The Difference Between Passing a Joint Commission Survey and Continuous Improvement

With the recent scrutiny placed on the Joint Commission (TJC) in publications like the Wall Street Journal, TJC has found itself on the defensive regarding its accreditations and how it holds hospitals accountable for safety violations. In response, TJC has been trying to open up a dialogue with the public about the importance of its mission and process when it comes to hospital accreditation.

In an article penned by Mark Pelletier, Chief Operating Officer, Accreditation and Certification Operations at TJC, he describes that during the 750 surveys conducted in the first half of 2017, over 40 deficiencies were found per hospital. He goes on to state the importance of making sure that TJC is fostering an environment of long-term continuous improvement versus short-term punishment when pursuing corrective actions for these deficiencies:

“Addressing deficiencies means directly resolving the issues or receiving a Centers for Medicare & Medicaid Services waiver to go beyond 60 days for resolving problems that need the additional time—such as constructing a fire-rated wall, replacing a fire-rated door or addressing inaccessible smoke and fire dampers, for example.

Hospitals face preliminary denial of accreditation if they don’t address deficiencies and document their improvements for us in one of these ways.

These observations are the core and essence of our work:  The accreditation process is about quality improvement — it’s not about “passing” a survey.  Outside healthcare, there is a lot of misunderstanding about that.

Yanking Accreditation Won’t Improve Quality

There’s a misconception that when adverse healthcare events happen, a hospital’s accreditation should be immediate[ly] revoked.  The hard reality is that there are no perfect hospitals. No hospital, no accreditor, no government regulator can guarantee that adverse events won’t happen in any organization.

When an adverse event happens or our surveyors find a deficiency, it’s important to remember that denying accreditation will not shut down the hospital. It will continue operating — usually without addressing the problem or finding out what caused the adverse event in the first place. Our job is to help that hospital make and sustain quality improvements so a similar adverse event doesn’t happen again.

During 2016, 41 hospitals received a decision of preliminary denial of accreditation or time-limited preliminary denial of accreditation.  Denying accreditation is a last resort, undertaken when a hospital over time has demonstrated an inability to resolve deficiencies and sustain improvement. Fortunately, all of the 41 hospitals that received preliminary denial last year accomplished all needed improvements were made to maintain accreditation.

Why is revoking accreditation a last resort? We want hospitals to improve. I don’t think it’s unreasonable to say the public does, too. Leaving troubled hospitals to work out patient safety problems on their own doesn’t increase the chance they’ll do so successfully.  It serves no one, especially patients and the communities they live in.

We’ve Uncovered Problems. Now What?

When a hospital has serious problems that put patients and staff at risk, state and federal agencies assess necessary regulatory action.

When we receive information about problems at a hospital we accredit or certify, we’re there to help the organization take necessary quality actions to improve as quickly and sustainably as possible. We work with hospital leadership and staff to:

  • Identify the underlying root causes and where processes broke down
  • Review the hospital’s short- and long-term plans to immediately mitigate risks to patients and staff
  • Address challenges to implementing a sustainable solution.

I am proud to work with The Joint Commission because we actively support accredited and certified hospitals and clinical programs in implementing changes that tangibly improve health care quality and safety.

Every day our surveyors make unannounced visits to hospitals and identify problems and breakdowns in processes before they cause harm to patients.  Very often, hospitals were unaware the problems existed.  That’s why hospitals partner with us for accreditation: to learn and improve.”

Read the entire article here: Accreditation is About Continuous Quality — Not ‘Passing’ A Survey

Is your hospital ready for your next accreditation survey, and the journey to continuous improvement. To prepare, hospitals have to make sure that they are following all of their detailed processes all of the time. Any breakdown in your processes would be put under the microscope by the TJC surveyor. Consider automation tools that help track the processes that TJC and other accreditation agencies focus on during their inspections. Systems such as iRIScope have been developed to ensure that processes and protocols are being followed since your managers can’t watch over every step of the way.