The Joint Commission's Division of Quality Measurement and Research has been contracted to complete a portion of a project to develop quality measures to assess and improve care for breast cancer patients undergoing chemotherapy in an ambulatory setting, according to an official announcement from the accrediting organization.
The National Philanthropic Trust's Breast Cancer Fund has provided funding to the Oncology Nursing Society Foundation (ONS) to develop this set of quality measures. It is hoped that the ONS will bring experience in examining patient-centered symptom screening and management measures affected by evidence-based nursing interventions to the table.
Testing will take place throughout the country this year looking at quality measures with emphasis on the reliability and validity of care for patients undergoing active treatment for early-stage breast cancer. The information gathered here will then be put to use in 2011 as measure sets are developed for the care of those patients in the first year of post-treatment.
Public comment on the Breast Cancer Care (BCC) Quality Measures is being accepted though March 19, 2010. Thirty to 50 test sites are also being set up to examine the measures.
The following are the BCC quality measures proposed:
The term "observed but corrected on-site" has been cropping up in survey terminology in recent site visits, and has left some in the field confused.
What, exactly, is an "observed but corrected on-site" (OCO) deficiency and how will it impact your survey? The Joint Commission has described that OCO deficiencies have the following characteristics:
Correcting these deficiencies does not require organizational planning or forethought
They are easily corrected, posing no significant threat to safety
For forms, adding missing elements or pieces of information that would not impact the process(es)
Policy does not follow practice; policy changed to match practice
If a deficiency is OCO, explains Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, the surveyor will flag this item in the report for review in central office. If accepted, it will not count toward the total of RFIs; however, it stays in the report.
"OCO" examples
What do "observed but corrected on site" items look like? Geffers cites the following as a few specific examples hospitals have encountered:
Immediately disposing of a multi-dose vial that was not dated
Disposing of an expired quality control test strip immediately
Missing dates for logs. If, for example, refrigerator logs are missing a few dates, but temperatures before and after missing dates are within range and no patterns or trends observed.
Stretchers or gurneys blocking medical gas shut off valves. Often, these blockages can be easily and immediately moved.
The same goes for food carts blocking fire extinguishers. If it's a matter of moving the cart, this is a readily fixable issue.
Here's an example many of us have encountered before: exit light partially burned out. This can be readily corrected when observed.
On the flip side, here are some examples that cannot be corrected on site, which The Joint Commission has addressed:
While immediately disposing of undated multi-dose vials is correctable, if a pattern/trend is found—e.g., undated vials are found in multiple units—this becomes a pattern or trend.
Missing refrigerator logs might be potentially correctable, but if temperatures are found out of range there is no procedure in place to make sure the items stored (food, medications) are useable
Because it would require significant consideration before being implemented, one cannot simply add a suicide risk assessment to an assessment form.
Failing-to-latch several fire doors (pattern and trend)
Hospitals look for ways to improve patient education all the time. Once in a while, this education pays dividends on multiple levels—such as the case of Parrish Medical Center in Boca Raton, FL.
Parrish Medical Center found that a significant portion of the hospital's patient population had Peripheral Arterial Disease (PAD) and an education program led to downstream revenue of nearly $500,000 through repeat visits for follow-up care and unrelated tests.
The program's original intent was to raise community awareness, standardize treatment, document outcome measures, and increase communication for those providing care to PAD patients.
Nurse educator Marialice Knight, RN, BSN, started the program at Parrish. "In 2003 … I became aware of a study by Partners, which performed ankle-brachial indexes on close to 7,000 patients," says Knight. "They found that 29% were positive for peripheral disease. It was weird that less than half of their physicians were aware they had this."
Knight presented this study to two physicians in the cardiac rehabilitation department. They worked together to take a proposal to the facility's administration for a plan to educate the community about this disease and perform screenings.
"Our administration immediately embraced it—not just as a community effort, but as a way of identifying these patients who were out there and had no idea" they were at risk, says Knight.
The organization was able to purchase 20 machines and recruited physicians to place the screening devices in their offices.
"We realized we weren't getting the volumes we wanted so we initiated further programs," says Knight.
The organization hosted screenings every September during Cardiovascular Disease Awareness Month between 2005 and 2007.
In 2007, the effort kicked into overdrive, and Knight and her associates began gathering data on who they were screening and what their risk factors were in accordance with the American College of Cardiology and American Heart Association guidelines.
"That's where we are today—since May 2007, we've done roughly 1,700 screenings," says Knight.
The program has evolved over time. The initial case study involved 883 patients, who heard about the study through advertisements calling for specific risk factors. Since the initial study, the program has been revised to target diabetics, smokers, hypertensives, people with high cholesterol, and people with vascular disease.
"As a result, our numbers [of screenings] are less, but we're targeting the people most at risk," says Knight.
Targeting the right people required the help of the communications office. "I've gone to the diabetes program, the pulmonary rehab center, the sleep lab, the heart failure group. I've invited their patients and have those clinicians send us those patients," says Knight. "It was so easy to have Kathie [Coon, communications specialist with Parrish] put an ad in the paper and then I can't even begin to describe the amount of people who came forward."
"We were equating it to any study," says Coon. "You try it for a while, look at what you can improve, and what you're doing right. The fact that [early on] they did so many tests, but only found a quarter of those receiving the tests had risk factors caused us to step back and make sure we get the right people into the program."
Knight suggests a hospital that wants to perform this kind of outreach needs marketing and communication support, and facilities shouldn't limit the outreach to just obvious choices.
"All of your support groups—stroke, cardiac, diabetes—reach out to them and invite them to your presentations as well," says Knight. "Go to their speakers' bureaus to speak to those groups."
The Joint Commission will wait to release National Patient Safety Goal (NPSG) 08.01.01 to the field so its advisory and board committees can review the draft, according to an official statement on its Web site.
NPSG.08.01.01, addresses medication reconciliation, which in years past The Joint Commission had targeted as part of its effort to prevent medication errors—which continue to be one of the most frequent causes of preventable errors in hospitals. However, since the standard's inception in 2005, hospitals have struggled to find the right combination of processes to meet the requirements of this goal.
The Joint Commission reduced the NPSG on medication reconciliation in March 2009 to help take off some of the burden on organizations—NPSG 8 continued to be evaluated during on-site surveys, but findings are not currently considered into the organization's accreditation decision, and no Requirements for Improvement (RFIs) are documented.
Additional revisions to NPSG 8 are expected to go through the Joint Commission's Standards and Survey Procedures Committee for approval sometime this spring.
Originally introduced by The Joint Commission in July 2002, staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility.
When first introduced, hospitals were required to track two human resource indicators and two patient outcome indicators, track data, and determine the variation in performance caused by the number, skill mix, or competency of staff.
"Hospitals collected the data, nurse leaders looked for correlations, and no correlations have been found," says Susan W. Hendrickson, MHRD/OD, RN, CPHQ FACHE, director of clinical quality and patient safety for Via Christi Wichita (KS) Health Network.
Hendrickson says that even if hospitals did find what they believed to be a correlation between staffing and patient outcome, when the information was examined more closely, it was not statistically valid.
Fast forward to June 2009: The Joint Commission suspended these standards because of the debate of the results from across the country.
This suspension was short lived as The Joint Commission recently announced the approval of its interim staffing effectiveness standards for 2010. The new staffing effectiveness standards will become effective July 1, 2010, and will remain in effect, as The Joint Commission continues to research the issues of staffing effectiveness.
Interim standards at a glance
The first requirement affects LD.04.04.05 EP 13 and states that at least once a year, the hospital/organization must provide written reports on all system or process failures, the number and type of sentinel event, information provided to families/patients about the events, and actions taken to improve patient safety.
"In a broader sense, EP 13 ties staffing to outcomes, and puts accountability at the leadership's feet," says Hendrickson.
She suggests that instead of reporting individual system or process failures annually to the board, hospitals should submit the reports to the board either quarterly or monthly. Hendrickson warns that reporting every time a medical error occurs can lead to a lengthy report for the board to comprehend.
Rather than compile an itemized list of failures, hospitals should instead classify the events and then report on them statistically. "Sentinel events, you will want to try to discuss the events as soon as possible, and disclose general information to the board," says Hendrickson. "And if a sentinel event did occur, then disclose information on any action taken to prevent similar events."
In addition to EP 13, the new interim requirements affect PI.02.01.01 EP 12-14.
EP 12 states that any time the organization has an undesirable event, it needs to evaluate the staff and their effectiveness. PI.02.01.01 EP 13 says that if a negative trend in the staff is noted, a report must be provided to the leadership.
In EP 14, a written report of the identified issues must be provided at least once a year to the leadership in charge of the patient safety program.
"The organization needs to have a process or policy that speaks to this so the surveyor can review the information," says Hendrickson.
"The new interim requirements include four new EPs, all of which are A- structure or a policy or plan, and three of them are direct impact standards," says Hendrickson. "The Joint Commission believes that if you are not in compliance, this is an immediate risk to patient safety because there are few processes to intervene."
Now, if an organization is cited for any staffing effectiveness, a short-term resolution is given, and the organization needs to come up with a solution within 45 days.
Patient and family education is one of those problematic standards and requirements for improvement that boggles the mind of many hospital survey coordinators.
In the course of patient care, every patient/family interaction is an opportunity to educate, says Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago.
The primary objective of patient education is to help patients and families understand their rights and responsibilities in their care, treatment, and services. Patients receive education and training specific to their needs and appropriate to the care, treatment, and services provided.
Eisenberg suggests incorporate patient teaching into your hands-on care. Some examples of organizational initiatives include:
"New" medication (first dose) monitoring (engage the patient in the process)
Medication administration and reconciliation (this is a great opportunity for patient teaching)
Advance directives (referrals to chaplains, social work or patient representative department)
Infection control/hand hygiene (share key points with patients as you take these actions)
Accreditation coordinators do not have to be an expert on every topic to begin teaching, says Eisenberg. Instead:
Ask the patient to review information and ask or write down questions. Go over the questions with the patient; answer what you know and defer other questions to clinical experts as appropriate.
For select topics, use teaching guides to help guide you.
Refer complex questions to clinical experts (e.g., advanced practice nurses and physicians)
Eisenberg recommends teaching topics by focusing on "need to know" instead of "nice to know" topics. Identify family members or significant others to involve in patient teaching.
The goal of discharge instructions is to provide the needed information to patients, family members, or significant others so that patients will be safe and comply with the recommended medical regimen until they reach the next level of care (e.g., clinic visit). Focus on:
Actions patients need to take (e.g., medicines, activities, diet, and appointments)
Who to call with questions
Signs and symptoms to report to physician or when to seek immediate medical treatment
Know your resources
Remember:
Patient education
Communication aids, such as interpreter services and language line
Know your patient and make a difference. To comply with the latter:
During hand-offs between departments/levels of care/change of shift report, share outstanding patient education requirements
Include important patient education components while developing competencies, policies, and procedures
While patient education is happening, remind staff to take credit for their teaching by:
Documenting each patient education interaction
Reviewing education provided daily and providing follow-up teaching as needed
Relief will come to facilities waiting for their unannounced survey from The Joint Commission, as a new and more collaborative process will take place in 2010, the organization announced recently. The new process is designed to be more sensitive to the time demands on facilities and staff during the survey process.
The Joint Commission will issue an e-mail alert to the facility that is scheduled to be surveyed saying which programs will be surveyed. This alert will also point the facility to the extranet page for a list of survey activities for each applicable accreditation program. In addition to getting this new alert, organizations will be able to work with the surveyor during the survey to determine the best time for various survey activities.
Those accreditation organizations looking to survey in 2010 should expect to experience this new agenda. The new process does not affect certification reviews.
Hospitals should also take note that The Joint Commission has released its 2010 survey guide. This guide provides details for preparing for an upcoming accreditation survey by offering advice on facilitating the on-site survey process, discussing logistics involved with the survey, how to meet surveyor needs for information and material while on-site, and a list of on-site survey activities.
The US has seen a steady improvement over the past seven years in patient care quality, according to The Joint Commission's new annual report.
The annual report, "Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2009," looks at heart attacks, heart failures, pneumonia, and surgical conditions, and provides evidence of improvements made.
"In addition to saving lives and improving health, improved quality reduces healthcare costs by eliminating preventable complications," Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission, said in a prepared statement. "Quality improvement is an important aspect of the ongoing reform effort to make healthcare accessible to more Americans and 'bend the curve' on increasing costs."
The Joint Commission, like CMS, has focused its energies on preventable conditions in recent years. "By eliminating the preventable complications that today drive up the cost of care, we would easily save billions of dollars lawmakers are struggling so hard to locate," said Chassin.
The Joint Commission now tracks 31 measures in the annual report—five more were added for the calendar year 2008. More than 3,000 Joint Commission accredited hospitals contributed data to the report. This year's report showed significant growth since the first report issued in 2002.
For example:
The overall results of heart attack care have seen great improvement from 2002, rising from 86.9% in the 2002 report to 96.7% in 2008.
Overall heart failure care has improved since 2002, from 59.7% to 91.6% in 2008.
Pneumonia care results have also improved significantly, rising from 72.3% to 92.9%.
However, The Joint Commission reported that some areas finished with low rates of performance—specifically the percent of hospitals providing fibrinolytic therapy within 30 minutes of arrival, and providing antibiotics to intensive care pneumonia patients within 24 hours of arrival.
