This is the first of a three post series on the failure of external accreditation mechanisms to make the US Health Care Industry safer. The first post will serve as background and discuss the current state of Clinical Safety, while the next two will discuss All Hazards Natural Disasters and Biological Agents, while the third in the series will focus on Man-made Hazards such as Active Shooters, Terrorism and Workplace Violence in Health Care and a summary of thoughts on how and why this is such an intractable problem give the billions of dollars spent to improve safety in the industry.
Current State: Accreditation has Failed to Improve Outcomes
The Skinny on TJC Accreditation (BMH, posted on September 9, 2014 by Abby Norman) caught our attention and started us thinking about all the Nationâ€™s healthcare external evaluation mechanisms.Â Since The Joint Commission has enjoyed a near monopoly in the industry we will use its mission statement as a starting point, and continue with some observations about how this mission has not been achieved.
The stated mission of TJC: â€œTo continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and valueâ€.
We felt it would a good opportunity to respond with what in our opinion should beÂ a more critical viewÂ Â of entire external accreditation system, most of the oversight deeming entities – TJC, HFAP and DNVÂ -Â and TJC in particular. Founded in 1951,Â JCAHO (now TJC) has enjoyed aÂ close relationship with Congress and the Veterans Administration (VA) and quicklyÂ became a quasi-monopoly, receivingÂ an enormous amount of goodwill from those responsible for oversight of the organization. TJC has grown to be the premier global accrediting authority in the US, Â boasting 20,500 clients and through Joint Commission International (JCI), they have expanded to many other countries,Â offeringÂ accreditation often required to qualify for US contracts (Military, VA, State Department, Selected Corporate) abroad.
As with all large and bureaucratic organizations, especially those in a position to virtually monopolize the market without determined oversight, TJC has developed some conflicts of interest in the market and in some cases become a victim of regulatory captureÂ by some of the largest organizations in the industry. This was most clear when after finally incorporating strongÂ Emergency Management standards into the accreditation program, TJC climbed down and did not score the new standards after the industry balked. As early as 1998, TJC, then JCAHO, had come under criticism by its’ own regulators, as stated in the Presidential Advisory Commission on Consumer Protection in March 1998:
â€œConflicts of interest can arise from multiple sources. For example, private sector accrediting bodies have, as one of their customers, the entities that the organization accredits. The organizations to be accredited sometimes are the organizations that fostered creation of the accrediting entity, and often are necessarily involved in identifying the standards to which they will be accountable.â€
We will break out the clinical and safety/security categories below, but from an overall perspective of Quality, Access and Affordability, a recentÂ Commonwealth Fund reportÂ suggests that the US Healthcare System continues to lag other advanced economies, despite a whopping 18% of GDP being thrown at the problem. While we do not agree with several issues raised in the report, an objective claim can be made that the US spends too much for too little and does not provide enough access to care. ThisÂ interactive chartÂ (tool)Â we developed makes some global country comparisons and shows how the US has slipped in terms of spending and longevity versus other advanced economies.
We view accreditation as the key mechanism that should offer a steady rate of improvement in measurable quality and results in both Clinical and Physical Safety and Security. Unfortunately, the facts speak for themselves in both of these areas; we have not seen the benefits of continuous improvement, and in our opinion, the quasi-monopoly accreditation structure and lack of competition in setting and measuring the performance standards has hindered, ratherÂ than advancedÂ the healthcare industry’s ability toÂ continuously improve. We have long said in posts and our books that TJC accreditation is necessary, but not sufficient to keep patients safe, especially in our specialty discipline of physical safety and security and emergency management.
Clinical Care: Diagnosis, Treatment andÂ Outcomes
Primum non nocere (First, Do No Harm)Â There are two essentialÂ categoriesÂ of Â Safety and Security. The first isÂ ClinicalÂ and is focused on the quality of care, prevention of medical errors, and keeping the patient safe during their hospital stay from a medical treatment perspective. In this area, we are not experts, but can cite several examples from those who are:
“To Err is Human“, the seminal work published by the Institute of Medicine (IOM) in 1999,Â opened the industry’s eyes to the fact that as many as 98,000 patients died as a direct result of medical error in the diagnostic, therapeutic, preventative and other categories of care. There was theÂ predicableÂ hue and cry in the industry as medical error was shown to be a leading cause of preventable death in the country. But, as with many pronouncements, the urgency died down and the industry settled back into a routine within a few years.
To Err is Human â€“ To Delay is Deadly -Â Ten years later, a million lives lost, billions of dollars wasted,Â published by the Consumer’s Union in 2009, was a follow up to the initial study, which found that little progress had been made, and estimated using CDC numbers, that in the area of Hospital Acquired Infections (HAI) alone, there were about 100,000 deaths a year in the US. According to the report:
“Despite this initial flurry ofÂ activity (after the To Err is Human report) , progress slowed onceÂ the media moved on to theÂ next crisis. When the IOMÂ published a follow-up report inÂ March 2001, the release barelyÂ registered. By 2004, theÂ deadline for the IOMâ€™s goal ofÂ a 50% reduction in errors, noÂ national medical error reportingÂ bills had been passed andÂ the initial outrage surrounding the report had faded. MovementÂ towards systematic change to the health-care systemÂ remained â€œfrustratingly slow.â€
A September 2013 new, â€œEvidence-based Estimate of Patient Harms Associated with Hospital Careâ€Â paperÂ from theÂ Journal of Patient SafetyÂ reports that deaths from preventable medical errors areÂ in the range fromÂ 210,000 to 400,000 per year:
“Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year.Â Serious harm seems to be 10- to 20-fold more common than lethal harm.” (emphasis added).
This means millions of incidents of serious harm to patients, an outrageous number, in an environment that was not outrage-fatigued, as America seems to be in the light of no legislative action (or even deep discussion) in this area. Â As opined inÂ Forbes:
“If you arenâ€™t alarmed enough that our country is burying a population the size of Oakland every year, try this: you are paying for it. Hospitals shift the extra cost of errors onto the patient, the taxpayer and/or the business that buys health benefits for the infected patient. My nonprofit, which provides aÂ calculator of the hidden surcharge Americans pay for hospital errors, finds most companies are paying millions or even billions of extra dollars for the cost of harming their employees.”
And follows withÂ this:
â€œThe reason many hospital leaders fail to put a priority on safety is that we as a country havenâ€™t forced them to do so. On the contrary, we haplessly pay them for these errors. We tolerate hospital lobbyistsÂ insisting on hiding their error rates. We fail to insist on safety when we choose where to seek care or when we put together our businessâ€™Â health benefits. When we donâ€™t demand safety, they donâ€™t supply it.
Itâ€™s time for Americans to make clear to hospitals that they must earn our business, and our trust, and we will not pay with our lives for their failure to act.â€
Finally on the clinical side, the recentÂ Veterans Administration healthcare scandalÂ can serve as an excellent case study in the effectiveness of accreditation and TJC accreditation. TJC has enjoyed a monopoly with the VA for decades; just in the past ten years that means there would have been literally thousands of surveys of the 500+ VA hospitals and clinics. Despite this and many other warnings from the OIG and input from the Presidential transition team, TJC singled out the medical center in Phoenix, the one at the center of the 2014 scandal, as one of the top 20 hospitals in the nation in its 2010 report to Congress.
Our next post in this series will examine theÂ other Side of Safety and Security; Physical Safety and Security andÂ All Hazards Preparedness.