint Commission-accredited and 4,643 (76.2%) non-Joint Commission-accredited HHAs. Dependent variables included three composite measures of care (Care of Patients, Provider-Patient Communications, and Specific Care Issues) and two global rating measures. Data were analyzed using a series of longitudinal random effects logistic regression models.

RESULTS

This study found no association between Joint Commission accreditation and the two global HHCAHPS measures, modest significant increases for Joint Commission-accredited HHAs in measure rates for the Care of Patients and Communication composite measures (p < 0.05), and a more significant increase for the Specific Care Issues composite measure related to medication safety and home safety (p < 0.001).

CONCLUSIONS

These findings suggest that Joint Commission accreditation may be positively associated with some patient experience of care outcomes. This relationship was most pronounced when there was significant overlap between the focus of the accreditation standards and focus of the HHCAHPS items.

An Interview with Mark Chassin

Mark Chassin, MD, FACP, MPP, MPH, former president and CEO of The Joint Commission, is one of this year's recipients of the John M. Eisenberg Patient Safety and Quality Awards. During his 14 years as president, Dr. Chassin oversaw the activities of the nation's predominant standards-setting and accrediting body in health care. He introduced profound changes to Joint Commission accreditation and certification programs during that time. Under his leadership, accreditation shifted away from simply citing deficiencies to helping to drive improvement, as summarized in the motto, "Evaluate, educate and inspire." He has had a remarkable career and is being recognized with an Honorary Lifetime Achievement Award by The National Quality Forum and The Joint Commission, the sponsors of the Eisenberg Awards.

The evidence base for US joint commission hospital accreditation standards: cross sectional study

OBJECTIVE

To evaluate the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based.

DESIGN

Cross sectional study.

SETTING

United States.

PARTICIPANTS

Four Joint Commission R3 (requirement, rationale, and reference) reports released by July 2018 and intended to become effective between 1 July 2018 and 1 July 2019.

INTERVENTIONS

From each R3 report the associated standard and its specific elements of performance (or actionable standards) were extracted. If an actionable standard enumerated multiple requirements, these were separated into distinct components. Two investigators reviewed full text references, and each actionable standard was classified as either completely supported, partly supported, or not supported; Oxford evidence quality ratings were assigned; and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the strength of recommendations.

MAIN OUTCOME MEASURE

Strengths of recommendation for actionable standards.

RESULTS

20 actionable standards with 76 distinct components were accompanied by 48 references. Of the 20 actionable standards, six (30%) were completely supported by cited references, six were partly supported (30%), and eight (40%) were not supported. Of the six directly supported actionable standards, one (17%) cited at least one reference of level 1 or 2 evidence, none cited at least one reference of level 3 evidence, and five (83%) cited references of level 4 or 5 evidence. Of the completely supported actionable standards, strength of recommendation in five was deemed GRADE D and in one was GRADE B.

CONCLUSIONS

In general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.

Association between patient outcomes and accreditation in US hospitals: observational study

OBJECTIVES

To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations.

DESIGN

Observational study.

SETTING

4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017.

PARTICIPANTS

4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).

MAIN OUTCOME MEASURES

Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission.

RESULTS

Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06).

CONCLUSIONS

US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.

Institutional Ethics Resources: Creating Moral Spaces

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called "moral spaces," reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings.

The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events

BACKGROUND

More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs.

METHODS

This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE.

RESULTS

The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial.

CONCLUSION

Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged.