I had the privilege to represent AAHPM at the 18th Annual Liaison Network Forum at The Joint Commission (JC) headquarters in Oakbrook Terrace, Ill. I suspect many of us, in our professional career, have some hesitancy when approaching the JC but the “newer and friendlier” JC have some progressive, visionary work for the future of healthcare. It was a two-day conference and networking opportunity for 70 invited representatives from a diverse healthcare contingent representing a variety of organizations from the American Hospital Association, to the CDC to the Undersea & Hyperbaric Medical Society, Inc. All a friendly lot and it was very nice to see the AAHPM represented.

The JC enterprise actually has three divisions: the Joint Commission is the certification and accreditation company which is most familiar to us as the auditors showing up at our institutions doorsteps, The Joint Commission Resources which addresses safety and quality, nationally and internationally ( 41 countries so far) through provisions of education, publications , consultations and evaluation services, and the Center for Transforming Healthcare, a newer 501 C3 company which serves to offer solutions through setting up collaborative performance improvement projects with healthcare organizations in order to disseminate effective, durable solutions to the world.

The keynote plenary for the conference was given by Mark Chassin MD, MPP, MPH, President of the JC. In a nutshell, he set the stage for the future vision of the JC which is to transform healthcare into a “High-Reliability Industry” much like nuclear power and commercial air travel, which have highly effective process improvement and fully functional safety cultures. So a “simple” formula:

Robust Performance Improvement (RPI) + Safety Culture = High Reliability.

RPI involves systematic, highly effective strategies and tools for solving complex problems. Sort of a dynamic, continuous “root cause analysis” over time. RPI’s work to solve both routine processes like hand washing AND rare adverse events like wrong site surgery. Jerod M. Loeb, PhD the JC Executive VP for Quality Measurement and Research, points out that organizations must understand specific causes of problems they are trying to fix and then target interventions to those causes. He goes on to say the real challenge is the solutions (“Best Practices”) developed through this process may not work for all organizations across the board. Therefore the JC is suggesting “re-tooling” (the new buzz word) already established measures. Their newly published NEJM article (see reference below) summarizes this concept well.

Developing a Safety Culture involves trust, reportable, and appropriate use of RPI’s. The JC pointed out it’s not about developing a “blame-free “message but developing a culture that can separate small errors (blameless) from egregious(blameworthy)ones. The “Swiss Cheese Model”of assessing errors in healthcare that lead to harm was discussed extensively with emphasis on institutions assessing errors systematically, and establishing one code of behavior for all.

With all the “Big Picture” discussion at the conference as noted above, where did Hospice and Palliative Medicine fit in?
1) All issues mentioned above are important to HPM including RPI and Safety.
2) The attendees networking opportunity reinforced the support we have from a multitude of groups including the AHA, Critical Care Nurses, Critical Care Medicine, Pediatrics, the ANA, Physician Executives, Healthcare Executives, Nurse Practioners, Professional Chaplains, Women’s Health, the VA, Oncology Nursing, National Association of healthcare Quality.
3) The JC supports hospice care essentially by reinforcing the Hospice Medicare Benefit Conditions of Participation. They had no comment on the potential COP’s for face-to-face physician/NP visit mandates.
4) The JC supports palliative services and noted they were involved in standards development in the past but stated after this summer’s board meeting, they are still reluctant to develop a certification/accreditation process because they do not see any “ownership in the service” referring to funding support like CMS, Private Insurer, etc. They noted needing more “proof of sustainability” in order to move forward with certification. They agreed to listen to any input on this issue.
5) “Hand-off” communication in hospitals as patients move through different services was a hot topic and one HPM can make impact through a continuum of care model.
6) Unlike hospitals, long term care currently has no universal, comprehensive pain assessment standards.
7) The JC is reluctant to establish standards for chaplaincy services in hospitals due to fear of “creating a demand that can’t be filled by workforce”.
8) Maternal Mortality is increasing in the US and got a lot of attention especially related to future development of prenatal care standards. This also coincided with NICU and prenatal discussions.
9) The JC is just now starting to write standards for Children’s Hospitals. Input desired
10) The JC plans on writing standards for Long Term Acute Care Hospitals (LTACH) in 2011 which are an important population of patients for HPM.
11) The JC was embracing CMS COP’s for Telemedicine but CMS has momentarily stopped any work in this area and the JC does not know what will happen but reinforced their position that it is important for the future.
12) Health Information Technology is a complex integration program for the next few years. On example given is SNOMED-CT has no eMeasure code for “hospice care” in the comfort care section.

Overall, the meeting was very productive and interactive. The JC continues to emphasize their desire to collaborate with other organizations. With a growing number of competitive enterprises like the JC, we should expect more outreach, dialogue, and ability to contribute to their activities.

Chassin MR, Loeb JM, Schmaltz SP, Wachter RM, “Accountability Measures- Using Measurement to Provide Quality Improvement”, NEJM, June 29, 2010.