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KKKKKKK.KKKKKmKw1811KKKK ADDITIONAL EDUCATIONAL EVENTS RELATED TO 8UALITY AS SURANCE/JCAHO ACCREDITATION CCURRIN G IN FY 90 EVENTS: Consultant Visits, Mock Surveys TYPE: Face-to-face training/activities at each facility SUMMARY: Consultants external to VA expertise in Joint Commission survey process work with individual medical centers to develop facility-specific educational activites that will enhance their JCAHO activities and meet specific needs identified during last survey. AUDIENCE: Clinical Service Chiefs DATE & TIME: Through FY 90 and early FY 91 LOCATION: At each VA facility CONTACT: Local RMEC EVENT: "Drug Use Evaluation" TYPE: National Training Program, Regional SUMMARY: The program is designed to assist medical centers to improve the quality of, and develop a more effective drug use evaluation within medical centers. Emphasis is placed on methods for accomplishing Drug Utilization and Evaluation which are least resource intensive. AUDIENCE: Chiefs of Staff, Chiefs of Nursing, Chiefs of Pharmacy and QA Coordinators from old Regions 1 and 4. DATE & TIME: September 18 - 20, 1990. LOCATION: Chicago, IL CONTACT: Louise Rodriguez, Chief of Clinical Pharmacy QA VACO, FI'S: 373-7500 or \Villiam Deutsch, Program Director, CEC, FI‘S: 280-4174 < I ox m W > M ADDITIONAL EDUCATIONAL EVENTS RELATED TO UALITY AS SURANCE/JCAHO ACCREDITATION CCURRING IN FY 90 continued EVENT: "Preparing for Compliance: The New Joint Commission Nursing Care Standards" TYPE: Satellite Video Teleconference SUMMARY: Produced by AHA, in cooperation with the Joint Commission, the program addressed changes in Nursing Standards, why the changes were made, and how the changes will affect nursing procedures and preparations for Joint Commission AUDIENCE: Quality Assurance Coordinators/Managers, Nursing QA Coordinators ‘DATE & TIME: July 31, 1990 LOCATION: Received at each VA facility CONTACT: Lynn D. Ward, Program Director, St. Louis CEC EVENT: "Quality Assurance in Substance Abuse: A Committment to Excellence" TYPE: Workshop SUMMARY: The conference is designed to enhance the participant’s knowledge and understanding of issues relating to external JCAHO survey and accreditation. Quality Assurance is the main focus of the program. AUDIENCE: Chiefs and clinicians of inpatient and outpatient alcohol and drug dependence programs at selected VAMCS. DATE & TIME: July 24 - 26 and September 1990. LOCATION: Chicago, IL and Birmingham, AL CONTACT: Walter H. Cox, Associate Director/Education, Birmingham RMEC i $425;fo T4»?! xwwwww x wwww m g3 xmmw w THE JOINT COMMISSION ON , ACCREDITATION OF HEALTHCARE ORGANIZATIONS Reprinted from the JAMA' Journal of the American Medical Association August 21, 1987, Volume 258 CODW/gh! 1987. American Medical Association Special Communication — A History of the Joint Commission on Accreditation of Hospitals James S. Roberts, MD; Jack G. Coale, MA; Robert R. Redman, MA THE HISTORY of the Joint Commis- sion on Accreditation of Hospitals is a story of the health professions’ commit- ment to patient care of high quality in the 20th century. The story began on a summer day in England in 1910. While riding back to London from a visit to a tuberculosis sanitarium, Dr Ernest Codman was explaining his end-result system of hospital organization to Dr Edward Martin. According to Dr Cod- man, his system would enable a hospital to track every patient it treated long enough to determine whether or not the treatment was effective. If the treat- ment was not effective, the hospital would then try to find out how to pre— vent similar failures in the future. Dr Martin responded that he thought Dr Codman’s system was one ofthe impor- tant reasons why an American college of surgeons should be established: An American College would be a fine thing if it could be the instrument with which to introduce the End Result Idea into hospitals; in other words to standardize them on the basis of service to the individual patient. as demonstrated by available records.‘ Beyond establishing the concept of a linkage between an American college of surgeons and hospital standardization, this conversation was also the first exv pression of the principle that was even- From the DIVIStOn of Research and Planning (Dr Roberts). and the Departments 01 Corporate Relations (Mr Coale). and Publications (Mi Redman). Jomt Com- missmn on Accreditation oi Hospita 5. Chicago Reprint requests to Joint COmmtSSlOn on Accreditav tion 01 HOSDIlalS. 875 N Michigan Ave. Chicago, lL 60611 (Mr Coate) JAMA. Aug 21. 1987—«VOI 258. No 7 tually to guide the standardization pro- gram: service to the patient. Dr Martin’s interest in improving con- ditions in hospitals was shared by other physicians and by hospital adminis- trators in the United States and Can- ada. Conditions in hospitals were em- barrassing to the professions. Most hospitals were little more than board— inghouses for poor and sick persons. Patients were not examined when they were admitted, and because histories and diagnoses were seldom recorded, For editorial comment see p 951. medical records were useless. Most hos- pitals also lacked the equipment and services necessary for conducting proper preoperative and postoperative evaluation of surgical patients. Further- more, few efforts were made to deter- mine the results of patient care and treatment. Leading physicians believed that the basis of the most serious prob- lems was the lack of organized medical staffs. Certainly, no efforts were made to determine a physician's competence to practice in a hospital, and no one was held responsible for the quality of care provided to patients.2 While conditions in hospitals were viewed as grim, many involved in medi- cine and hospital administration were optimistic about the future. The source of their optimism was the convergence of significant advances in the science of medicine and in management concepts, as well as the recognition of the value of 10 hygiene in health care. Technological progress in the practice of medicine, particularly in the performance of sur- gery in hospitals, offered considerably safer care for patients. Management principles developed during the indus- trial revolution were also being applied successfully in all types of businesses, including hospitals. Interest in for- mulating standards of care and in devel- oping systems to produce better prod- ucts more efficiently began to spread. Dr Codman’s end-result system was just one example of the application of management principles to hospital care. These several factors were the back- ground against which the Third Clinical Congress of Surgeons ovaorth America met in November 1912. At this historic meeting, Dr Franklin Martin made a proposal that was to lead to the found- ing of the American College of Sur- geons. Immediately following that pro- posal, Dr Allen Kanavel set forth the following resolution at the request of Dr Edward Martin: Be It Resolved by the Clinical Congress of Surgeons of North America here assembled, that some system of standardization of hospi- tal equipment and hospital work should be developed, to the end that those institutions having the highest ideals may have proper recognition before the profession, and that those of inferior equipment and standards should be stimulated to raise the quality of their work. In this way patients will receive the best type of treatment, and the public will have some means of recognizing those institutions devoted to the highest ideals of medicine.3‘P”“”“75’ Joint Commissmn History—Roberts et at It is a tribute to Dr Martin’s foresight that he managed to associate this first official expression of the need for hospi- tal standardization so closely with the proposal that would result in the crea- tion of the American College of Sur- geons. There appeared to be a clear realization that the hospital standardi- zation program must have the backing of a national organization if it were ever going to have a chance to succeed. Largely because of his efforts, hospital standardization became one of the stated purposes of the College when it was founded in 1913. During the first few years of its ex- istence, the College focused its energies on solving problems of vital concern to its survival and success. Hospital stan- dardization quickly and unexpectedly became one of these problems. During the first three years of its existence, the College found it necessary to reject 60% of the applicants for fellowship because the 50 case records required from each fellowship applicant provided the col- lege with an insufficient basis to deter- mine clinical competence.‘ Shortly thereafter, John Bowman, PhD, the di- rector of the College, used his influence with the Carnegie Foundation, New York, to obtain a gift of $30 000 to launch a hospital standardization program. From Oct 19 to 20, 1917, 300 fellows from the Committees on Standards from every state in the union and every province in Canada, as well as 60 leading hospital superintendents, met in Chi- cago to discuss hospital standardiza- tion. During the conference, the partici- pants described existing conditions in hospitals and discussed the kinds of improvements that would be necessary to ensure the proper care and treatment of patients. This conference, the papers and some of the discussions of which are published in the first issue of volume 3 of the 1917 Bulletin of the American Col- lege of Surgeons,z is of interest not only because it established the foundation for hospital standardization, but also because it created the concept that knowledgeable and experienced health care professionals should assess condi— tions in the hospital environment and work to achieve consensus on standards that would have the greatest positive effect on the quality of care provided to patients. That concept continues to un- derlie the accreditation process today. On Dec 20, 1917, two months after the Conference on Hospital Standardiza- tion, the American College of Surgeons formally established the Hospital Stan— dardization Program, and in March 1918, the College published a “Standard on Efficiency” in the Bulletin. Expect- ing to approve at least 1000 hospitals JAMA, Aug 21, 1987—Vol 258, N0. 7 The Minimum Standard" 1. That physicians and surgeons privileged to practice in the hospital be organized as a definite group or staff, Such organization has nothing to do with the question as to whether the hospital is “open" or “closed," nor need it affect the mrious existing types of staff organization. The word STAFF is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the "regular staff," "the visiting staff," and the “associate staff.” 2. That membership upon the staff be restricted to physicians and surgeons who are (a) full graduates of medicine in good standing and legally licensed to practice in their respective states or provinces, (b) competent in their respective fields, and (c) worthy in character and in matters of professional ethics; that in this latter connection the practice of the division of fees. under any guise whatever, be prohibited. 3. That the staff initiate and, with the approval of the governing board of the hospital. adopt rules, regulations, and policies governing the professional work of the hospital; that these rules, regulations, and policies specrfically provrde: (a) That staff meetings be held at least once each month. (In large hospitals the departments may choose to meet separately.) (b) That the staff review and analyze at regular intervals their clinical experience in the variousdepartments ol the hospital, such as medicine, surgery, obstetrics. and the other specialties; the clinical records of patients. free and pay. to be the basis for such review and analyses. 4. That accurate and complete records be written for all patients and filed in an accessible manner in the hospital— a complete case record being one which includes identification data; complaint; personal and family history; history of present illness; physical examination; special examinations. such as consultations, clinical laboratory, X»ray and other examinations; provisional or working diagnosis; medical or surgical treatment; gross and microscopical pathological findings: progress notes; final diagnosis; condition on discharge; follow-up and, in case of death, autopsy findings. 5, That diagnostic and therapeutic facilities under competent supervision be available for the study, diagnosis, and treatment of patients, these to include, at least (a) a clinical laboratory providing chemical, bacteriological. serological, and pathological services: (b) an X-ray department providing radiographic and fluoroscopic servrces. 'Reproduced with permission from the American College of Surgeons (Bull Am Coll Surg 1924;824.) during the first year, the College staff began testing the program in April 1918. The results of the field trials were announced by Bowman at a conference on hospital standardization in New York on Oct 24, 1919. Bowman told the au- dience that 692 hospitals of 100 beds or more had been surveyed and that only 89 hospitals had met the standardsflpfl” While these results are not surprising when one considers conditions in hospi- tals at the time, the results were nevertheless shocking. Although the College made the num- bers public, it burned the list of hospi- tals at midnight in the furnace of the Waldorf Astoria Hotel, New York, to keep it from the press. Some of the most prestigious hospitals in the country had failed to meet the most basic standards. However, 109 hospitals corrected defi- ciencies after their initial surveys and were subsequently approved. Although the field trials were disappointing, they dramatically demonstrated the need for a national hospital accreditation pro- gram, and they solidified national sup- port for the program. Consequently, the College’s Board of Regents adopted five official standards for the program at its December 1919 meeting (Table).3“"’*39“9°’ These stan- dards, which are collectively known as the Minimum Standard, define those factors then considered essential to the proper care and treatment of patients in any hospital. Dr Franklin Martin, one of the individuals who developed the con- tent of the Minimum Standard, said it was intended to safeguard the care of every patient within a hospital by insisting upon competence on the part of the doctors, and upon adequate clinical and pathological laboratory facilities to insure correct diagnosis; by a thorough study and diagnosis in writing for each case; 11 by a monthly audit of the medical and surgi- cal work conducted in the hospital during the preceding interval; and by prohibiting the practice of the division of fees under any guise whatsoever? That these standards are as essential to the provision of quality care in hospitals today as they were in 1919 is no small tribute to the men who contributed to their development. In 1924, Dr Franklin Martin said that the Minimum Stan- dard had “become to hospital better- ment what the Sermon on the Mount is to great religion.“ With the adoption of the Minimum Standard, the accreditation process that continues today was set in motion. The following steps are included in this process: the development of reasonable standards that every organization should be expected to meet and that the health professions agree will have a positive effect on improving the quality of patient care; the voluntary request for survey and approval by a health care organization; the survey of the organiza- tion by professionals who assess compli- ance with the standards and provide consultation to support achievement of greater levels of compliance; and the subsequent efforts of organizations to use the standards and survey results to improve patient care. The Minimum Standard was consid- ered to be a beginning. The College knew that hospitals would advance and change, and it expected the Hospital Standardization Program to evolve with them. Ensuring that the standards and the accreditation process remain re- sponsive to conditions in health care organizations and focused on issues that will protect and promote quality of care has proved to be one of the greatest challenges'to the health professions. The Hospital Standardization Pro- gram had a strong beginning, and the value of the program became broadly Jornt Commission History—Roberts et al apparent. The case records submitted to the College by surgeons in approved hospitals provided an acceptable basis for evaluation, and the quality of care in these hospitals improved noticeably. As news of the program’s success spread, more and more hospitals sought ap- proval. The number of approved hospi- tals rose from 89 in 1919 to 3290 in 1950, over half of the hospitals in the United States. By 1950, the size and scope of the program had increased significantly, and the College, which had already invested $2 million in the Hospital Stan- dardization Program, was having diffi- culty in supporting the effort alone. In addition, the increasing sophistication of medical care, the growing number and complexity of modern hospitals, and the rapid emergence of nonsurgical specialties after World War II required that the standards be revised, ex- panded, and updated, and that the scope of the survey be extended. TheSe considerations clearly suggested that the Hospital Standardization Program needed the support of the entire medi- cal and hospital field. Consequently, the College solicited the support and par- ticipation of other national professional organizations in'the creation of an inde- pendent organization that could devote all of its efforts to improving and pro moting voluntary accreditation. After considerable deliberation, the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association joined the American College of Surgeons on Dec 15, 1951, to form the Joint Commis- sion on Accreditation of Hospitals as an independent, nonprofit organization. The Canadian Medical Association withdrew in 1959, to participate in the development of its own program, the Canadian Council on Hospital Accred- itation. The College officially conveyed its program to the Joint Commission on Dec 6, 1952, and the Joint Commission began to offer accreditation to hospitals in January 1953. In addition to carrying on the Col— lege’s program, the Joint Commission preserved the traditions established by the College. The accreditation process remains voluntary, the standards con- tinue to represent what health profes— sionals agree is most conducive to the provision of quality care to patients, and the accreditation survey still provides an evaluation that achieves its most beneficial effects through a combination of evaluation, education, and consulta- tion. Also, as in the past, the informa— tion obtained in the survey process is still held in confidence between the Joint JAMA, Aug 21. 1987—VOI 258, N0. 7 Commission and the organization sur- veyed. The Joint Commission today is di- rected by a 22-member Board of Com- missioners. Seven commissioners are appointed by the American Medical As- sociation; seven by the American Hospi- tal Association; three by the American College of Physicians; three by the American College of Surgeons; one by the American Dental Association, which accepted an invitation to become a corporate member in 1979; and one is a private citizen appointed annually by the rest of the board. Under the direction of the Board of Commissioners, the Joint Commission continued to expand the College’s pro- gram, which was now called the Hospi- tal Accreditation Program. It hired and trained a cadre of experienced sur- veyors and focused the survey on medi- cal staff and patient care issues; and just as the College of Surgeons had done, it periodically revised the standards to reflect the evolution of hospital care. In August 1966, the Joint Commission board made a major decision to under- take a complete revision of the stan- dards to reflect an optimal achievable rather than a minimal essential level of care. This decision, which redefined the Joint Commission’s role in health care, was made for two reasons. First, the majority of hospitals in the country had achieved and were maintaining the min- imum standards, and because of this, the standards no longer challenged hos- pitals to reach for the levels of quality care the Board of Commissioners thought could now be achieved. The second reason was even more compel- ling. Dr John Porterfield, who was then the director of the Joint Commission, described it as follows: In the mid 1960s the Joint Commission found itself no longer the advanced and lonely leader. The Federal government wrote its conditions for participation in Medicare. State after state with new and refurbished licensing authority wrote regulatory codes, where there had been few or none before. ,They did have some premise on which to build and it is more than coincidence that the federal conditions and, more particularly, the state codes bore a strong family re- semblance to the Joint Commission’s accred- itation standards. From advanced leader, the Joint Commission seemed almost overnight to be struggling to stay even in the vanguard of progress. And it was challenged, most seriously, as being no longer necessary be— cause now everybody was.beginning to do what it had once done alone.7 When the government moved toward usurping the Joint Commission’s role as the definer of the minimal acceptable level of hospital care, it became neces- sary and appropriate for the Joint Com— 12 mission to become the definer of the optimal achievable level of care. In doing so, the Joint Commission was not only realizing the intentions of the founders of hospital standardization, but also assuming a role that was more compatible with the ideals of the health professions that supported voluntary accreditation. The publication of the optimal achiev- able standards in the 1970 Accreditation Manual for Hospitals was a landmark.” In little more than 50 years, the one- page set of standards that specified a minimal essential level of performance had developed into a 152-page manual of state-of—the-art standards. The Joint Commission did not intend the term optimal achievable to mean the ideal. It meant the best that could be achieved at the time, given the legal and other concerns that must be accommodated in national standards to make them as effective as possible.9 The publication of these standards was a clear indication of the tremendous progress hospitals had made since the beginning of this cen- tury and of the impact of voluntary accreditation on the quality of hospital care. In the early 19605, concern for the quality of care provided in other types of health care organizations that were proliferating throughout the country led the Joint Commission and other national professional organizations to discuss the possibility of developing new accreditation programs. The expansion of the Joint Commission to include pro- grams for other types of health and health-related organizations seemed only natural after the successful lead- ership it had demonstrated in improv- ing hospitals. The Joint Commission had experience and expertise, and it had national scope and acceptance. A principal organization for voluntary ac- creditation would also give unity and strength to new accreditation efforts and would afford the greatest opportu- nities for the coordination of efforts and consistency among approaches to ac— creditation. Working with an ever-expanding number of national professional organi- zations, the Joint Commission devel- oped standards and accreditation pro- grams for a broader variety of health care settings. An accreditation program for long-term care facilities was estab- lished in 1965, for organizations serving developmentally disabled persons in 1969, and for psychiatric facilities, sub- stance abuse programs, and community mental health programs in 1970. An accreditation program for ambulatory health care programs was established in 1975 and for hospices in 1983. Joint Commission History—Roberts et al During the expansion, the Joint Com- mission established what are now called Professional and Technical Advisory Committees. One of these committees advises each Joint Commission accred- itation program on standards develop- ment and survey procedures. Each com- mittee is composed of approximately 15 individuals who are usually appointed as representatives of national organiza- tions having expertise relevant to the particular accreditation program. In addition, approximately 15 experts on education and publications and 15 on health care safety serve on committees that advise the Joint Commission in these areas. All Joint Commission ac- creditation services are supported by education, publications, and research activities. Through its Board of Commissioners, the various committees that advise the Joint Commission on a regular and ad hoc basis, the thousands of facilities that participate in the accreditation process, and a standards development process that includes extensive review by the field, the Joint Commission maintains close working relationships and contin- uous communications with health pro- fessionals. Through these mechanisms, the Joint Commission monitors the health care environment and has access to the best advice available in health care. This is of incalculable value in the Joint Commission’s efforts to maintain state—of—the-art standards and survey processes, as well as education pro- grams and publications. These mecha- nisms also give the Joint Commission a large measure of assurance that current issues and trends will be fully discussed before important decisions are made. In addition to its close working rela— tionships with the health professions, the national professional organizations that represent them, and the wide array of accredited organizations, the Joint Commission has important relation- ships with government. These relation- ships began in 1965, when Congress passed Public Law 89-97, the Medicare Act. Written into this law was a provi- sion that hospitals accredited by the Joint Commission were “deemed” to be in compliance with most of the Medicare Conditions of Participation for H aspi- tals‘o and, thus, deemed to meet eligi- bility requirements for participation in the Medicare program. Because a hospi- tal that was certified for Medicare was also considered certified for Medicaid, hospitals accredited by the Joint Com- mission were similarly eligible for Medi- caid participation. Consequently, hospi- tals that desired to participate in the Medicare and/or Medicaid programs could undergo either a certification in- JAMA, Aug 21. 1987—VOI 258, No. 7 spection by a state agency or an accred- itation survey by the Joint Commission. Government oversight and responsi— bility were added to this system in 1972 through amendments to the Social Se- curity Act, Public Law 92-603. These amendments required the Secretary of the Department of Health and Human Services to validate Joint Commission findings on a selective sample basis or on the basis of substantial complaint. The law also required the Secretary to include an evaluation of the Joint Com- mission accreditation process, as gleaned from validation surveys, in his annual report to Congress on Medicare. Accredited psychiatric and tuber- culosis hospitals were not accorded deemed status by the Social Security Act. Instead, the Act required that such hospitals be accredited by the Joint Commission to participate in Medicare and Medicaid. Because this require- ment impinged on the voluntary nature of the accreditation process, the Joint Commission sought and finally suc- ceeded in obtaining elimination of this mandate in the Deficit Reduction Act of 1984, Public Law 98—369. The Joint Commission also has devel- oped relationships with state govern— ments. 'lbday, 39 states and the District of Columbia have incorporated the Joint Commission’s hospital accreditation re- quirements, in whole or in part, into their hospital licensure systems. In most of these states, however, licensure is not granted merely on the basis of accreditation, but rather on the basis of an acceptable review of Joint Commis- sion findings by the state licensing agency. All of the affected states have retained the enforcement powers that accompany responsibility for licensing hospitals. Even though a hospital is considered licensable if it is accredited, the hospital must still comply with li- censing laws and regulations. Accredited hospitals have been con- sidered to meet Medicare health and safety standards for over 20 years now, and the Joint Commission has consider- able experience with state licensure programs. Through this time, there is no evidence that these arrangements have had any negative effects on Joint Commission standards and survey pro- cesses. On the other hand, there is considerable evidence that these coop— erative relationships with government have had synergistic effects that benefit all concerned. The combination of private sector and public sector responsibilities has served as a stimulus for the Joint Commission to improve its accreditation process. A two-year study of the Joint Commis- sion, state agencies, and what was then the Department of Health, Education, and Welfare, was conducted by the Gen— eral Accounting Office and reported to Congress on May 14, 1979, in publication HRD-79—37, The Medicare Hospital Certification System Needs Reform.u Although the report identified deficien- cies in the procedures of all three orga- nizations, it praised the Joint Commis— sion for the consistency, effectiveness, and economy of its standards-setting, surveyor-training, accreditation-sur- vey, and decision-making processes. At the state level, cooperative ar- rangements with the Joint Commission have provided states with an alternative perspective on the strengths and weak- nesses of the hospitals under their ju- risdiction and have enabled them to concentrate their resources and en- forcement efforts on problem facilities. These arrangements have reduced the number of surveys that hospitals have had to undergo and, consequently, there have been considerable savings of time, effort, and money for these hospi- tals. No history of the Joint Commission’s voluntary accreditation program effort would be complete without a discussion of quality assurance. The first national requirements calling for regular review and evaluation of the quality of care provided to patients in hospitals were part of the minimum standards of the American College of Surgeons. After the Joint Commission assumed respon- sibility for the College’s program, ef- forts were undertaken to develop stan- dards for the various services in modern hospitals. These standards paralleled the minimum standards with regard to their emphasis on review and evaluation of the quality of care provided. How- ever, most in-hospital evaluations that were conducted were informal and sub— jective and were based on an individual practitioner’s knowledge and experi— ence in evaluating records and in ob- serving the performance of others. At the same time, those involved in quality assurance research were devel— oping methods to make the review and evaluation process more structured and objective. While various approaches were proposed, all involved two com- mon elements. These focused on the use of systematic review procedures and the development of objective and valid crite- ria for measuring the actual quality of care being provided. Both of these ele- ments constituted the essence of a medi- cal audit methodology that the Joint Commission began promoting in the early 19705. As a result, retrospective outcome-oriented audits were con- ducted throughout the country. Medical audits even became requirements of the Joint Commission History—Roberts et al Professional Standards Review Organi- zations legislated in 1972, in Public Law 92-603. While encouraging the medical audit as a method of reviewing quality of care, the Joint Commission also directed at- tention to enhancing and clarifying other quality assurance standards. Re- quirements concerning medical staff— monitoring functions were consolidated and clearly defined as surgical case, pharmacy and therapeutics, blood and antibiotic usage, and medical records review. Standards were also adopted that called for review and evaluation of both the quality and appropriateness of care provided by medical and support service departments. Safety manage- ment, infection control, and utilization review standards were also strength- ened. Finally, the Joint Commission adopted standards that asked hospitals to consider relevant results of quality assurance activities in reviewing the credentials and delineating the clinical privileges of medical staff members. This was the first explicit reference in Joint Commission standards to the im—_ portant relationship between quality assurance activities and the delineation of clinical privileges. Despite this quality assurance focus, most relevant hospital activities con- sisted of formal audit studies. In too many cases, these studies became pa- per exercises conducted to meet Joint Commission or Professional Standards Review Organization requirements. Be- cause of this, the quality assurance ef- Reterences 1. Codman EA: An autobiographic preface, in The Shoulder: Rupture of the Subraspinatus Tendon and Other Lesions in or About the Supracmmial Bursa. Boston, Thomas 'Ibdd Co Printers, 1934, pp v-vi. 2. Hornsby JA: Hospitals as they are: The hospital problem of today—what is it? Bull Am Coll Surg 1917;1:4-11. 3. Davis L: Fellowship QfSurgeons: A History of the American College of Surgeons. Chicago. Amer— ican College of Surgeons, 1973. fort was compromised and failed to ef- fect the desired intent. Preoccupation with the audit requirement rather than quality of care had left hospitals at the periphery of meaningful quality assur- ance activities. To address this problem, the Joint Commission developed a new quality assurance standard in 1979, which elimi- nated the numerical audit requirements and directed hospitals to develop a hos- pital—wide program that integrates all quality assessment activities. The pur- pose of the standard was to shift the attention of hospitals toward a system— atic quality assessment process, the central element of which was the moni- toring and evaluation of all important aspects of patient care to-identify and correct patient care problems. Since adoption of the new quality assurance standard for hospitals in 1979, the Joint Commission has estab- lished similar standards for all of the other types of health care organizations that it accredits. Through this stan- dard, the Joint Commission intends to foster the integration of quality assur- ance mechanisms into the core manage- ment systems of accredited facilities. Clearly, quality assurance activities are increasingly linked to the processes of planning, budgeting, and tracking the utilization and cost of limited resources in many health care organizations to- day. The evolution of voluntary accredita- tion has spanned most of the 20th cen- tury and is an integral feature of the era 4. Schlicke CP: American surgery’s noblest experi- ment. Arch Surg 1973;108:379-385. 5. Martin FH: Fifty Years of Medicine and Sur- gery: An Autobiographical Sketch. Chicago, Lake- side Press, 1934, p 338. 6. Stephenson CW: The College's role in hospital standardization. Bull Am Coll Surg 1981;66:17-29. 7. Porterfield JP: From the director's office. Bull JCAH 1972;421-2. 8. Joint Commission on Accreditation of Hospitals: 1970Accreditation Manualfor Hospitals. Chicago, Copyright 1987, American] Medical Association. Reprinted with permission from the JAMA Journal of the American Medical Association, August 21, 1987, Volume 258, pp. 936-940. 14 of modern medicine. Beginning with the commitment of the American College of Surgeons, the process has steadily gained the support of the hospital and medical fields. Today, the Joint Commis- sion accredits approximately 5000 of the 6500 hospitals in the United States and 2800 other health care organizations. Approximately 1% to 2% of those who seek accreditation do not achieve this status—a reflection of the strong pro- fessional motivation of those seeking accreditation to meet the established standards. Since the Joint Commission began, the voluntary accreditation movement has spread to Canada and Australia, and in 1981, the Catalonia province of Spain implemented the first hospital accreditation program in Europe. Inter- est in voluntary accreditation and qual- ity assurance systems in health care is now spreading rapidly to other coun- tries. Since 1917, the voluntary accredita- tion movement has been a consistent and persistent voice for quality in health care. The future holds its own chal- lenges, but as in the past, meeting those challenges provides substance to the merits of voluntarism—of the willing- ness of the health professions to regu- late themselves on the basis of their ideals, integrity, and commitment to patient care. The Table is reproduced from reference 3, with permission from the American College of Sur- geons. Joint Commission on Accreditation of Hospitals, 1971. 9. Porterfield JP: Mechanisms for hospital stan- dards. Bull JCAH 1968;48:1-4. 10. US Dept of Health, Education, and Welfare: Conditions of Participation for Hospitals Social Security Administration, 1966. 11. US General Accounting Office: The Medicare Hospital Certification System Needs Reform: Re- port to Congress US General Accounting Office, 1979. THE JOINT COMMISSION’S AGENDA FOR CHANGE --STYMULATING CONTINUAL IMPROVEMENT IN THE QUALITY OF CARE- Contributed by Dr Dennis O’Leary, President, JCAHO. INTRODUCTION--THE MERGING OF PUBLIC INTERESTS IN THE VALUE OF HEALTH CARE. ' The 1980’s were years of dramatic change in the United States health care delivery system. The institution of major reforms in payment mechanisms for hospitals and physicians and the development of more intense provider competition were dramatic characteristics of the period but perha s the most far-reaching change was that the country’s long-standing priority for quality care was reshaped by compe ing demands for greater efficrency in the delivery of services and for more objective evidence of the effectiveness of care. As a new decade begins, those who pay for and consume health care increasingcliy are expecting an objective accounting of the results of care. Organizations that are able to demonstrate that they prov1 e care in an e fective and efficient manner are likely to be the winners in this new environment. This striking chan e in public policy and societal e ectations occurred at a time when a major re-evaluation was already underway within tfie J omt Commission. There had een mounting indications that the steady accretion in the volume of standards had resulted in a blurring of the evaluation focus and, indeed of performance expectations. It was becoming clear as well that the historical concentration on analysis of capability should be supplemented by the monitoring of actual performance. In 1986, this searching review process led to a determination to embark on a multi-year initiative to reshape the nature, though not the fundamental purposes, of accreditation. It was thus agreed that the methods the Joint Commission used to evaluate and monitor health care organizations could and should be improved. The shift in public policy and the commitment to improve the accreditation process both grew from a wide-spread belief that health care organizations could provide services more effective] while also serving as more prudent stewards of the enormous investment made by government, business and the public in the health care system. Simply stated, a broad-based conseilnsus had evolved that value--the relationship and balance between quality and cost--must become the new objective in healt care. This consensus is, of course, but a precursor to organizational change. Incorporation of this concept into the day-to-day operation of health care or ' trons will be the challenge for the 19905 and health care organization leaders will be in the spotlight as they direct, an lead, corporate culture change. This effort will be paralleled by steady and substantial improvement in the methods used to evaluate and improve governance, management and clinical care activities. Those who govern and manage health care organizations have historically devoted their energies to the management, vauisition and deployment of resources. This set of activities has large] been detached from the systematic identification of community needs, and resource allocation has infrequently been guided by information derived from assessment of patient outcomes and organizational performance in the delivery of services. In fact, the ability to s stematically collect and use indicators of patient functional, physiological, and psychological outcomes is in its infancy in e vast majority of health organizations. To all appearances, the two ingredients of an assessment of the value of an organization’s care--its cost and its quality--have been addressed independently in most health care organizations and with widely differing levels of sophistication. Attention must now be devoted to im roving and applyin methods for the assessment and im rovement of patient care. The critical coroll of this effort is the obv10us need foriealth care managers, governing b y members and health care practitioners to wor together far more closely to evaluate and improve the rocesses that lead to efficient delivery of quality care--that lead to real value. This must be a cross-organizational initiative that involves conscious efforts to overcome traditional but artificial internal barriers. The purpose of the Agenda for Change is to guide organizations in meeting these needs. Drawing from its widely accepted role in fostering improvement in the quality of health care, the Joint Commission intends to apply its standard-setting, evaluation, decision-making and education capabilities to support the improvements that are clear y necessary to meet t e demand for value in health care. The Agenda for Change is the overarching initiative that encompasses these activities. Through the Agenda for Chan e, the accreditation process and expectations of organization performance will progressively evolve over the coming decade. < fl {7. m f 7:! a» THE JOINT COMMISSION’S AGENDA FOR CHANGE continued --STYMULATING C 0N TINUAL IMPROVEMEN TIN THE QUALITY OF CARE UNDERLYING CONCEPTS OF THE AGENDA FOR CHANGE The Agenda for Change is guided by the following interrelated and self-reinforcing concepts. 1. Patient outcomes are influenced by ALL of the activities of a health care organization. The effectiveness and efficiency with which a health care organization addresses its patients’ needs is the combined result of the performance of its governance, managerial, clinical and support service functions. 2. Continual improvement in the quality of care should he a priority goal for a health care organization. The complexities involved in providing patient care increase almost daily. The constant evolution of medical management sciences combined with the unique characteristics of each patient, make perfection an elusive, and largely unattainable goal in health care. The unrealistic expectation that quality can be "assured" must be replaced by the more achievable goal of continual im rovement. Most health care organizations are composite networks of human performance which must function e fectively and efficiency to support patient care. The fragility of these systems offers many continuing opportunities for meaningful improvement. 3. The Joint Commission should focus on those activities of a health care organization that are most important to the quality of care. There is a finite set of activities performed by a health care organization that are essential to quality and should be addressed in national standards. Conversely, requirements that are not clearly relevant to quality of care should be deleted from existing standards. 4. 'Ii‘aditional standards compliance assessments should be complemented by Joint Commission collection, analysis and feedback of data that reflects the actual performance of accredited organizations in undertaking key activities. Health care organizations should have timely access to data that displays their own performance over time and their performance relative to others. Such data would provide the or anization with both an early warning of performance areas requiring attention and a constantly evolving baseline against which to judge the effectiveness of its organization-wide r am of continual improvement. Some organizations have created or arranged linkages to central databases t at incorporate relevant performance measures, but many others do not have such capabilities or opportunities. Large databases provide a context for assessing individual organization performance. SPECIFIC OBJECTIVES OF THE AGENDA FOR CHANGE These underlyin concepts lead naturally to specific objectives. These objectives address redirection of the standards, establishment 0 performance, monitoring capabilities, and improvement in the survey process, and are summarized below. Objective #1 -- Redirection ofJoint Commission Standards. There are three aspects of this objective which is expected to result in a significant net reduction in standards volume. A. Reducing the number of complexity of standards. Efforts are already underway to eliminate outdated standards, to reduce standards duplication, and to delete unnecessary and constraining structural requirements, including narrowly-defmed assrgnments of responsibility. This is an on—going activity. B. Refocusing the standards on key functions. Joint Commission standards have, for years, contained requirements for the performance of functions that are generally believed to be essential to the provision of quality care (e.g., control of infections; systematic monitoring using key indicators; matching individual credentials with demonstrated competence). The eventual intent is to reform the standards manuals along functional, rather than structural, lines. THE JOINT COMMISSION’S AGENDA FOR CHANGE continued "SHMULATING CON TINUAL IMPROVEMEN TIN THE QUALITY OF CARE C. Creation of standards that provide a foundation for continual improvement Current standards do not offer a cross-organizational perspective and have not directed sufficient attention to factors that are integral to effective continual improvement activities. Greater emphasis will be placed on the role of leaders in establishing, directing and sustainin a quality im rovement program; the general methodologic requirements for systematic an broad-base quality assessment and improvement activities; and the management of information that supports quality assessment and improvement activities. These priority areas may in the future be supplemented by other standards development initiatives if and when additional needs become apparent. Objective #2 -- Establishment of Performance Monitoring Capabilities. There is general agreement both within the health care field and among purchasers and users of health care services that external evaluation should be focused more on performance and less on capability to erform. While standards re-direction will provide a framework for this change in em hasis, there is a separate and compe ' g need to develo actual performance monitoring capabilities. Thus, an essentiafbomponent of the Agenda for Change involves the creation of useful performance measures and the establishment of an interactive reference database. The articulation of clinical performance expections (e.g., ractice guidelines) is a related need that is being undertaken by a variety of other organizations. The major aspects 0 this Agenda or Change objective include the following. A. To develop a rigorous method for the creation of valid performance measure. There is a paucity of relevant literature and a large and growing demand upon health care organizations to provide performance data. Performance indicators should address important questions about the appropriateness, effectiveness, interpersonal and other aspects of quality care. Given the virtual absence of existing guideposts, the development of performance indicators must draw upon expert consensus, provide for appropriate testing, and apply standard requirements for evaluating performance indicators. The Joint Commission has created a sound method for performance indicator development and intends to encourage its use by other organizations who have a clear stake in meaningful performance evaluation. B. To develop and test sets of performance indicators that relate to the performance of key organization functions. Key organization functions may involve the direct provision of care or may be less obvious to the patient. Indicator sets that are at various stages of development include obstetrics care, anesthesia care, oncology care, cardiovascular care, trauma care, infection control, and medication usage. Candidate areas for further Joint Commission indicator development include laboratory services, imaging services, perioperative care (including appropriateness determinations), home care, mental health services, long term care and ambulatory care. The Joint Commission has neither the desire nor the intent to be the sole or even the primary source for indicator development. Indeed, health care organizations must themselves eventually determine the unique aspects of the services they provide and develop appropriate additional measures to monitor performance. C. To establish affordable mechanisms for the Joint Commission and health care organizations to support data collection, transmission, analysis and feedback. This set of activities is an essential precursor to the creation of an interactive database through which performance trends may be monitored and organizations can compare their performance with others. An integral com onent of the testing of indicators is the identification of efficient and reliable methods for data handling by the ealth care anizatron and by the Joint Commission. This effort requires careful attention to data definitions, efficient approac es to data transmission, and reporting formats that are clear and useful.. D. To establish a national database that incorporates both standards compliance information and performance data. The interplay of standards compliance and performance information should rmit a more so histicated understanding of the clinical and managerial factors that exert the greatest in uenoe on the ac 'evement of positive patient outcomes. This database is expected to be an important resource to health care organizations in assessing their performance and to the Joint Commission in enhancing its monitoring capabilities. THE JOINT COMMISSION’S AGENDA FOR CHANGE continued «STIMULATYNG CON TIN UAL IMPROVEMENT IN THE QUALITY OF CARE Objective #3 - Improvement in the Survey Process. The Joint Commission will continue to conduct periodic on-site surveys to assess compliance with standards. These surveys must be tailored to accommodate the progressive changes in standards em basis and to direct particular attention to the effective use of performance measures. Specific aspects of this objective mclude the following. A. To direct greater attention to the effectiveness of the communication and collaboration among the governing body, management, clinicians, and su port staff. For a number of organizations, t ese attributes have proven to be essential in achieving excellence in patient care and organizational success. B. To develop the capability to assess the rigor and effectiveness with which organizations apply performance measures and use the resulting data to improve performance. Except in extreme cases of poor performance, indicator data will not per se form the basis for accreditation decisions. The Joint Commission intends to assess the or anization’s application of relevant performance indicators and the effectiveness with which it addresses identifi issues. Effective use of performance measures and data will thus be primarily a standards compliance consideration. C. To reassess surveyor recruitment criteria and training requirements. Effective evaluation and helpful consultation through the survey process will become even more important. Several options are under consrderation to support the provision of both types of services. D. To enhance the consistency of standards interpretation and the precision with which the Joint Commission makes accreditation decisions. Attention is being directed to assuring the clarity of standards intent and to providing additional descriptions of acceptable approaches for demonstrating standards compliance. Simplification of the com uterized decision process is also a high priority. These efforts are expected to further reduce variances in eva uation consistency. CONCLUSION The contemplated improvements and refinements in the accreditation process will have far-reachin implications both for the Joint Commission and for accredited health care organizations. Implementation of the Agenda or Change is current and is intended to be an evolutionary process in the years ahead. A successful transition will require the careful shepherding and appropriate allocation of limited resources. Further, the re-orientation to continuous improvement and the organizational culture change that this implies are daunting challenges for each health care organization. The Joint Commission believes that the change process must begin now and views itself as an important resource in assisting organizations to meet these important challenges. At the same time, the Joint Commission is committed to an on-going assessment of the field’s readiness for change and an implementation process that is progressive but not revolutionary. The Agenda for Change is oriented to the future, but the future is now. In its effort to provide better services to the field, the Joint Commission 18 currently devoting major resources and energy to its own uality improvement pro am. This effort has provided a sobering appreciation of the extent of behavioral change that 15 required in order to e ect true improvement in organizational performance. Organizational leadershi , staff training, and the development and use of performance indicators are all mtegral components of the program. Tlfis is the type of transformation envisioned by the Agenda for Change. The Joint Commission’s e rience with the Agenda for Change has reaffirmed its conviction that the persistent and active search for improvement me the most effective means for answering the public call for value in the provision of health care services. The work products of the Agenda for Change should serve as valuable resources for organizations as they seek to meet this objective. m FACTS ABOUT JOINT COMMISSION ACCREDITATION The Joint Commission accredits more than 5,400 hospitals and evaluates and accredits more than 3,200 other healthcare programs. Joint Commission accreditation is available for -general and psychiatric hospitals -nursing homes and other long term care facilities -psychiatric facilities such as substance abuse programs, community mental health center, programs for the mentally retarded and developmentally disabled, and adult and adolescent psychiatric programs -outpatient surgery centers, urgent care clinics, group practices, and community health centers -hospices -home care organizations -managed care organizations The Joint Commission is governed by a 24-member Board of Commissioners with members representing -the American College of Physicians; -the American Hospital Association; -the American College of Surgeons; -the American Medical Association; -the American Dental Association; -plus, three public members. The Joint Commission on Accreditation of Hospitals was founded in 1951. The name was changed to the Joint Commission on Accreditation of Healthcare Organizations in 1987. More than 400 physicians, nurses, healthcare administrators, medical technologists, psychologists, respiratory therapists, pharmacists, durable medical equipment experts, and social workers are employed by the Joint Commission to perform the surveys. Healthcare organizations voluntarily seek Joint Commission accreditation because -it enhances community confidence -it may fulfill state licensure requirements -it affects medical staff recruitment -it may favorably influence insurance premiums -it provides a staff educational tool -it expedites third-party payment m TWELVE REASONS FOR MAINTAINING J CAHO ACCREDITATION 0|th 9‘ l—A G H H H N . Community confidence is enhanced. The accreditation process impacts quality positively and the public knows it. . Medical staff recruitment, pride and status are directly affected. . Third-party payment is significantly expedited. . Recruitment of non-physicians staff is materially impacted. . Education programs(non-physician), residencies, and internships are often made available only in accredited organizatlons. Lenders and bond underwriters routinely require accreditation survey reports as a portion of the submission packet. . Managers find that external standards are readily accepted as a valid reason for required performance. . Government agencies favor accredited facilities in program placements, and consider accreditatiOn status in testimony assessments. . Some voluntary agencies, managed care plans, and professional societies limit benefit availability based upon accreditation. . Some foundations will fund research and service projects more readily when the setting for the activity is an accredited organization. . Since the Darling case, organizations are held accountable to accreditation standards by courts. Liability risk is reduced, therefore, by thorough conversance with standards, which is best gained through the accreditation process. . Physicians conducting peer review and committee obligations find that resistance is lessened when they can point to an external, national source for quality standards which are monitored and enforced. < :1: 8 w W > H J CAHO MONITORING AND EVALUATION PROCESS 21 u QUALITY MANAGEMENT AND THE TEN-STEP PROCESS QUALITY MANAGEMENT COMPONENTS: Utilization review Safety and risk management Quality control _credentialing and privileging _comp1iance with policies and procedures Infection control _X_Monitoring and evaluation (M&E) J CAHO TEN-STEP M&E MODEL: 1. Responsibility . Scope . Important aspects of care Indicators . Thresholds . Collect and organize data . Evaluate care goqamznmto Take action 9. Assess actions and document improvement 10. Communicate and integrate relevant information H J CAHO SCORING GUIDELINES Copyright 1988 by the Joint Commission on Accreditation of licalthcare Organizations and reprinted with permission. Scoring Guidelines for the Medical Staff Purpose of the Scoring Guidelines The Joint Commission on Accreditation of Healthcare Organ— izations sets forth specific responsibilities for a hospital's medi- cal staff as part of its goal of providing high quality in patient care. These responsibilities are delineated in the “Medical Staff' chapter of the Accreditation Manual for Hospitals (AMH). These standards and required characteristics discuss various compo— nents of the medical staffs functioning, including appointment, bylaws and rules and regulations, organization, clinical priv— ileges, reappointment and reappraisal, monthly review, and the monitoring and evaluation of the quality and appropriateness of patient care (which encompasses the medical staff monitor- ing functions). This book has been prepared as a guide to hospi- tal medical staffs in understanding the bases for surveyor scoring in these areas and as a means of increasing surveyor consistency. The publication of these types of guidelines is relatively new in theJoint Commission accreditation and deCIsion-making process. As the guidelines continue to be tested and refined in the field, updated information will continue to be presented in revised editions. This second edition of Hospital Accreditation Program Scoring Guidelines: Medical Staff Standards contains clar— ification of the scoring guidelines for the standards in the "Medi- cal Staff" chapter of the AMH. Also reflected in this edition is the most current information on the Joint Commission's monitoring and evaluation process for measuring the quality and appropriateness of patient care. Use of the Scoring Guidelines Scores of I through 5 are listed for the key standards and required characteristics in the “Medical Staff“ chapter. These numbers correspond to those in the rating scale on the right of each page in the AMI-i. They have been assigned the following values: 25 I Substantial compliance. The hospital consistently meets all major provisions ofthe standard or required characteristic. 2 Significant compliance. The hospital meets most provisions of the standard or required characteristic. 3 Partial compliance. The hospital meets some prowsions of the standard or required characteristic. 4 Minimal compliance. The hospital meets few provisions of the standard or required characteristic. 5 Noncompliance. The hospital fails to meet the provisions of the standard or required characteristic. In some cases, the standard or required characteristic will not apply to a particular hospital. When this is the case, the designa- tion for the score for that particular standard or required char- acteristic is NA. Recommendations will be returned to the hospital for all required characteristics scored 3, 4, or 5. These recommenda- tions may also be included in a contingency on the accreditation status of the hospital, depending on the scope and severity of this and related issues. The contingency will require a response on the part of the hospital in a written progress report at a des- ignated time or may be addressed in a subsequent focused survey. A score of I does not result in a recommendation. nor does a score of 2, unless the surveyor makes a statement for essentially "consultative" reasons. The accreditation decision is based on an aggregation of the hospital's scores rather than on its individual scores. The scoring guidelines in this book discuss the specific activities that are currently reviewed and evaluated in order to assign one of the scores for a particular standard. required characteristic, or group of such. For many of the standards and required characteristics, a detailed discussion of the intent, or of other pertinent information. is included to further clarify the scores. When assigning scores of 3, 4. or 5, surveyors must include specific documentation to justify their scores. This documentation is included in accreditation survey reports sent to the surveyed organization after the accreditation decision is reached, allowing the organization to use it as a reference in determining what steps are necessary to improve its provision of care. Use of the Guidelines for Determining Compliance The information presented in this book is intended to be used only as a guide for determining a hospital's compliance with specificJoint Commission requirements. For it to be useful, staff ofa hospital should keep the following in mind: 0 The guidelines only provide a framework for surveyor judgment regarding an organization’s degree of com- pliance. They do not preempt surveyorjudgment or the consideration of some aspect of hospital operations adversely affecting patient care and safety. even if the standards do not specifically address those operations. They are intended to improve the consistency of the survey process by providing objective and uniform bases for surveyor judgment. The guidelines do not include all the required charac— teristics appearing under each standard. For example. they do not include those required characteristics for which no further clarification is necessary, because the meaning is self—evident (eg. the provision that certain services be directed by a qualified physician is specifi— cally stated in the required characteristic, and no further clarification is necessary). If the guidelines are consistently met, that aspect of the standard or required characteristic is substantially in compliance. An organization must be prepared to pro- vide evidence of its compliance with each standard that is applicable to its operations. To be accredited, the organization must demonstrate that it is in substantial compliance with the standards and required charac- teristics overall. and not necessarily with each applicable one. Scoring Guidelines for the Medical Staff An organization must demonstrate substantial compliance with Joint Commission standards to be accredited. Substantial com— pliance with a specific standard, however, may be short of total or complete adherence to the standard’s stated requirements and intent. Substantial compliance is usually indicated by the fol- lowing: - A specified organizational structure is present, or a func- tion is performed; ‘ 0 The function, as performed by the organization. is appropriate and effective, and its effectiveness can be measured and is documented; and 0 The function has been in place for the required amount of time. usually at least the past l2 months. The final determination of substantial compliance is based on the demonstrable (ie, evident during the survey) or docu- mented maintenance of the standards intent (eg, improve- ment in important aspects of clinical performance, care. services). Assurances or verbal descriptions of compliance. or statements of impending compliance, do not meet the require- ment. Other Useful Information in addition to the scoring guidelines, this book contains two appendixes. ln Appendix A, the “Medical Staff' chapter of the l989 edition of the A/W-l is reproduced. Those referring to this book can use this chapter for easy reference when determining their own degree of compliance with these Joint Commission requirements. Appendix B, "Resources," contains useful information for those interested in learning more about medical staff issues. This section contains a listing, with brief descriptions, of varibus Joint Commission publications and education programs of interest to the medical staff Through its publications and education programs. the Joint Commission continues to carry out its commitment to promoting high quality in patient care. Information pertaining to these guidelines will be disseminated as it becomes available. Monitoring and Evaluation Standard MS.6 As part of the hospital’s quality assurance pro- gram, the medical staff strives to assure the provision of quality patient care, through the monitoring and evaluation of the quality and appropriateness of patient care. Opportunities to improve patient care also are addressed. Required Characteristic MS.6.l.l Monitoring and Evaluation of the Quality and Appropriateness of Patient Care Provided by All Indi- viduals with Clinical Privileges. 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Sanazaro, MD Example of the 10-step JCAHO process. Note:AIl 10 steps should be evidenced in writing and available to reviewers. M HOSPITAL ORGANIZATION -200-bed general acute care facility -Medical center provides: medicine surgery intensive care coronary care level II Triage Area w SCOPE (Sugestion: Scope/Mission Statement in Annual Review) The Anesthesia Department: - 3 Anesthesiologists (includes chief) - 3 CRNAs under chief’s supervision Staff responsible for preoperative, intraoperative and postoperative care of patients undergoing surgical and invasive procedures requiring the use of general or major regional anesthesia. Approximately 350 surgical procedures per month. The most common are: - TURP - Hernia repair - Peripheral vascular surgery - abdominal surgery - Thoracotomy - Major joint surgery Anesthesia administered in: - Main OR - Radiology - ICU (for selected procedures) - CCU (for selected procedures) All patients seen in a multidisciplinary recovery room, except for procedures performed in special care units. The Anesthesia Department Staff is also a part of the cardiopulmonary resuscitation team. < fl 5:: w W > M RESPONSIBILITY (Sugestion: Include in Annual Review and/or Medical Staff Bylaws as Responsibility of a Service Chief) Chief of Anesthesia: - Delegated responsibility for QA monitoring and evaluation in the department, - Approves staff-developed M&E - Insures that all staff are adequately oriented to the anesthesia M&E process, - Has oversight responsibility for the entire process, - Assigns responsibility for quality assurance data aggregation, tabulation and analysis to appropriate staff, - Assures that most pertinent findings are included in monthly meeting agenda and - Makes provisions for the accurate recording of key points, conclusions, recommendations or actions and the specific follow-up in monthly meeting minutes; and signs these minutes indicating involvement in the process. m IMPORTANT ASPECTS OF CARE (Suggestion: Include in Minutes of Monthly Stafir Meeting and CEB for approval) A. Appropriateness of administration of anesthetics, B. Effectiveness of administration, C. Appropriateness of monitoring patient’s physiologic parameters intraoperatively and D. Appropriateness of monitoring patients’s physiologic parameters postoperatively. M INDICATORS (Sugestion: Include in Minutes of Monthly Staflr Meeting and CEB for approval) A. Patients diagnosed with CNS complications occurring during or within one day following the administration of anesthesia, subcategorized by American Society of Anesthesiologists - Patient Severity (ASA-PS) class (1 and 2 vs. 3, 4 and 5), elective vs. emergent procedure, and age. 9‘ Patients developing peripheral neurologic deficit during or within 2 days following the administration of anesthesia. 0 Patients with cardiac arrest during or within 24 hours following the administration of anesthesia, excluding patients with required intraoperative cardiac arrests, subcategorized by ASA-PS class (1 and 2 vs. 3, 4 and 5), elective vs. emergent procedure, and age. .5 Patients with acute myocardial infarction during or within 2 days following the administration of anesthesia, subcategorized by ASA-PS class ( 1 and 2 vs. 3, 4 and 5), elective vs. emergent procedure, and age. 5’1 Patients with unplanned respiratory arrest during or within 24 hours following the administration of anesthesia. 2!! Unplanned in-patient admissions to the hospital following out-patient procedures involving anesthesia. Unplanned admission of patients to an intensive care unit following the administration of anesthesia. :91 Death of patients during or within 48 hours following the administration of anesthesia, subcategorized by ASA-PS class (1 and 2 vs, 3, 4 and 5), elective vs. emergent procedure, and age. ‘ h - Patients with discharge diagnosis of fulrninant pulmonary edema developed during or within 1 day following the administration of anesthesia. 9" Patients diagnosed with aspiration pneumonitis, occurring during or within 2 days following the administration of anesthesia. Patients developing postural headache within 4 days following the administration of spinal or epidural anesthesia. Patients experiencing dental injury during anesthesia care. . Patients requiring reintubation in the recovery room following the use of general anesthesia 23?.” Patients experiencing ocular injury during anesthesia care. NOTE: The Task Force has recommended to the Joint Commission that indicators A through H be further tested for possible inclusion in the J CAHO performance monitoring system. In addition the Anesthesia Care Task Force recommends that all of the above indicators (note: indicator M was not apart of this recommendation) are of value, and should be considered for use in individual hospital quality assurance programs. Please note: The final wording of each indicator may be subject to revision by the Task Force following the results of further testing. THRESHOLDS (Sugestion: Include in Minutes of Monthly Staff Meeting and CEB for approval) The threshold for indicator "M" is set at 3%. That is, when 3% or more of all intubated patients receiving anesthesia require reintubation in the recovery rooom, peer review is required for each case. < I: 83 m a > m COLLECT AND ORGANIZE DATA ( Suggestion: Include in Minutes of Monthly Sta]?r Meeting) The anesthesiologist or CNRA assigned QA responsibility collects information on a locally developed form. NOTE: The above data collection sources represent a sample and may not be sufficient to gather all the necessary elements. m EXCERPT FROM ANESTHESIOLOGY SERVICE MONTHLY STAFF MEETING MINUTES, JULY 15, 1990 I. Indicator M: Reintubation in the recovery room following the use of general anesthesia. A. 31 cases using general anesthesia' 1n June including: 12 abdominal surgeries (one which required reintubation m RR) 5 thoracotomies (one which required reintubation m RR) 6 femoral femoral bypass 8 femoral popliteal bypass B. Findings: 1. 60 cases met indicator evaluation 2. TWO cases of reintubation in the recovery room required peer review: Case number 4390 thoracotomy Case number 5478 abdominal surgery 3. Inadequate reversal of muscle relaxants was ruled out in each case. No record of tidal or minute ventilation in either case. In case number 5478, the anesthesiologist said he always sets the ventilator on eight breaths per minute and 800 cc tidal volumes. No blood gases had been checked intraoperatively 1n either case, although baseline gases had been obtained on the thoracotomy case preoperatively. Neither the mass spectrometer nor the end tidal C02 monitor had been used in either case. COMMUNICATE AND INTEGRATE RELEVANT INFORMATION: Service minutes are compiled quarterly for Executive Committee of Clinical Executive Board. Subsequently, they are linked to the performance evaluation and reappointment process. INDIVIDUALS WHO ASSISTED IN THE DEVELOPMENT AND/ OR REVIEW OF THE AN ESTHESIA CASE STUDY Robert E. Benway, MD Chiefi Anesthesiology Section VA Medical Center Tampa, FL Joan Cummings, MD AC OS Extended Care VA Medical Center Hines, IL Roxane Rusch, RN Regional Accreditation Consultant Western Region San Francisco, CA Paul Sanazaro, MD Reviewer-consultant MEDICINE CASE STUDY MEDICINE CASE STUDY Lead consultant-reviewer: John R. Payne, MD Examples of the ten-step JCAHO process. Note: All ten steps should be evidenced in writing and available to reviewers. m HOSPITAL ORGANIZATION: -350-bed medical center -Medicine is the largest service with 100 beds < I a a: W p RESPONSIBILITY: Chief of Medicine Service: - responsibility for the monitoring and evaluation of the appropriateness and quality of patient care in service. - assures that decentralized drug usage reviews and invasive procedure review are conducted within the service. - assures adequate service representation on committees that perform the required medical staff functions of pharmacy and therapeutics, blood usage review and medical records review. - assures that infection control, utilization management, safety and risk management issues are addressed. - shares information from the required medical staff function committees with entire staff regularly. (Pharmacy and Therapuetics, Medical Records and Blood Usage Review) - oversees preparation of Medicine Service meeting agenda which includes indicators that are outside thresholds and trending information. - presents quarterly sunnnaries of the Medicine Service quality assurance activities to the Clinical Executive Board. - assigns responsibility for tabulating data related to indicators and comparison to thresholds monthly to Assistant Chief of Medicine. - assigns indicator development and threshold identification to staff physicians with expertise in area in which indicator is to be developed. - assigns peer review activities to stafi physicians with expertise in specific clinical areas. < a: 8: w W > N SCOPE: (Sugestion: Revise scope/mission statement at time of annual review/evaluation of QA progam) Medicine Service includes: - Allergy and Immunology - Cardiology - Endocrinology - Gastroenterology - Internal Medicine - Oncology - Infectious Diseases - Pulmonary Diseases Approximately 40 staff physicians. Medicine staff serve as consultants in their primary clinical specialty based upon their category of clinical privileges. Diagnosis and treatment occur in inpatient bed sections. Acute triage occurs in emergency room. Chronic management and acute followup occur in the outpatient clinic. Most common diagnosis seen: Coronary Artery Disease Chronic Obstructive Pulmonary Disease Diabetes Congestive Heart Failure Acute Myocardial Infarction Medical Service Invasive Procedures Special invasive procedures: - angiography (cerebral & lymph) - arteriography — bronchial brushing & lavage - bronchogram - bone marrow aspiration - cardiac catheterization - temporary cardiac pacing - pericardiocentesis - Swan-Ganz catheterization - abdominal paracentesis - thoracentesis - spinal tap Biopsy and excisions: - needle biopsy of bone marrow - kidney - liver - lung - thyroid - closed pericardial - peritoneal and pleural biopsy - skin biopsy - small intestinal biopsy V H S R A SCOPE: continued Endoscopies with and without biopsy: - bronchoscopy - colonsoscopy - duodenoscopy - esophagoscopy - mediastinosoopy - ERCP - peritoneoscopy - sigmoidoscopy Other special non-invasive procedures: - echocardiography - ECG interpretation - peripheral vascular studies - pulmonary function interpretation - esophageal and endotracheal intubations with respirator management < a a m W » > MEDICINE SERVICE MONTHLY MEETING STANDING AGENDA 1. Utilization Review Note: this includes such things as workload patterns for the month, i.e., number of admissions and discharges, types of diagnoses, types of treatments and procedures accomplished. 11. Infection Control Note: this includes the service’s infection control profile as reported by the Infection Control Committee III. Quality Control Note: this includes policy and procedure review and compliance issues, credentialing and privileging, etc. IV. Monitoring and Evaluation of Clinical Care Note: this includes a review of indicators, thresholds as well as a review of trends, DUE, invasive procedure review and information from required medical staff function committees of Pharmacy and Therapeutics, Medical Record and Blood Usage Review. V. Safety and Risk Management Note: this includes a review of patient incidents, complications, deaths, safety committee items referred to Medicine Service. < E % w W > IMPORTANT ASPECTS OF CARE: A. Effectiveness of management in patients with chronic obstructive pulmonary disease B. Appropriateness of preventive management in patients with diabetes C. Effectiveness of management of the patient in diabetic ketoacidosis D. Effectiveness of volume management in patients with volume overload related to congestive failure E. Appropriateness of diagnosis of patients with myocardial infarction INDICATORS (The following are examples of gotential indicators which correspond to the ImportantAspects of Care) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Patients admitted with primary diagnosis of COPD with arterial oxygen tension (PaOz) less than 55 tort or oxygen saturations by oximetry less than 85% 24 hours after hospitalization subcategorized oxygen mode and bronchodilator treatment choice. Patients readmitted for COPD exacerbation within 14 days of discharge from acute care. Patients with diabetes over the age of thirty who do not receive a yearly eye exam by an opthamologist subcategorized by insulin treated, oral agent and diet controlled diabetics. Patients with diabetes who do not have yearly urine check for protein. Patients with insulin diabetes who fail to have annual review of home glucose monitoring technique. Patients admitted for DKA in whom acute IV insulin therapy is discontinued in the presence of persistent ketones in the urine or blood. Patients admitted for DKA whose anion gap is greater than 15 after 18 hours of therapy. Patients admitted for DKA whose serum potassium magnesium or calcium are abnormal after 24 hours of therapy. Patients with CHF who require transfer to a special care unit for worsening failure after eight hours of management on a general medical unit. Patients with CHF treated with digoxin who develop digitalis toxicity during acute treatment. Patients with CHF whose potassium is not WNL within 8 hours of acute treatment. Patients admitted for R/O MI who rule out. Inpatients who suffer myocardial infarction while on any general medical unit subcategorized by monitored and non-monitored bed. Patients with significant discrepancy between pre-cardiac catheterization diagnosis and catheterization findings. THRESHOLDS: This example utilizes "the effectiveness of management in patients with COPD" as the important aspect of care. The indicator for this important aspect is "patients readmitted for COPD exacerbation within 14 days of discharge from acute care." The threshold established and approved by the staff and Chief of Medicine for this example is 5% or more of all COPD patients discharged who are readmitted within 14 days of discharge. < m 8 m 75 > COLLECT AND ORGANIZE DATA: - QM staff collect data relative to COPD readmission within 14 days as they collect data for the occurence screens. - The Assistant Chief of Medicine compares the tabulated data monthly with the thresholds to determine which items need to be discussed at the monthly service meeting. - The indicator worksheet is updated monthly to identify trends in practice. These trends are reported by the Assistant Chief of Medicine to the Medical Service monthly meeting. < . a! w W > EXCERPT FROM THE M&E PORTION OF MEDICINE SERVICE MEETING MINUTES, JUNE 1990 IV. Service Monitoring and Evaluation of Clinical Care A. Indicator #2 COPD readmissions: Threshold 5% (Attachment 1) 1. m5 2readmissions/27 COPD discharges = 7.4% Pulmonologist review was performed on case #4436 and #8731 representing two unique patients. #4436 - Patient was on oxygen per nasal prong until two hours prior to discharge. #8731 - Patient had tapering steroid schedule ordered on day of discharge, but patient failed to take the medication in the prescribed decreasing dose. :2 EVALUATE ~ IMPROVEMENT MONITORING & EVALUATION INDICATOR TRACIGNG FORM FOR INDICATOR NUMBER 2 Attachment #1 - Medicine Service Minutes June 1990 JUN JUL AUG SEP OCT NOV THRESHOLD(%) 5% ACTUAL PERF. 7.4% # READMISSIONS FOR COPD IN 2 14 DAYS # COPD DISCHARGES 27 V H S R A W EXCERPT FROM THE M&E PORTION OF MEDICINE SERVICE MEETING MINUTES, JULY 1990 IV. Service Monitoring and Evaluation of Clinical Care A. Indicator #2 COPD readmissions: Threshold 5% (Attachment 1) 1. Findings: 3 readmissions/32 COPD discharges = 9.3% This represents a trend of 7.4% in June and 9.3% in July. Pulmonologist review was performed on case #4390 (2 admissions in 14 days) and #2075. #4390 - Patient had no radiological report indicating improvement in his acute condition on day of initial discharge. Infiltrates during the first readmission were treated with vigorous pulmonary toilet. His only set of room air gases were obtained 12 hours prior to his second discharge which indicated a saturation of 91% and C02 of 43. It was noted in his discharge summary that these gases were baseline for this patient. His last radiograph had been taken 48 hours prior to discharge. Progress notes upon second discharge indicate improvement by physical exam. However, no outpatient follow-up visits were scheduled. It was noted upon the second readmission that the patient was in acute bronchospasm with right sided failure and pneumonia. After a one day course of management by a pulrnonologist utilizing vigorous pulmonary toilet and bronchodilator therapy, the patient was moved to a general medical ward. There he was discharged some six days later with stable room air gases and a radiograph which demonstrated clear improvement. Upon discharge, his treatments, including broncholdilator therapy and antibiotics, had been stable for the last twenty-four hours. #2075 - Patient was readmitted for acute COPD exacerbation. His wife relayed history of continued smoking. No evidence of physician advice prohibiting smoking in any in- or outpatient records for last year. EVALUATE ASSESS ACTIONS TAKE ACTION EXCERPT FROM THE M&E PORTION OF MEDICINE SERVICE MEETING MINUTES, JULY 1990 continued < I :1 w W > MONITORING & EVALUATION INDICATOR TRACKING FORM FOR INDICATOR NUMBER 2 Attachment # 1 - Medicine Service Minutes July 1990 JUN JUL AUG SEP OCI‘ NOV THRESHOLD(%) 5% 5% ACTUAL PERF. 7.4% 9.3% # READMISSIONS FOR copn IN 2 3 14 DAYS # COPD DISCHARGES 27 32 V H S R A EXCERPT FROM THE M&E PORTION OF MEDICINE SERVICE MEETING MINUTES, AUGUST 1990 I. Approved Discharge Stability Criteria COPD Discharge Stability Criteria Oteck if present: 1. Blood gases are stabilized for 24 hours prior to discharge. 2. Treatments (e.g. oxygen, medications, inhalation) are stabilized for 24 hours prior to discharge. 3. Patients are discharged on the same treatments received for at least 24 hours prior to discharge (exception decreasing doses of corticosteroids). 4. Radiology reports show improvement in any acute condition and/or stability in the patient’s chronic condition. 5. Progress Notes reflect improvement in the patient’s conditions. 6. Progress Notes reflect improvement in congestive heart failure, if present. 7. Documentation of patient education in the following areas: a. smoking b. nutrition c. hydration d. medications and treatments 8. A follow-up outpatient appointment is scheduled within two weeks of discharge. V H S R A W EXCERPT FROM THE M&E PORTION OF THE MEDICINE SERVICE MEETING MINUTES, DECEMBER 1990 IMPROVEMENT V H S R A $ “ 80 MONITORING & EVALUATION INDICATOR TRACKING FORM FOR INDICATOR NUMBER 2 Attachment # I - Medicine Service Minutes Dec. 1990 JUN JUL AUG SEP OCT NOV THRESHOLD(%) 5% 5% 5% 5% 5% 5% ACTUAL PERF. 7.4% 9.3% 11% 3%* 3% 0% # READMISSIONS FOR COPD IN 2 3 4 1 1 o 14 DAYS # com DISCHARGES 27 32 34 30 31 28 * implemented Discharge Stability Checklist in September. COMMUNICATE AND INTEGRATE RELEVANT INFORMATION: Chief of the Medicine Service reported a summary of these and other Service QA activities to the Clinical Executive Board in the first quarter QA Summary Report. < E 3 m w > INDIVIDUALS WHO ASSISTED IN THE DEVELOPMENT AN D/ OR REVIEW OF THE MEDICAL CASE STUDY Joan Cummings, MD ACOS/Extended Care VA Medical Center Hines, IL John Payne, MD Reviewer-consultant Roxane Rusch, RN Regional Accreditation Consultant Western Region San Francisco, CA Paul Sanazaro, MD Reviewer-consultant < I 83 U: W a» A, ,AA,AA,AA,A AA,AA,A, , AAA,AAA,AA,AAA,,A,,AA,,AAAMAAAAAAAAAAAAAA ,.,,A ,AA,”...WAA AAA,AA,AA, AA ,,AA,,AA,,.AE,AVA,V.AAA,,,,AAA,,AV AAAAVAVA,VA,A,AA,.AAAEAA ,AmWVwV,VAA, ,AA,AA,AA. AA,A,, AAA,V, .VAA.AA,A,AV,A.,.m,aAA ,A,AA,AmAVAw AVA,AA AA. 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HOSPITAL ORGANIZATION: - 400-bed tertiary VA medical center ~ Medical center provides: acute medical surgical care Affiliated with three medical schools Four hundred forty-two physicians (include fee basis and contract services) are involved in: - General medicine - Nephrology - Neurology - Cardiology - General surgery - ENT - Plastics - Orthopedics - Cardio/thoracic/vascular - Neurosurgery No ambulatory surgery. Outpatient invasive diagnostic and therapeutic procedures. < :1: 1°. w W > SCOPE: 24-hour, seven-days-a-week service: ward units, OR, RR, Radiology, ICU, Cath Lab, GI, GU, Dental, ENT clinic, Level HI triage. Approximately 4,764 surgical procedures: - 4176 tissue - 588 non-tissue Approximately 5,883 invasive procedures: - 4321 inpatient - 1562 outpatient RESPONSIBILITY: Chief of Surgery: - delegated responsibility for the quality and appropriateness of Surgical Case Review. - participates in the development, implementation and monitoring of all SCR activities. - signs all monthly Surgical Case Review Committee (SCRC) meeting minutes. Physicians and Specialists: - review surgical and invasive diagnostic and/or therapeutic cases for appropriateness, quality and adequacy. - participate in surgical case peer review as does any clinically privileged employee who conducts an invasive procedure. This list includes, but is not limited to, radiologists, anesthesiologists, cardiologists, gastrointerologists, urologists, PAs and nurse practitioners. - integrate information into SCRC meeting and service level M&E as verified by minutes. Pathologists: - review all tissue cases for adequacy (confirmation, diagnosis and accuracy) of surgical intervention and determine if there is a discrepancy in the pre- and post op diagnosis. - review invasive diagnostic and/or therapeutic cases, if there is a submission, for diagnosis correlation. - determine specimen collection accuracy and that appropriate amount was collected. Surgeons: — review tissue cases for appropriateness (indication for surgery). - approve clinical indicators. - evaluate the surgical intervention to assure it meets clinical standards related to technical performance and mortality and morbidity. - integrates information into SCIPRC meetings and service level M&E, verified by minutes. Approving medical staff body: the Clinical Executive Board (CEB). - approves list of procedures for review or exemption. - takes action to resolve patient care issues. - approves service or committee criteria. < l 8 m w > IMPORTANT ASPECTS OF CARE (INVASIVE PROCEDURES) (examples only fiom total list of Cardiology/Cardiovaswmr invasive pmcedures) INDICATORS: Excerpt from Cardiovascular and Cardiology Sections Invasive Procedures Clinical Indicators Indicators submitted from Cardiovascular and Cardiology to CEB and approved in minutes of CEB, October 1989. l. CORONARY ARTERIOGRAMS: A. Appropriateness is met if one of the following is present: Cardiovascular Procedures, Tilkian, MD; Daily, RN, 1986 - Chest pain _ CHF- - Acute involving MI - Old MI (greater than 6 weeks) Now Asypmtomatic - Recent MI (less than or equal to 6 weeks) Now Asymptomatic - Post MI (Same Admission) - Cardiac Arrest - Prior cardiac surgery - Prior PTCA - Evaluation for revascularization -Prior IV thrombolytic therapy -Arrhythmia — Positive Exercise Treadmill Test (ETT) - Positive Radionuclide Angiography (RNA) B. Quality is met through all of the following: - Hematoma not requiring intervention less than 10% - Persistent (greater than 5 minutes) hypotension less than 5% - Transient loss of pulse not requiring surgery less than 3% - Infection of access site less than 3% - Stroke or TIA 0.2% - all cases reviewed - Myocardial infarction 0.2% - Loss of peripheral pulse or vascular injury requiring surgery 0% - Bleeding requiring transfusion 1% - Ventricular fibrillation less than 2% - Death 0.2% - all deaths reviewed NOTE: All percentages indicate that you should expect to have up to that % to occur 2. CORONARY AN GIOPLASTY: A. Appropriateness is met if one of the following is present: Cardiovascular Procedures Tilkian, MD; Daily, RN, 1986 - Proximal left anterior descending coronary, left circumflex coronary artery or dominant right coronary artery stenosis with angina or demonstrable ischemia. - Multiple discrete lesions in a single vessel with angina or demonstrable ischemia. - Selected cases of multi-vessel coronary artery stenosis with angina and/or demonstrable myorcardial ischemia. - Acute evolving myocardial infarction with or without the use of thrombolytic therapy. - Saphenous vein bypass graft stenosis or internal mammary graft stenosis with symptoms or signs of ischemia. - Restenosis after a first or second successful angioplasty. - Variant angina in the presence of fixed anatomic obstruction. - Atherosclerosis with high grade obstruction following cardiac transplantation. - Selected patients who are not acceptable candidates for coronary artery bypass surgery who may benefit from palliative angioplasty. INDICATORS: continued B. Quality outcome indicators include: - Myocardial infarction less than 5% - Emergency bypass surgery less than 3% - Death 0.5% - all deaths reviewed - Hematoma not requiring intervention less than 10% - Stroke or TIA 0.2% - all cases reviewed - Persistent (greater than 5 minutes) hypotension less than 5% - Transient loss of pulse not requiring surgery less than 3% - Bleeding requiring transfusion 1% - Loss of peripheral pulse or vascular injury requiring surgery 0% - Infection at access site less than 3% - Ventricular fibrillation less than 2% NOTE: All percentages indicate that you should expect to have up to that % to occur. 3. CORONARY ARTERY BYPASS GRAFTING (CABG) A. Appropriateness of indications for surgery. 1. Left main coronary artery stenosis of 50% or greater. 2. Three-vessel curonary artery stenosis of 70% or greater with: a. depressed left ventricular function h. normal ventricular function but significant inducible ischemia 3. Single and two-vessel coronary artery stenosis of 70% or greater with significant inducible ischemia not amenable to medical management. 4. Unstable angina refractory to medical therapy. 5. Stable angina refractory to medical therapy that is disabling or severely restricts activity. 6. Failed angioplasty or other interventional procedure. B. 5 Quality outcome indicators. 1. Events warranting case review of each occurrence: a. Death b. Re-operation for bleeding c. Cerebrovascular accident (1. Mediastinitis e. Renal failure requiring dialysis 1‘. Other conditions requiring return to the OR g. Readmission to the hospital within 30 days of operation < I 8 (A W > INDICATORS: continued 2. Events warranting review if occurring more frequently than expected based on literature and prior institutional experience. a. Cardiac - peri-operative MI - atrial arrhythmias - ventricular ectopy requiring ICU admission or cardioversion b. Respiratory - ventilator dependence (greater than 2 weeks) c. Renal - renal failure requiring dialysis (1. GI - peptic ulceration - pancreatitis - prolonged ileus (greater than 1 week) - any condition requiring abdominal exploration e. Infections - mediastinitis - pneumonia - urinary tract infection - superficial wound infection - pseudomembranous colitis f. Hematologic - transfusion reaction - deep venous thrombosis - pulmonary embolism 3. Results based on follow-up data. a. Improvement in anginal symptoms (e.g., NYHA class) b. Occurrence of subsequent cardiac events (e.g., MI) c. Return to work status (1. Survival < I 8 w W :> THRESHOLDS: In the absence of an existing data base, collect local data for internal use and comparison. As an interim measure, set thresholds at zero bases or 100%. Each occurence requires specialist peer review. < :1: E U: W > m COLLECT AND ORGANIZE DATA: Tissue: Pathologist documents (see form) comparison of tissue and the diagnosis (from the lab slip or medical record) with the approved criteria. The percentage of cases meeting the indicator is graphed by provider and by indicator. This graph is submitted to the SCRC monthly. Non-tissue: The cases are screened from data colleded from clinic logs and ICU/OR forms by Quality Management staff (RNs and LPNs) using approved criteria. Cases not meeting the criteria are submitted for peer review. Aggregations of these findings are provided to the SCR committee and appropriate service chiefs. SAMPLE: SCR PATHOLOGIST TISSUE REVIEW FORM Specimen: Muscle BX., left thigh Clinical Indications: 67 yr. old black male with slowly progressive muscle weakness X 7 yrs. Pre-op dx: 0p Findings: Post Op Dx: Gross: received fresh are several pieces of soft translucent yellow tan tissue measuring up to 2cm in greatest dimension. Portions are submitted for fixation and glutaraldehyde and a portion is snap frozen in dry ice for special stains, the remainder of tissue is submitted for light microscopy. Microscopic: the sections show a small amount of muscle with fat and fascia. The muscle shows advanced atrophy and fibrosis with compensatory hypertrophy of remaining fibers. There is no evidence of active inflammation or vasculitis. Diagnosis: Preliminary DX: muscle with advanced atrophy and fibrosis. Further studies pending consultation with AFIP. Quality/appropriateness Review: Check All Which Apply. 1. XX Significant pre- & post-op diagnosis discrepancy noted. 2. Pathology diagnosis fails to support the pre- or post-op diagnosis. 3. Unexpected neoplasm discovered. 4. Surgery performed was based on previous biopsy material or outside diagnosis in which the slides were not recently reviewed by a local VAMC pathologist. 5. Frozen section diagnosis differs significantly from final pathology diagnosis. 6. g of prostrate chips if TURP. 7. Evidence of inappropriate removal of tissue (margins not free, etc.) 8. Clinical indications & criteria are not met. 9. If not met, conclusion: Surgery was: (check one) _justified, __ not justified, _ of questionable need 10. If not met or questionable, explain below and give reasons for conclusion. 11. _XX__Did discrepancy between frozen section affect treatment? yes. 12. _Date reviewed by tissue committee: May2 15, 1989 Comments and Followup Actions; Muscle chosen was end stage --- should have been deltoid muscle ---was any muscle better than no muscle? Pathologist number: 295 Date: 6/15/89 V H S R A EXCERPT FROM SURGICAL CASE REVIEW PORTION OF THE MINUTES, SURGICAL SERVICE MONTHLY STAFF MEETING - JUNE 21, 1989 I. In this hospital during the month of May there were 420 surgical and/or diagnostic procedures performed. Of these 420, tissue was removed in 300 cases and in 299 cases the pre- and post-op diagnosis, correlated. The one case which did not correlate, #1020, was presented to the Chief of Surgery for review of the clinical management with the treating physician. 11. Out of the 420 involved procedures in May, 120 cases were not tissue. 117 of these cases met indications for the procedures. Three cases involving cardio/thoracic Indicator #5 were not met. A. Cardiothoracic Indicator #5, Arteriograms: 1. Three out of 20 cases failed screening indications criteria for arteriograms in May. (Five of two hundred cases have failed to date.) EVALUATE CARE 3. One case, #1000, by provider #301 failed peer review by reviewers #102 & #103. The case involved a 70- year-old WM who was admitted for an M1. The patient underwent an arteriogram to R/0 the diagnosis of CAD and to assess the status of his coronary arteries. Findings: Appropriateness criteria for this patient were met. However, the arteriogram led to an emergency surgery for a perforated artery. Subsequently, the patient underwent the indicated CABG. He died in the OR. EXCERI’T FROM SURGICAL CASE REVIEW PORTION OF THE MINUTES, SURGICAL SERVICE MONTHLY STAFF MEETING - DECEMBER 21, 1989 ASSlES ACTIONB; " DOCUMENT IMPROVEMENT < m 3 m :5 > M EXCERPT FROM SURGICAL CASE REVIEW PORTION OF THE MINUTES, SURGICAL SERVICE MONTHLY STAFF MEETING - JANUARY 21, 1990 IUNICATE “ I TEGRATE INDIVIDUALS WHO ASSISTED IN THE DEVELOPMENT AN D/ OR REVIEW OF THE SURGICAL CASE REVIEW CASE STUDY Ruby Atchinson, RN Cardiovascular Clinical Specialist VA Medical Center Durham, NC Joan Cummings, MD ACOS/Eidended Care VA Medical Center Hines, IL Betty Goolsby AA/Director for UR VA Medical Center Durham, NC James Hughes QA Coordinator VA Medical Center Mountain Home, TN Debbie Kinert, RN, MSN, CPQA, CNA Executive Assistant to the Director Special Projects VA Medical Center Durham, NC Hazel McNeely QA Coordinator VA Medical Center Asheville, NC Jane Penny QA Coordinator VA Medical Center Durham, NC Debbie Sigmon Assistant QA Coordinator VA Medical Center Asheville, NC INDIVIDUALS WHO ASSISTED IN THE DEVELOPMENT AND/OR REVIEW OF THE SURGICAL CASE REVIEW CASE STUDY continued W. Keith Sloan, MD Consultant reviewer Sharon Teague QA Coordinator VA Medical Center Fayetteville, NC Guy Young QA/UR Coordinator VA Medical Center Salisbury, NC < m m N > 101 x t W; m m xxm n ,2, a m?! - PSYCHIATRIC CASE STUDY PSYCHIATRIC CASE STUDY Lead consultant-reviewer: Donald Widmann, MD Examples of the JCAHO ten-step process. NOTE: all ten steps should be evidenced in writing and available to reviewers. NOTE: Outpatient Psychiatry Service is surveyed as part of Psychiatry Service, and not separately m HOSPITAL ORGANIZATION: -500-bed tertiary care facility - medical center provides acute. medical, surgical and psychiatric care as well as preventative care and follow-up outpatient setting. 105 ” RESPONSIBILITY: Chief of Outpatient Psychiatry Service: , - implements a quality assurance program which includes the monitoring and evaluation of patient care provided by the Outpatient Psychiatry Service. - prepares a monthly summary of the relevant quality assurance findings and activities. - reports the monthly summary to the Chief of Psychiatry at the monthly Psychiatry Service meeting. - participates in overall QA activities of Psychiatry Service. W SCOPE: Workload: 40,000 visits per year 2,200 unique patients Outpatient Psychiatry Service multidisciplinary team includes: - four psychiatrists, - seven psychologists, - twelve nurses, - two occupational therapists, - three recreational therapists, - six social workers and psychiatry assistants. Four program areas in Outpatient Psychiatry: - Mental Hygiene Clinic, - Day Treatment Center, - Veterans Workshop, - Drug & Alcohol Rehabilitation Unit. The Mental Hygiene Clinic provides a wide range of biopsychosocial treatment services to psychiatrically disabled veterans. Therapies include: - individual, group and family treatment modalities, - medication profile management and renewal, - physical examination, and - follow-up of chronic stable medical conditions. The Day Treatment Center provides two distinct services the Day Program and the Afternoon Program. The Service goal of the Day Treatment Center is to foster independence, avoid hospitalization and the use of emergency services and to increase the likelihood of successful volunteer or paid employment for the patient. The Day Program provides: - therapeutic groups, - milieu therapy, - a medication clinic and - one-on-one meetings with counselors to aid patients in achieving increased self esteem and better reality testing. The Afternoon Program provides: - group work in independent living skill, - socialization and support, through community leisure resources. m SCOPE: continued The Veterans Workshop provides psychiatric and vocational rehabilitation via paid work tasks. The Service goal is the development of good habits, increased motivation and self esteem and the acquisition of independent living and vocational skills. The Drug and Alcohol Rehabilitation Unit Outpatient Clinic aids, supports and hastens the recovery process in patients without dual diagnosis. The Service goals are the development of lifestyles that include abstinence and responsibility. Programs include: - individual, group and family counseling, - supervised disulfiram and/or naltrexone, and - methadone. IMPORTANT ASPECTS OF CARE: A. Appropriateness and accuracy of biopsychosocial assessment. B. Appropriateness of level of care for psychiatric outpatients. C. Effectiveness of treatment programs for psychiatric outpatients. D. Minimization of risk/side effects in patients receiving psychiatric medications. INDICATORS: This represents a list from which Outpatient Psychiatry staff selected indicators. 1. Psychiatric outpatient admissions to acute inpatient psychiatric units within seven days of a psychiatric outpatient encounter in any of the outpatient programs subcategorized by emergent and nonemergent admission. 2. Patients actively participating in outpatient programs who require outpatient emergency services, subcategorized by medical emergency and psychiatric crisis patients. 3. Psychiatric outpatient admissions to acute inpatient medical unit within two weeks of physical exam or follow-up of a chronic medical condition in the Mental Hygiene Clinic. 4. Patients started on antabuse without baseline liver chemistry prior to initiation. 5. Patients with SGOT > 200 started on Antabuse without evidence of SGOT monitoring within two weeks of initiation of Antabuse. 6. Patients in the Veterans Workshop without gainful employment after one year. 7. Patients who do not improve at least one functional level within one year of entry into the Day Treatment Center. 8. Patients in the Outpatient Drug and Alcohol Treatment Clinic who fail to maintain abstinence as determined through observed urine and/or breath sample within the first three months of Antabuse initiation. 9. Patients who do not maintain abstinence after six months of discharge from acute inpatient Alcohol Rehabilitation Program. 10. Patients who do not attend aftercare sessions at least twice per month after four months of completion of inpatient or outpatient Alcohol Rehabilitation Program. 11. Patients in the Methadone program who fail to maintain clean urines for two successive tests. 12. Patients in the Methadone program arrested during treatment. 13. Patients in the Methadone program that are not employed if eligible for employment. 14. Patients requiring inpatient acute detoxification while actively seen in outpatient psychiatry program. 15. Patients found to have a major psychiatric disorder, for example, Schizophrenia or Bipolar Disorder (referred to as Dual Diagnosis), after acceptance into an outpatient Drug Rehabilitation Program. 16. Suicides or attempted suicides among patients actively participating in outpatient psychiatric programs. 17. Patients prescribed antipsychotic agents with evidence of Tardive Dyskinesia, Parkinsonism, Akinesia and Akathisia at any time after initiation of prescribed medication. 18. Patients without Lithium levels checked every six months in outpatient setting. 19. Patients more than sixty years old on antipsychotic medications with orthostatic changes (systolic < 100 and diastolic < 70) upon physical exam in the Mental Hygiene Clinic. < I: m we > 110 INDICATORS: continued 20. Discharged Bipolar patients who remain on maintenence doses of Lithium and antipsychotic medications more than six months after discharge. 21. Patients seen in the Mental Hygiene Clinic who remain on psychiatric medications for more than one year without rationale. < {I} {n W > 111 m THRESHOLDS: Indicators direct our attention to areas in which care concerns, or opportunities for improvement exist. To conclude that such a concern or opportunity exists, thresholds are developed for each indicator. Simply put, a pre-determined threshold is a point which, if dropped below or exceeded, triggers a peer review. For this example, indicator number 17, a threshold of 10% was agreed upon by the staff. COLLECT AND ORGANIZE DATA: Includes: - chart review - DHCP computer templates - patient logs - follow—up surveys - incident reports For the indicator chosen for this example, number 17 "Patients prescribed antipsychotic agents with evidence of Tardive Dyskinesia, Parkinsonism, Akinesia and Akathesia at any time after the initiation of prescribed medication," the following occurs: - a pharmacy template on DHCP captures patients prescribed antipsychotics, - on a monthly basis, these patient’s charts are reviewed to determine if EPS symptoms are present. - these findings and trends are reported by the Chief of Outpatient Psychiatry Service at the Psychiatry monthly meeting. EXCERPT FROM OUTPATIENT PSYCHIATRY SERVICE MEETING MINUTES, APRIL 1990 IV. Service Level Monitoring and Evaluation: (Any indicators whose thresholds were exceeded or dropped below during the month would be included in this section.) A. Indicator #17 - Patient prescribed antipsychotic agents with evidence of Tardive Dyskinesia, Parkinsonism, Akinesia and Akathisia (EPS) at any time after initiation of prescribed medication. Threshold: 10% April performance: 6 patients with BPS/32 patients on antipsychotic drugs = 18% 1. Findings: 6 patients were found upon case review to have the cluster of symptoms associated with Tardive Dyskinesia. All of these patients had been on antipsychotic drugs greater than 6 months and were over the age of 55. Five patients had previously experienced EPS when prescribed antipsychotic medications. No notation about this history was made in any of the charts by the physician currently prescribing these drugs. Only four of these patients had Abnormal Involuntary Movement Scale administered regularly during their monthly clinic visits. In all four patients who had AIMS testing accomplished, abnormal involuntary movement worsened over the course of three months. Only one patient had documentation of sound rationale not to treat these progressive symptoms. EVALUATE " V H S R A m w m 114 SAMPLE TRACKING FORM FOR INDICATOR NUMBER 17 MAR APR MAY JUN JUL AUG SEPT THRESHOLD(%) 10% 10% MONTHLY * 18% PERFORMANCE PATIENTS WITH ANTIPSYCH. * 32 * Indicator approved at March 1990 monthly service meeting. EXCERI’I‘ FROM OUTPATIENT PSYCHIATRY SERVICE MEETING MINUTES, MAY 1990 IV. EVALUATE CARE TAKE ACTION Service Level Monitoring and Evaluation: (Any indicators whose thresholds were exceeded or dropped below during the month would be included in this section.) C. Indicator #17 - Patients prescribed antipsychotic agents with evidence of Tardive Dyskinesia, Parkinsonism, Akinesia, and Akathisia (EPS) at any time after initiation of prescribed medication. Threshold: 10% May performance: 7 patients with BPS/35 patients on antipsychotic drugs == 20%. 1. Findings: 7 patients (case #8943, #2662, #4618, #2894, #5630, #4443, #1382) were reviewed by Staff psychiatrists during May. #8943-Patient reported feeling jittery and all nerved up. Patient had recently been started on Prolixin 10mg 010, Fluphenazine diecanoate 50mg weekly and Ativan 2mg TID. Patient was not on prophylaxis for EPS. The six remaining patients were noted to have signs of tardive dyskinesia. All six were over the age of 55 and had been on their antipsychotics medications for greater than 6 months. All six patients had previously experienced EPS while formerly prescribed antipsychotic drugs for other episodes. Only three patients had the Abnormal Involuntary Movement Scale (AIMS) accomplished during their monthly clinic visits. All three patients had deterioration of AIMS in the last several months. Only one patient was being treated for EPS. 3. Recommendations: The staff reaffirmed their standard that AIMS testing should be accomplished every three months on all outpatients taking antipsychotic medications. The staff decided that a means of targeting patients at risk for development of EPS should be developed for outpatients as well as inpatient psychiatry. Minimally, the staff agreed that the discussion about the choice to treat or not treat EPS should be documented on all patients on antipsychoticmedications. Additionally a discussion with the patient about stopping the drug should be documented if appropriate. une , eeting TheAssistant Chief Of Outpatient Psychiatry will revis ' chotic drug to add Stringent guidelines for AIMS teSt ASSESS: ACTIONS. -15.. ,. .. . AND; ons of the task oup andth Ass t IMPROVEMENT: .. V H S R A w M u SAMPLE TRACKING FORM FOR INDICATOR NUMBER 17 MAR APR MAY JUN JUL AUG SEPT THRESHOLD(%) 10% 10% 10% MONTHLY * 18% 20% PERFORMANCE EXCERPT FROM OUTPATIENT PSYCHIATRY SERVICE MEETING MINUTES, JUNE 1990 IV. Service Level Monitoring and Evaluation: (Any indicators whose thresholds were exceeded or dropped below during the month would be included in this section.) B. Indicator #17 - Patients prescribed antipsychotic agents with evidence of Tardive Dyskinesia, Parkinsonism, Akinesia, and Akathisia at any time after initiation of prescribed medication. 1. Findings/discussion: Care of 7 patients who were on antipsychotics (Case #6649, #7841, #3389, #2846,#3920, #4864) were reviewed by staff psychiatrist during June. #6649 - Patient complained of excessive sleeping and was noted to have dulled speech and a blunting of movement and affect over the course of several months. Since the patient was over 65 and had previously been diagnosed with organic brain syndrome, the clinician noted that this patient’s symptoms were related to a deterioration in his disease process. The patient was on Haldol 2mg BID and no prophylactic medication for EPS. The other six cases had symptoms associated with tardive dyskinesia. These patients had all been on antipsychotics for more than six months and were greater than 55 years of age. Upon review of previous outpatient records, four patients had previously experienced EPS while on antipsychotics but only three had AIMS testing performed at anytime during this treatment episode with antipsychotics. Of the four patients who previously experienced EPS, only one patient had AIMS testing every three months on an outpatient basis. This patient was the only patient of the six patients on EPS prophylaxis. In the three patients who had AIMS testing but were not on prophylaxis, all had worsening of their results over several months. However, no documentation of the decision not to treat for EPS was found. ‘A‘p'ers ent three month trend is noted i ve DyskinesiafThis trend includes failureto‘ e ‘velgp " EPS EVALUATE CARE 3. Recommendations: Review, revise and approve recommendations of task group appomted at May meeting. Educate staff on use of risk assessment tool. Review and approve revised service policy on management of patients receiving antipsychotic medications. Educate staff on accomplishment of AIMS testing. Consider development of treatment algorithym. m SAMPLE TRACKING FORM FOR INDICATOR NUMBER 17 MAR APR MAY JUN JUL AUG SEPT THRESHOLD(%) 10% 10% 10% 10% MONTHLY * 18% 20% 18% PERFORMANCE PATIENTS WITH EPS ON ANTIPSYCH. * 6 7 7 DRUGS PATIENTS ON ANTIPSYCH. * 32 35 38 DRUGS < I m 5:: > 119 SAMPLE TRACKING FORM FOR INDICATOR NUMBER 17 MAR APR MAY JUN JUL AUG SEPT THRESHOLD(%) 10% 10% 10% 10% 10% 10% 10% MONTHLY * 18% 20% 18% 15% 8% 7% PERFORMANCE PATIENTS WITH EPS ON ANTIPSYCH. * 6 7 7 5 3 3 DRUGS PATIENTS ON ANTIPSYCH * 32 35 38 33 34 40 DRUGS V H S R A COMMUNICATE & INTEGRATE RELEVANT INFORMATION: The Chief of Outpatient Psychiatry reports a summary of all relevant QA findings and activities to the Chief of Psychiatry Service during the monthly Psychiatry Service Meeting. < m U: W > 121 EXTRAPYRAMIDAL SYMPTOMS: PATIENT RISK FACTOR ASSESSMENT TOOL PATIENT SPECIFIC RISKS: AGENT SPECIFIC RISKS: Age: Above 55 ........ 3 points High potency medication ............. 4 points 40-55 .......... 2 points Moderate potency ................. 3 points Below 40 ........ 1 point Low potency .................... 2 points Sex: Female ......... 2 points Exposure over 60 days .............. 2 points Male ........... 1 point Exposure over 2 years ............... 3 points Male under 30 years . . 2 points Depot injections .................. 2 points History: Exposure to ECI‘ . . . 1 point Concurrent lithium therapy ............ 2 points Previous EPS ...... 2 points TWO or more antipsychotics ............ 2 points Diagnosis: OBS . . . . 3 points TOTAL . . . ..... . ....... . . . Schizoaffective and/or . Scores of 2-5 points--low risk affective disorder . . . . 1 point Scores of 6 to 8 points--moderate risk TOTAL . . . . ........... Scores above 8 points--extreme risk Scores of 2 to 5 points--low predisposition for EPS Score of 6 to 8 points--high predisposition Score of 9 to 12 points--extreme disposition TREATMENT SPECIFIC RISKS: No prophylaxis and no PRN for anti-BPS medication ............ 5 points No prophylaxis, but PRN order for EPS medication is written ....... 3 points Prophylactic medication for EPS but no PRN order ............ 2 points Prophylaxis and PRN coverage ........................ 1 point PRN of antipsychotics more than 5 times a week .............. 4 points PRN of antipsychotics 3 to 5 times a week .................. 3 points PRN of Antipsychotics 2 to 3 times a week .................. 2 points Ratio of antipsychotic PRN’s to anti-BPS PRN’s is greater than 3 to 1 . . . 4 points TOTAL........... ...... ...... Score of 1 to 4 points—-low treatment risk Score of 5 to 8 points--high treatment risk Score of 9 to 13 points--severe risk TOTAL RISK MANAGEMENT DESIGNATIONS GRAND TOTAL 4 to 15 points .................................. low risk 16 to 21 points .................................. high risk Greater than 21 points ............................. extreme risk Permission flanked by D. Thomasrigh lalr RN, CMS 1989. tsreserved. V H S R A m INDIVIDUALS WHO ASSISTED IN THE DEVELOPMENT AN D/ OR REVIEW OF THE PSYCHIATRY CASE STUDY D. Thomas Blair, RN, CMS Nursing Coordinator Extended Care Psychiatry VA Medical Center 'Ibpeka, KS Joan Cummings, MD ACOS/Extended Care VA Medical Center Hines, IL Tom Engelsing, MD Chief of DARU Outpatient Clinic VA Medical Center Menlo Park, CA George Norbeck, MD Unit Chief Mental Hygenist VA Medical Center Menlo Park, CA Roxane Rusch, RN RegionalAccreditation Consultant Western Region San Franscisco, CA Laurie Siedel, RN QA/UR Coordinator VA Medical Center Menlo Park, CA Dan Walls, MSW Section Chief Mental Hygiene Clinic VA Medical Center Menlo Park, CA Donald Widmann, MD Consultant-reviewer SPECIAL CARE CASE STUDY SPECIAL CARE CASE STUDY Lead Consultant-reviewer: Donald Widmann, MD Examples of the ten-step JCAHO process. Note: All ten steps should be evidenced in writing and available to reviewers. HOSPITAL ORGANIZATION - ZOO-bed general acute care facility - Medical center provides: medicine surgery intensive care coronary care level II Triage Area RESPONSIBILITY: Director of the Medical Intensive Care Unit (MICU): -responsible for implementing policies established by the Medical Staff for the continuing operation of the unit. - makes decisions, in consultation with the physician responsible for the patient, for the safe transfer of patients when the patient load exceeds optimal operational capacity. - assures that the quality, safety and appropriateness of patient care services provided within the unit are monitored and evaluated on a regular basis. - chairs multidisciplinary committee of medical staff called Medical Intensive Care Unit Committee. - serves as member on Drug Usage Evaluation Sub-committee of Pharmacy and Therapeutics Committee. - communicates significant QA findings and actions of the Medical Intensive Care Unit Committee monthly at Medicine monthly meeting. - prepares quarterly summaries of significant QA findings and actions of the Medical Intensive Care Unit Committee and reports this information to the Clinical Executive Board for approval through Medicine Service. U SCOPE: Medical Intensive Care Unit (MICU) is a combined medical/coronary care unit. Nine-bed unit, including one isolation room --- jointly managed by medicine and nursing. Medicine Service provides 24-hour physician care. Attending full-time internal medicine physicians supervise medical resident teams. Medicine Service appoints a Director of the Medical/Coronary Care Unit. Nursing staff includes: - a head nurse, - assistant head nurse, - staff nurses and - licensed vocational nurses. Nurse to patient ratio of 1:1 or 1:2. All RN’s are ACLS certified. Respiratory Therapy support is provided on all shifts. One therapist per shift is the minimum. Provides care to a variety of patients with acute medical and cardiac conditions requiring intensive monitoring and acute interventions for life threatening diseases. Diagnosis of patients typically seen include: - Chronic Obstructive Pulmonary Disease with Respiratory Failure, - Coronary Artery Disease, - Myocardial Infarction, - Liver Disease with Acute Gastrointestinal Bleeding, Patients who have undergone Percutaneous Transluminal Coronary Angioplasty and Cardiac Catheterization are recovered in this Medical Intensive Care Unit. Special treatments, procedures and monitoring include: - pacemaker insertion, - dialysis (peritoneal and hemodialysis), - lumbar puncture, - cardioversion, - intubation with mechanical ventilation, - administration of a variety of vasoactive agents - Swan Ganz, central venous and arterial pressure monitoring, - electrocardiography, - pulse oximetry monitoring. IMPORTANT ASPECT S OF CARE: The multidisciplinary stafl' of the unit agreed, using the framework of the ten-step process, on the following Important Aspects of Care: 1. Effectiveness of management of hemodynamically unstable cardiovascular disease patients on vasoactive drugs undergoing Swan Ganz catheter monitoring. 2. Timeliness of intervention in patient undergoing thrombolytic therapy. 3. Appropriateness of transfers to other areas. 4. Effectiveness of management of patients with acute respiratory failure who require intubation. INDICATORS: The following indicators were developed and selected by the Medical Intensive Care Unit Committee members and approved by the Chiq’ of Medicine. 1. Patients who have Swan Ganz catheters in place for greater than 48 hours. 2. Patients with M1 complicated by CHF on vasoactive therapy who fail to lose 1 kg per day while in special care. 3. Patients requiring parenteral inotropic and/or vasodilator therapy for greater than 3 days subcategorized by reason for therapy. 4. Patients with diagnosis of CHF with chest x—ray finding of CHF developing laboratory evidence of hypo- or hyperkalemia during their medical intensive care stay. 5. Patients with the initiation of thrombolytic therapy for treatment of Acute Myocardial Infarction greater than six hours after onset of pain. 6. Patients with acute myocardial infarction who receive t-PA without heparin therapy initiated within the first hour of t-PA therapy. 7. Patients who return to the Medical Intensive Care Unit within 48 hours of transfer to a less intense level of care subcategorized by diagnosis. 8. Patients reintubated within 8 hours of extubation. 9. Patients undergoing mechanical ventilation for acute respiratory arrest who develop pneumonia confirmed by X-ray and not evident upon admission subcategorized by length of time on the ventilator. 10. Patients who experience complications of prolonged intubation subcategorized by tracheal stenosis, GI bleeding, hypotension (90/60 or less), infection, ileus, and subcutaneous emphysema. M THRESHOLDS: Thresholds are recommended by the MICU committee and approved at the Medicine Service monthly meeting by the medicine staff. The threshold for review of patients with CHF becoming hypo or hyperkalemic was established at 5%; that is, when greater than 5% of patients have documented hypo or hyperkalemia, the Committee will perform an intense review of those cases. The threshold for timely thrombolytic therapy was established at 100%. In this case, the Committee will look at all cases where therapy was not administered within 6 hours of chest pain onset. 131 m COLLECT AND ORGANIZE DATA: Data related to these indicators is collected using locally developed forms by the multidisciplinary team members using a variety of sources including: - chart review, - Special Care flow sheets, - DHCP computer templates, - Special Care patient log, - incident reports, - respiratory flow sheets. Indicator #4 Example of Data Collection and Organization Data collection related to the indicator about hypo/hyperkalemia is collected using the laboratory DHCP file. On three days each week the lab profile of all patients in the Medical Intensive Care Unit with a diagnosis of CHF confirmed by chest x-ray is reviewed. The number of patients whose lab profiles are reviewed throughout the month becomes the total population or your denominator. The number of patients with hypo or hyperkalemia becomes your indicator population or your numerator. 12 with hypokalemia 3 with hyperkalemia X100=31% ————— X100 =7% 38 patients with 38 patients with CHF whose lab profiles CHF whose lab profiles were reviewed in June were reviewed in June Compare these percents with thresholds. Our threshold is 5% for both hypo and hyperkalemia. Our performance for June is 31% and 7%. Indicator #5 Example of Data Collection and Organization. Data collection related to the indictor about timeliness of thrombolytic therapy is taken from the emergency room (ER) flow sheet, the MICU flow sheet, and MICU log book. The population who received thrombolytic therapy is obtained from the MICU log book. This number serves as our denominator. The number of patients who did not receive thrombolytic therapy within six hours of chest pain onset is the group that we review; this is our numerator. This information is obtained by reviewing the ER and MICU flow sheets. The percent derived from this fraction is then compared monthly to our threshold. 6 patients receiving therapy in 6 hours X 100 = 75% 8 patients receiving thrombolytic Our threshold is 100%. Our performance for June is 75%. 132 m EXCERPT FROM THE M&E PORTION OF THE MEDICAL INTENSIVE CARE UNIT COMMITTEE MEETING MINUTES, JUNE 1990 . 1 VII. Monitoring and Evaluation of MICU care (Any indicators whose thresholds were exceeded or dropped below during the month would be included in this section.) C. Indicator #4: CHF patients with hypo/hyper kalemia. Threshold 5% - June Performance HYP° %= 31% Hyper 3% =5% 1. Findings: The Laboratory profile of 38 patients with CHF confirmed by CXR were reviewed during June, the first month of data collection since this indicator was approved. TWelve patients were found to have K + < 3.0 during course of treatment while two patients were found to have K + > 5. 0. Patients with hypokalemia were reviewed by three staff internal medicine physicians. In two patients, no K+ replacement was ordered even though the lab staff appropriately notified the MICU and treating physician. Two patients were on antibiotics which were thought to contribute to hypokalemia. The remaining eight patients were all on vigorous diuresis for management of failure. Although K + replacement was ordered in all cases, supplementation appeared inadequate and untimely to keep K > 3.3, which is commonly considered appropriate in patients with CHF. Five of the 8 patients who were on K replacement had arrythmias not previously noted on previous admissions. ALUATE CARE 3. Recommendations: The committee members recommended that physician/nurse education on fluid and electrolyte management of CHF patients be given. The committee suggested that a standing K replacement protocol be developed to be placed on the charts of all patients with CHF. .. provenien RT _. n‘bn CHF. fluidiand electrolfl " ocol unng'il‘ D. Indicator #5: Patients without timely thrombolytic therapy. Threshold 0% June performance 2/8 = 25% 1. Findings: The charts of eight patients who received thrombolytic therapy with any thrombolytic agent were \ reviewed during June. TWO patients of the eight patients did not receive the agent within the six-hour window of chest pain onset. One patient did not have a complete history taken by the ER nursing staff. Consideration 1 of this patient for thrombolytic therapy was delayed until the MOD saw the patient and contacted cardiology. j The second patient experienced treatment delays due to the unfamiliarity of the Medical Intensive Care staff on evening shift with the procedure for thrombolytic therapy. EXCERPT FROM THE M&E PORTION OF THE MEDICAL INTENSIVE CARE UNIT COMMITTEE MEETING MINUTES, JUNE 1990 continued 3. Recommendations: The committee members suggested that a standardized format for history taking be developed for ER personnel. It was suggested that this form include collection of data from patients about absolute contraindications to pharmocologic thrombolysis. The committee suggested that a protocol be developed to promote standardization and efficiency in the administration of thrombolytic agents. TAKE ACTION ASSESS ACTION AND DOCUMENT . V_ ..... “ ATTACHMENT - M&E PORTION OF THE MEDICAL INTENSIVE CARE COMMITTEE MEETING MINUTES SEPTEMBER 1990 MONITORING & EVALUATION INDICATOR TRACKING FORM INDICATOR # 5 Patients with the initiation of thrombolytic therapy for treatment of acute myocardial infarction greater than six hours after onset of chest pain. JUN JUL AUG SEPT THRESHOLD(%) 0% 0% 0% 0% ACTUAL PERE 25% 30% 0% 0% PATIENTS WHO DID NOT GET 2 3 0 0 numerator TX IN 6 HOURS PATIENTS WHO GET THROMBO. TX 8 10 9 11 denominator INDICATOR # 4 Patients with DX of CHF with CXR finding of CHF developing laboratory evidence of hypo or hyperkalemia during their medical intensive care unit stay. JUN JUL AUG SEPT THRESHOLD(%) hyper 5% 5% 5% 5% hypo 5% 5% 5% 5% ACTUAL PERF. hyper 5% 4.8% 5% 2% hypo 31% 26% 20% 8% PATIENTS WITH hyper 2 2 2 1 numerator hypo 12 11 8 4 CHF PATIENTS CONF. BY CXR 38 41 38 45 denominator V H S R A w COMMUNICATE AND INTEGRATE RELEVANT INFORMATION: As Chairman of the Medical Intensive Care Unit Committee, I communicate the significant QA findings and actions from MICU Committee at the Medicine Service monthly meeting. I prepare quarterly summaries of QA and M&E activities of the MICU Committee. 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Key terms used: 1. Joint Commission on Accreditation of Healthcare Organizations 2. Quality Assurance, Health Care 3. Monitoring or Evaluation Retrieval was restricted to a publication year of 1989 or 1990. BIBLIOGRAPHY continued t—I N b) P S" 57‘ .“ Cassidy DA; Friesen MA QA: applying JCAHO’s generic model. Nurs Manage 19901un; 21(6): 22-7 Raucher B; McKinley FW; Crimmins D; Dillon B; Marchione S J CAHO inspections for tertiary care facilities [letter] Infect Control Hosp Epidemiol 1990 May; 11(5):2 26 Fleischer D Monitoring for conscious sedation: perspective of the gastrointestinal endoscopist. Gastrointest Endosc 1990 May-Jun;36(3 Suppl): $19-22 Joel L Boston and the 1990 House. Am Nurse 1990 Jun; 22(6): 6 lngersoll S; Personnett JD A simplified approach to the ambulatory care diagnostic summary list. The Veterans Administration Medical Center at Sepulveda, California, develo d a one-page checklist as a "problem summary list." Use of the list has improved legibility of entries, compliance, 6 ficiency, and communication among prov1ders. QRB 1990 Mar; 16(3): 1 27-9 Peterson CD Quality improvement in pharmacy: a prescription for change_. Quality improvement activities offer pharmacists opportunities for establishing their roles as clinical practitioners, documenting their contributions to quality-of—care improvement, and bringing recognition to pharmacy as a clinical profession. Unfortunately, pharmacists haven’t yet reco ized the importance of or need for these programs. Drug usage evaluations and quali improvement still are not consi ered a benefit or an op rtunity but continue to be perceived as boring, tedious tasks t at must be rformed for the Joint Commission rather t an the patient. The time has come to refocus our emphasis on what real matters. We need to build quality im rovement programs not merely to placate the Joint Commissron but to improve t e quality of care for patients. We need) to build quality improvement programs that extend to the grass roots level of every organization so that everyone is involved, participating, and committed to correcting patient-care problems. ThlS commitment must become a routine habit, a daily acknowledgment, and an on oing process. Clinical practitioners must become actively involved in quality improvement programs by developing v d, reliable indicators to help ensure safe, appropriate use of drugs. We need to develop a computer model to assist in data collection for drug usage evaluations and quality improvement projects. And we must create a multidisciplinary team of practitioners, including physicians, nurses, and pharmacists, to thorou ly evaluate and respond to this information. A successful team effort means everybody wins, and the biggest winner of a1 is--and must be--the patient. QRB 1990 Mar;16(3):106-8 Malloy JA Home care accreditation through Joint Commission on Accreditation of Healthcare Organizations. As home care has become an increasingly viable alternative to inpatient care, the need for industrywide standards has become a major concern for consumers and ayors of health care. The Joint Commission on Accreditation of Healthcare Organizations has developed standards whic measure the uality of care and services provided by a home care organization. This article outlines the basic standards that a ome infusion therapy semce must meet in order to earn accreditation. J Intraven Nurs 1990 May-Jun; 13(3): 185-7 < I w W > 141 BIBLIOGRAPHY continued 8. 3° New JCAHO data spotlights quality problems. Am JNuIs 1990 May; 90(5): 18 Kisslo J; Millman DS Reimbursement update: looking toward the 1990s. Some Medicare carriers have independently decided to treat all billings for echocardiographic services as radiologic, whereas others have decided to treat billings from multispecialty practices that include a radiologist as radiologic services The result is that the radiology fee schedules are being applied, even though the services were not supplied by radiologist: J Am Soc Echocardiog 1990 Mar-Apr; 3(2): 154-7 . Marder RJ Relationship of clinical indicators and practice guidelines. QRB 1990 Feb; 16(2): 6 0 . Horowitz IR Focus review: an old concept revisited. Medical students throughout the world learn clinical skills in a physical diagnosis course. Clinicians can use this a proach to design a focus review to serve as a method of evaluation in the quality assurance of healthcare and as a researc tool. Md Med J 1990 May; 39(5): 465-8 . LaHaise S A comparison of infection control software for use by hospital epidemiologists in meeting the new J CAI-I0 standards. To choose a microcomputer software package for our hospital e idemiology division, the two leading commercial softwar packages for infection control, AICE (ICPA, Inc., Austin, Texas and NOSO-3 (Epi Systematics, Inc., Ft. Meyers, Florida) were compared for the types of epidemiologic analysis likely to be required to satisfy new Joint Commission on Accreditation of Healthcare Organizations (J CAHO) 1990 Infection Control Standards. The test dataset was a surgical database of 3,235 operations wi 292 (9%) wound infections. Though NOSO-3 was more flexible in terms of the amount of data items one could record, it required seven times longer to learn, nine times more disk space to store and two times as long to enter cases than AICE. Six simple infection control reports (i.e., line listings, crosstabulations, stratified rates and graphs?l required only seven computing steps and approximately 11 minutes to process with AICE, but 22 steps and over two ours with NOSO-3. All analytic results from AICE agreed with the results obtained with the Statistical Analysis System (SAS, SAS Institute, Inc., Cary, North Carolina , but analyses such as service-specific rates performed with NOSO-3 differed because of a design flaw in the NOSO-3 ta structure. Infect Control Hosp Epidemiol 1990Apr; 11(4):] 85-90 . Coleman RL; Kirven L] Jr The staff psychiatrist and the Joint Commission survey. The psychiatrist on a hospital’s medical staff has a major role in maintaining the quality standards established by the J oinl Commission on Accreditation of Healthcare Organizations and in reparin for its accreditation survey. The authors review the medical staffs role in quality assurance activities, including deveFopment of clinical indicators, monitoring of clinical data, er review of roblems, and plannin for improved care. Other areas of hospital operation requiring the attention oft 6 medical staff) are the functioning o the medical executive committee, hospltal bylaws, and procedures for granting, denying, and amending clinical privileges. Hosp Community Psychiatry 1990Apr; 41(4): 412-5 < I U: W > 142 BIBLIOGRAPHY continued 14. Moska MT JCAHO gets lukewarm reviews from its CEO opinion survey. CEOs from 9% hospitals gave the J CAHO mixed reviews in a recent survey: 38 rcent thought J CAHO’s performance had improved over the ast five years; 26 percent thought it had worsened; and percent saw no change. Depending upon who you talk to, t e results are either good or bad. Hospitals 1990 May 5; 64(9): 46, 48-9 . Baer DM; Belsey RE The evolving ggglatory environment and bedside metabolic monitoring of the acute care patient. Chest 1990 May; 97(5 Suppl):1 915-197S . Eastman TR 'Ibchnique charts responsibility of users [letter] Radio! Technol 1990 Mar-Apr; 61(4): 317 . Coulton CJ Quality care assurance. Mt Sinai J Med 1989 Nov,- 56(6): 435-9 . Neumann-Flugaur C Planned and systemic QA process to assure continual improvement in thrombolytic therapy administration. J Nurs QualAssur 1990 May; 4( 3): 79—82 . Francis ML; Merolla C Usilg standards for obstetrical nursing QA. J Nurs QualAssur 1990 May; 4(3): 61-8 . Eubanks P Nursing restructuring renews focus on patient-centered care. This car, the JCAHO will issue revised nursing standards that make the patient the center of care. This new focus is a si ' lcant switch from the existin standards, and nursing experts predict that the structures of all other direct patient care jobs in the hospital will be ected. Hospitals 1990Apr 20; 64(8): 60, 62 . Koska MT Candid discussion is aim of J CAHO’s CEO exit conference. Hospitals 1990Apr 20; 64(8): 114, 116 . Brill JM Risk management is team effort. Am Nurse 1990 Mar; 22(3): 34 < {I} tn :6 > 143 BIBLIOGRAPHY continued 23. Moody ML Revising a drug information center quality assurance program to conform to Joint Commission standards. Revisions in the quality assurance (QA) program for a drug information center DIC) at a lar e community teaching hospital are described. The initial QA program, implemented in 1984, was base on 25 speci 1c criteria an on the periodic evaluation process that was stressed by the Joint Commission on Accreditation of Hospitals at that time. In 1985 the hospital was surveyed for reaccreditation, and the Joint Commission stressed a new approach to QA that replaced periodic evaluation with an ongoing, planned process. Accordingly, the 25 specific QA criteria were replaced With 10 general indicators. Since 1985 the Joint Commission has shifted its focus to patient outcomes. The 10 eneral criteria hav‘ now been reduced to two specific criteria: the total number of questions received by the DIC staff an; the rcentage of responses that are appropriate. Drug information responses given by the DIC pharmacist as well as by the rontline pharmacists are momtored. As Joint Commission requirements for QA programs evolve, the QA program for this DIC is revised to ensure that it always meets the current standards. Am JHosp Pharm 1990Apt; 47(4): 792-4 'Ihmmelleo AD Legal case briefs for nurses. MO.: nurse blows whistle: termination issue; M'l'l: reduced earning capacity: workers’ comp. Regan Rep Nurs Law 1990 Feb; 30(9): 3 . David G; Price SC Performing JCAHO dose calculations with the aid of a microcomputer spreadsheet program. AJR Am J Roentgenol 1990Apr; 154(4): 863-6 . Fauman MA Monitoring the quality of psychiatric care. Modern medical quality assurance depends on the identification and continual monitoring of important parameters or indicators of care. Indicators are defined as measurable clinical variables, often related to high volume, high risk, or problem-prone areas of medical care. Althou the identification and monitoring of indicators is often a complex task, there are several areas in psychiatry where ef ective indicators can be developed. The process of indicator development 1; discussed and several suggestions are made for effective clinical parameters to monitor. Psychiatr Clin North Am 1990 Mar; 13(1): 73—88 BIBLIOGRAPHY continued 27. Schyve PM; Prevost JA From quality assurance to quality improvement. As we are learning to master the methods of quality assurance, a new conceptual ap roach focused on quality improvement is being advocated. But this new approach is not a derailment for he th care practitioners committed to improve patient care quality. Rather, it is a pro essive step that builds upon the concepts and methods of quality assurance. Whereas quality assurance tends to ions on correcting problems in patient care quality--especially individual practitioners’ problems--quality improvement focuses on finding opportunities to improve quality by changing systems as well as individual practitioner behavior. Whereas quality assurance tends to rely primarily on standards or gu1delines for the structures and processes of care and the intensrve review of individual cases with undesirable outcomes, quality improvement also utilizes statistical profiles of outcomes, structures, and processes as baselines against which improvement can be measured. Whereas quality assurance may en ender defensiveness in an individual practitioner, quality improvement is based on the health care practitioner’s profgessional ethic and pride in providing even better care to patients tomorrow than is possible today. To improve patient care quality, it is necessary to examine the structures, processes, and outcomes of care. The structures and processes can be controlled by the practitioner and organization; the outcomes are the benchmarks against which the effectiveness of the structures and processes can be evaluated. Outcomes in health care are the effects of more than just the structures and processes controlled by the practitioner and organization. Therefore, outcomes are not direct and complete measures of the uality of the care provided. They are instead indicators of performance. These indicators can focus attention on caret at lies outside the normal statistical parameters of performance and can provide baselines a ainst which improvements can be measured. The monitOring and evaluation process described in Joint Commission stan ards is a method for establishing priorities and usin indicators to improve the quality of patient care. This method can be used to focus case-based review of care and to esta lish baselines for continuous improvement. This conceptual approach that emphasizes quality improvement and the use of the monitoring and evaluation process is iding the Joint Commissron’s develo ment of clinical indicators and revision of its standards and survey process to help ealth care organizations in the transition from quality assurance to quality improvement. Psychiatr Clin North Am 1990 Mar; 13(1): 61-71 . Uttermohlen DM Taxpayers on the ward. Quality improvement through the Citizen Monitoring Program. This cha ter describes the Massachusetts Citizen Monitoring Program and discusses the program’s history and rationale. Althou the program has great intuitive and political appeal, little data currently exists with which to assess its effectiveness in improving patient care. The monitoring and evaluation model of the Joint Commission on Accreditation for Healthcare Organizations is roposed as an alternative to the present program. Under the proposed model, the program should become more 6 ficient and effective. Psychiatr Clin North Am 1990 Mar; 13(1): 49-59 . American Academy of Pediatrics Committee on Hospital Care: Medical staff appointment and delineation of pediatric privileges in hospitals. Pediatrics 1990Apr; 85(4):6 07-17 . Pelletier LR; Poster EC; Kay K Contraband: the hidden risk. In a 28-month retrospective study of contraband possession in an in atient psychiatric setting, 54 incidents of contraband confiscation were identified. Incidents were analyzed according to day and shift of occurrence, nature of contraband, patient diagnoses and characteristics, and patient outcome of contraband possession. Stud findings stress the importance of clearly stated contraband policies and procedures, especially in light of patient and staffy rights and responsibilities. QRB 19901an; 16(1): 9-14 < m m :1 > 145 m BIBLIOGRAPHY continued 31. J ohnsson J Groups vie for lucrative managed care accreditation business. The race is on to determine which organization will become the accreditation ency of choice for the managed care industry. At stake is enormous clout at the state and national levels--and a lot 0 money. Squaring off against the traditional accreditation leader, the Joint Commission on Accreditation of Healthcare Organizations, are: the National Committee for Quality Assurance, the American Association of Preferred Provider Organizations, and the Utilization Review Accreditation Commission. Hospitals 1990 Apr 5; 64(7):3 5-6, 38 32. Kriebel M A profile of hospice programs in Pennsylvania. The annual survey reports by the Pennsylvania Hospice Network allow a longitudinal look at programs in Pennsylvania from 1985 to 1987. Comparisons are made of data on the programs, on hospice atients, on services provided, on bereavement care, and on volunteer involvement. Findings consistent over the t ee years suggest profiles of "typical: programs, patients, and care provision. Changes in reported data which may indicate trends are noted. Differences etween pro ams which were Medicare certified or accredited by the Joint Commission for Accreditation of Hospitals are observe as are differences between certified or accredited programs and others. Hosp! 1989; 5(3-4): 51-71 33. Farnsworth PB The elimination of the requirement for medical libraries in hospitals [see comments] Comment in: N YState J Med 1990 Feb; 90(2): 76-7 N YState J Med 1989 Nov; 89(11): 601-2 34. Rifkin AM; Evans GE; Hall GD Antitrust’s recent attack on the peer review practitioner: is the Health Care Quality Improvement Act a viable remedy? Peer review, an increasingly important function in the hospital setting, is unique in that physicians are granted the task of evaluating and supervising the actions of their counterparts. Regardless of the consequences resulting from the _ peer-review system now operating within the hospitals, it will continue to be a mainstay until a more workable alternative IS proved successful. Md Med J 1990 Jan; 39(1): 21-32 35. Kneedler JA OR directors’ survey A report from the Special Committee on Critical Issues. AORNJ 1990 Feb; 51(2): 470-3, 475-8 36. Palmer PN ’lmmediately available’—two words that require many more to explain them [editorial] AORNJ 1990 Feb; 51 (2): 429-30 37. Moran EJ Infection control investment saves in the long run. Hospitals 1990 Mar 5; 64(5): 58 V H S R A w BIBLIOGRAPHY continued 38. 3 Winchester DP The assurance of quality care for the cancer patient. Quality assurance is receiving increasing attention in a Chan ' health care delivery system dominated by cost containment. Quality is being defined by health profession , patients, hospitals, the purchasers of care, and government. None seem to agree entirely. A meaningful future for assurance of quality of care for the patient with cancer will require thoughtful program development by a widely diverse group of organizations dedicated to this goal. Cancer 1990 Feb 1; 65(3 Suppl): 7 76-9 . Thomson-Keith E Joint Commission standards. How AORN provides input. AORNJ 1989 Dec; 50(6): 1260-2 . O’Leary D Agenda for change [editorial] ASHA 19901an; 32(1): 37-8 . Murray NS Hospice accreditation: a useful tool for quality assurance. Am J Hosp Care 1989Jul-Aug; 6(4): 44-6 . Proctor ME Creative methods of meetinhICAHO inservice requirements for hospital staff. J Nurs Staff Dev 1989 Nov-Dec; 5(6): 285-6 43. Larson E; Oram LF 44. From process to outcome in infection control. Nuts Qua] Assur 1989 Nov; 4(1): 18-26 Koska MT J CAHO: pilot hospitals’ input updates Agenda for Change; How is the Agenda for Change program progressing? Despite some setbacks during its first year, officials at the Joint Commission on Accreditation of Healthcare Organizations say that the program is heading toward its ambitious goal of evaluating the clinical and organizational performance of hospitals. Hospitals 19901an 5; 64(1): 50—2, 54 . Characteristics of clinical indicators. This article will appear early next ear as Chapter 2 in the Primer on Clinical Indicator Development and A plication, a Joint Commission guidebook on ciinical indicators. This section of the Primer defines clinical indicators an discusses their use in monitoring and evaluating factors in patient care. Examples are given of the two types of indicators, sentinel event and rate-based, which may measure either outcomes or processes of care. An explanation of indicator-specific information sets is also covered. QRB 1989 Nov; 15(11): 330-9 147 w BIBLIOGRAPHY continued 46. Simpson R JCAHO plan brings change to health care. Am Nurse 1989 Nov-Dec; 21(10): 30, 32 47. Hoskins EJ A quality assurance program for a state university student health center. The New Mexico State University Student Health Center redes' ed its quali assurance program to follow the Joint Commission’s ten-step process for monitoring and evaluation. T is article out ' es the scopes of care in the Health Center’s different units and provides case-study examples, including important aspects of care and indicators, to illustrate the monitoring and evaluation process as it is used for both retrospective studies and concurrent monitoring. QRB 1989 0ct; 15(10): 320-6 ‘ 48. Koska MT Be aware, not afraid, of JCAHO complaint standards. How does your hospital handle complaints? You had better have a good answer to this uestion. As of this January, the Joint Commission on Accreditation of Healthcare Organizations, Chicago, will require ospitals to formalize their methods of responding to patient complaints. Hospitals 1989 Dec 5; 63(23): 40 49. Beck RS JCAHO. Conn Med 1989 Oct; 53(10): 611 50. Larson E The infection control community’s response to the Agenda for Change_. Am J Infect Control 1989 Oct; 17(5): 241-3 51. Patterson CH Perceptions and misconceptions regarding the Joint Commission’s view of quality monitoring: The Joint Commission recently has revised its hospital standards for infection control to reflect more accurately current state-of-the-art practices. In addition, the Joint Commission’s Agenda for Change initiatives include the development of clinical indicators; one of the topics that will be included in those clinical indicator sets will be infection control. How the hospital chooses to organize itself to conduct the historically required monitoring and evaluation of clinical patient care currently re uired by the standards of the Joint Commission is at the option of the hospital. How the hospital will organize and collect ata specific to infection control indicators yet to be developed by the Joint Commission has not been determined and will not be defined until specific research and development projects are completed. The hospital is expected to have in place infection prevention, surveillance, and control rograms; it also is expected to have in place a quality assurance program that focuses not only on solving identified problems but also on the improvement of patient care quality. How the hospitals organize and/or integrate these activities is also at its option. It is expected that qualified professionals will direct and enforce infection revention, surveillance, and control practices; indicators for infection control can provide data that will help assess e relative success of those practices and activities. The Joint Commission is not developmg the capability to judge, on its own part, the actual uality of care provided by an organization seeking accreditation. Rather, the Joint Commission is committed to deve oping more accurate means to evaluate the structures, processes, and outcomes of diagnosis and treatment activities, as well as their interrelationships. Clinical excellence 15 supported by quality in the organizational environment and the managerial and leadership contexts within which patient care is delivered. Both clinical and organizational excellence are essential components of uality, and the Joint Commimion is convinced that it is appropriate and timely to undertake more direct assessments of 0th. Am J Infect Control 1989 Oct; 17(5): 231-40 w BIBLIOGRAPHY continued 52. Keil OR The challenggif buildingjulality into clinical flgineeringmgrams. Biomed Instrum Technol 1989 Sepv0ct; 23(5): 354-7 53. Peterson CD; Goldberg DE Pharmacy-coordinated process for evaluaflg physician drug prescribing. A pharmacy-coordinated process is described in which the frequency and types of inappropriate drug prescribing are evaluated as part of the medical staff quality assurance and physician credentialing program. A pharmacist intervention program was im lemented at an 838-bed private hospital to review all medication orders for appropriateness and to mtervene with sicians and nurses when problems in drug prescribing or administration were identified. During a five-year periog there were more than 6500 drug therapy interventions. Because of the recurrent problems ident' ed, the medical staff asked the pharmacy department to develop a process for objectively evaluating the quality of prescribing practices that could be used in the medical staff qualitylalssurance program and in physician credentialing. The drug-prescribin activities of physicians applying for c ' 'cal privileges are subjected to a "macro": review by using a computerized cfinical financial information system to extract drug-use information from patients’ bills. In a "micro": review, patient records are retrospectively analyzed b Pharm.D. clinical specialists; all medications prescribed by the physician for those patients being evaluated are scrutinized. Appropriate response scores are calculated by dividlng the number of appropriate res 011565 by the total responses. The pharmacy department in this hospital has assumed a more active role in patient care t ough its participation in a process for objectively evaluating the quality of prescribing practices. Am J Hosp Phann 1989 Sep; 46(9): 1787-91 54. Larsen RD; Bennion SD; Leonard TE Monitoring and evaluation in an Army health clinic. In 1987, the authors implemented an indicator monitoring systemthat allows for ongoing evaluation of im rtant aspects of care at the Erlangen Health Clinic, Erlanfi n, Federal Republic of Germany, a US. Army primary me ical clinic serving approximately 1,200 patients a mont . Staff develo ed rospective and retros ective mdicators based on identified high-risk, 'gh-volume areas, and established thresholds o eva nation for each of the mdicators. A numerical auditing mechanism 15 used to record compliance with established objective criteria that determine whether or not a case is deficient. A peer review committee reviews and recommends actions for deficient cases. QRB 1989Aug' 15(8):2 3&45 55. Donofrio MT; Barron DM; Winters SL; Gomes JA; Gorlin R Cardiopulmonary resuscitation: qualifications and performance of housestaff and trained internists. Eighty-six physicians in the Internal Medicine Department of the Mount Sinai Medical Center were evaluated on attitudes and knowledge of basic and advanced cardiac life support. Information was athered over a one-week riod using a self-administered questionnaire. Eighteen (21%) of the respondents did notinow of the availability of be cardiac life support courses at this institution. Of the physicians who had never taken either course, 8 (25%) stated it was because it was not offered at a convenient time or place. All house staff officers were noted to have com leted both courses, a percentage much higher than that of the trained internists (p less than .0001). Previous forma training in cardiac life sup ort was found to be associated with a higher level of confidence in the ability to administer cardiac lifesaving techmques ( less than .0001) and a higher overall knowledge score (p = .003). We determined that the house staff officers in internai) medicine were the physicians most qualified to perform resuscitation efforts because of their completion of life support courses, their confidence in administering these techniques, and their greater overall knowledge. Wider publicity on the availability of cardiac life support courses, more convenient scheduling of such courses, and mandatory certification in basic life support for all physicians, with additional certification in advanced cardiac life support for physicians with extensive ward responsibility, are needed. Mt Sinai J Med 1989 Sep; 56(4): 27934 56. Horton JL A look at home health _agencies. Non-certified agency Fla Nurse 1989Aug; 37( 7): 9 149 asic and advanced ” BIBLIOGRAPHY continued 57. Silberstein LE; Kruskall MS; Stehling LC; Johnston MF; Rutman RC; Samia CT; Ramsey G; Eisenstaedt RS StrategiLsfor the review of transfusion practices [published erratum appears in JAMA 1990 May 2; 263(17): 2302] The intent of this report is to familiarize health care professionals with the concept of effective quality assurance in regard to blood use. Although evaluation of the ap r0 riateness of transfusion therapy is now required by the Joint Commission on Accreditation of Health Organizations, fieaffh care facilities have little experience with this as ect of professional quality assurance. To this end, the Committee on Transfusion Practices of the American Association of Blood Banks, in Arlington, Va, in this report has provided examples of indications and audit criteria for individual blood components and roducts and commented on areas of controversy surrounding their use. Audit criteria from different institutions may var: cause of differences in local interpretation of the indication, different patient opulations, and, in some instances, the availability of blood and laboratory services. Several ap roaches to the review 0 transfusion practices are discussed in relation to clinical settings and pertaining to particular lood components. It is evident from these examples that there wil be an increased need for trained ersonnel to perform the initial review process as well as for physicians trained in transfusion medicine to oversee t e transfusions and provide the necessary consultation. JAMA 1989 Oct 13; 262(14): 1993-7 5 . fl McCarty P Nurses see new horizons for organized nursipg: Am Nurse 1989 Sep 7} 21(8): 1, 10-2 59. Infectious medical wastes. Council on Scientific Affairs. A number of recent incidents involving improper handling and disposal of hospital waste have prompted the demand for more stringent le 'slation to cover the management of infectious hos ital waste. Resolution 53 (December 1987 Interim Meetin ) called or the American Medical Association to promote t e passage of federal legislation for the proper dispos of infectious hospital waste. This resolution has prompted a Council on Scientific Affairs report on the current status of infectious hospital waste management and of state and federal regulations to control such waste. The Council ha concluded that existing federal and state regulations for the management of hazardous waste--in conjunction with the accreditation program of the Joint Commission on Accreditation of Healthcare Organizations and the guidelines of the Environmental Protection Agency and the Centers for Disease Control, if adhered to and properl enforced--should be adequate to ensure that the public and environment are not endangered. Therefore, the Council oes not favor additiona federal legislation at this time and recommends that this report be accepted in lieu of Resolution 53. JAMA 1989 Sep 22-29; 262(12): 1669-71 8 . Jackson BS Ownership imbalance [editorial] 1 Nurs Adm 1989 Sep; 19(9): 4-5 0\ pa . O’Lwry D An interview with Dennis O’Leary: responding to harsh criticism of the JCAHO [interview by Helen Ripple] Nurs Econ 1989 May-Jun; 7(3): 126-8 62. Feutz SA I._egal implications of institutional standards for nurses. J Nurs Adm 1989Jul—Aug; 19(7): 4-7 83 . Reichard DA Providing J CAHPO approved CEU’s for the ophthalmic staff. Insight 1989Aug; 14(4): 15 V H S R A m BIBLIOGRAPHY continued 64. Winchester DP Assuringjflality cancer care in an evolvEghealth care delivery system. CA 1989 J ul-Aug; 39(4): 201—5 65. Micheletti JA; Shlala TJ Evolving Quality assurance initiatives in home healthcare. Nur's Manage 1989Aug; 20(8): 24-6, 28 66. Moska MT JCAHO accreditation: top trouble spots for hospitals. Hospitals 1989Aug 5; 63(15): 34 67. Robinson ML JCAHO emphasizes patient outcomes. Hospitals 1989 Jul 20; 63(14): 21 68. van Schoonhoven P Quality patient care and blood usage review [editorial] Transfusion 1989 Jul-Aug: 29(6): 471-2 69. McFee AS; Gilbert J The outcome index. A method of quality assurance in the special care area. A method of quality assurance for a surgical intensive care unit is described. A system outcome score is devised, incorporating only easily obtained objective components that reflect the likelihood of death. Through the use of a derived outcome index, the actual mortality rate is com ared with the predicted mortality rate as a method of monitorin the qualit of care provided. Subroutines exist to i entify errors in data entry, to detect malicious interference in patient care, to ad nonscor components for the purposes of clinical studies, and to facilitate retrieval of a concise summary of the major events during the stay of every patient admitted to the intensive care unit. Arch Surg 1989 Jul; 124(7): 825-9 70. Wenzel RP Expamfiigroles of hospital epidemiolgy: quality assurance. Infect Control Hosp Epidemiol 1989 Jun; 10(6): 255-6 71. McCarty P ANA requests two seats on board of JCAHO. Am Nurse 1989 Jun; 21(6): 26 30 72. Kleiber C; Chase L Solving documentation problems with a pediatric flow sheet. In September/October 1988, Pediatric Nursing published a pediatric intensive care unit (PICU) flow sheet for documenting assessments and nursing interventions. In this article, a hospital’s pediatric flow sheet that allows for entries related to general diatric practice is presented. It decreases the amount of time required to chart as well as the number of medical record orms used to comply with J CAHO standards for nursing. documentation. Pediatr Nurs 1989 May-Jun; 15(3): 253-7 151 W BIBLIOGRAPHY continued 73. Gould EJ Home care nursing: professional and political issues. Concern for quality, cost, and access dominate the health care system in the eighties. State and national actions, demographic changes, and technological advances are converging to create many changes in the home care delivery system. Knowledgeable nurses can influence the evolution of home care services to assure that patients receive appropriate acute and long term home care services. Concern for quali care, changing patient needs, and availability 0 care are the major issues facing home care nursing in the eighties, an will continue to be into the nineties. Reimbursement policies of third party payers, medicare/medicaid regulations, state licensing, employer benefit programs, state health programs, home health care providers, professional/trade associations, and consumer advocac groups are some of the key forces reshapinfg the practice of home health nurses. Knowledge of these factors will enab e nurses to influence effectively the design 0 institutional and governmental policies which affect the care nurses deliver to patients at home. I N YState Nurses Assoc 1989 Mar; 20(1): 4-7 74. Scearse P Accreditation: the good, the bad, and the ugly; I Prof Nurs 1989 May-Jun; 5(3): 123, 168 75. de Savorgnani AA Quality assurance activities in healthcare facilities. Since the 19605 there have been concerted efforts to initiate, develop, and promulgate quality assurance policies and protocols in healthcare facilities in the United States. These activities were spurred main] by the Joint Commission on Accreditation of Healthcare Organizations, which ensures that hospitals monitor and eva uate their services based on redetermined criteria. This paper considers how quality assurance activities have been implemented in healthcare acilities, reviews various obstacles to the full development of the quality assurance program, and suggests several areas in which corrective actions could be ndertaken. Milit Med 1989 Jun; 154(6): 322-6 76. String ST; Brener BJ; Ehrenfeld WK; Hollier LH; Moss CM; Queral LA; Rutherford RB; Towne J B lnterventional procedures for the treatment of vascular disease: recommendations regardingglality assuming, development, credentialingg'iteria, and education. Regional Vascular Society Committee on lnterventional Therapy. J Vasc Surg 1989 May; 9(5): 736-9 77. McAfee RE Medical staff enforcement. Dilemmas and decisions. Cancer 1989Jul 1; 64(1 Suppl): 317-8; discussion 320-3 78 Marder R J Joint Commission plans for clinical indicator development for oncolog; Cancer 1989Ju1 1; 64(1 Suppl): 310-3; discussion 314-6 152 W BIBLIOGRAPHY continued 79. Coffin C; Matz K; Rich E Al__gorithms for evaluating the appropriateness of blood transfusion. Medicare regulations and the guidelines of the Joint Commission on Accreditation of Healthcare Organizations require assessment of the a propriateness of transfusions by a hospital committee. A set of criteria maps for component transfusion review by nurses or technical personnel was designed, tested, and modified. The algorithms were based on written guidelines developed by a group of physicians. In the first lEzrt of the study, 196 medical records of patients from medical and surgical diagnosis-related groups with the highest ut' ' tion of blood (Group I) were screened. Forty patients were excluded because of a pre-existin transfusion protocol. Of the remaining 156 patients, 146 (94%) received red cell transfusions, of which 96 percent were indicated, 1 rcent not indicated, and 3 percent controversial. Thirty-five patients (22%) received fresh-frozen plasma transfusions, 0 which 69 percent were indicated, 11 percent not indicated, 17 percent controversial, and 6 percent Indeterminate. In the second part of the study, medical records were screened from 99 randomly selected patients who had received red cell transfusions (Group II), and the results were similar to those in Group I. Ph ician review was necessary in 20 percent of the transfused patients screened with the criteria maps. It is concluded t t algorithms for transfusion review can be developed and used easily to fulfill regulatory and accreditation requirements an to plan focused educational programs. Transfiision 1989 May; 29(4): 298-303 80. Nelson CW; Goldstein AS Health care quality: the new marketing challenge_. More and more buyers of health care are evaluating the quality of care as well as the cost. To stay competitive, providers must now learn how to sell quality. Health Care Manage Rev 1989 Spring; 14(2): 87-95 81. Schlepp S 11115 for a freestandinggenter to survive a Joint Commission survey. Achieving accreditation for a freestanding facility is no different from achieving accreditation for a hospital. "Our standards do not drop because we work in a freestanding facility,": Phillips sai AORNJ 1989Apr; 49(4): 1113-7, 1120 82. Koska MT Medical stall” cooperation key to JCAHO plans. Hospitals 1989 May 5; 63(9): 48 83. 'IhmmelleoAD Nurse-expert’s testimony held admissible. Case in point: Wicklifl'e v. Sunrise Hosp., Inc. (766 P. 2d 1322--NV (1988)). Regan Rep Nuts Law 1989 Mar; 29(10): 2 84. Pederson S Should the American Nurses’ Association (ANA) have the sole responsibility for establishing the standards of practice? Part IV. Prairie Rose 1989 Jan-Mar; 58(1): 12-3 a . Holthaus D J CAHO confidentiality undggoes public scrutiny. Hospitals 1989Apr 20; 63(8): 56 58 153 H BIBLIOGRAPHY continued 86. Koska MT Soflware eases Agenda for Chflge abstractiflL Hospitals 1989 Apr 5; 63(7): 28 ~l Harris SH; Kreger SM; Davis MZ A problem-focused gualigx assurance promm. Nurs Manage 1989 Feb; 20(2): 54-6, 58, 60 88. 'li'ofinoJ JCAHO nursing standards. Nursing care hours and LOS per DRG—Part [1. Nurs Manage 19891an; 20(1): 33-5 89. 'Ii‘ofino J JCAHO nursing standards. Nursing care hours and LOS per DRG-PART I. 8 Blair TD Risk Management for Extrapyramidal Symptoms Quality Review Bulletin 1990 Mar: 116-124 CREDITS A R S _ FACULTY BIOGRAPHIES GALEN L. BARBOUR, MD Galen L. Barbour, M.D., was born on April 20, 1941 in Denison, Texas. He attended the University of North Dakota from 1958-59 and Little Rock University from 1959-61 where he received his bachelor of science degree in 1961. He graduated from the University of Arkansas School of Medicine in 1965. In 1965-66, Dr. Barbour completed a rotating internship at the Akron General Hospital in Akron, Ohio. From 1966-68, he served in the United States Air Force and received a Commendation Medal in 1968. In 1974, Dr. Barbour received the Willard 0. Thompson Memorial Scholarship for study at Oxford, England. Dr. Barbour’s academic appointments include assistant professorships at the University of Arkansas Medical Center from 1971 to 1980. Since 1980, he is professor of medicine and vice—chairman for the Department of Internal Medicine at the Eastern Virginia Medical School. Since 1980, Dr. Barbour has been Chief of Medical Service at the VA Medical Center in Hampton, Virginia, where he was Acting Chief of Staff during 1984 and 1986—87. During 1989, he was Acting Deputy ACMD for Clinical Affairs (VACO). Dr. Barbour was certified by the American Board of Internal Medicine with Subspecialty Certification in Nephrology in 1974. He received American Board of Internal Medicine Certification in 1972 and again in 1980. Dr. Barbour has performed extensive medical research. Since 1971, he has served on and chaired many committees in various areas of medicine such as kidney disease, internal medicne, medical education and other areas. Since 1979, he has done several medical journal editorial reviews. JOAN CUMMINGS, MD (No information available at time of publication. ) m FACULTY BIOGRAPHIES continued DENNIS O’LEARY, MD Dennis S. O’Leary, MD. was born in Kansas City, Missouri on January 28, 1938. He received his bachelor of arts degree from Harvard College in 1960 and his doctor of medicine degree from Cornell University in 1964. Following two years of internal medicine training at the University of Minnesota Hospital, he completed his residency at Strong Memorial Hospital in Rochester, New York in 1967, and then served an additional year as chief resident in medicine and fellow in hematology. He is board certified both in internal medicine and in hematology. After three years as director of the coagulation research laboratory at Walter Reed Army Institute of Research, Dr. O’Leary joined the faculty and staff at the George Washington University Medical Center in 1971. During his fifteen years at George Washington, he achieved the academic rank of professor of medicine and assumed various administrative responsibilities including associate dean for graduate medical education and medical director for the University Hospital and for the faculty practice plan. From 1977 through 1985, he held the senior management position of Dean for Clinical Affairs and served as Vice President of the George Washington University Health Plan, an academic HMO. In 1981, Dr. O’Leary received national attention for his role as hospital spokesman following the attempted assassination of President Reagan. In recognition of his performance, he received resolutions of commendation from both the American Medical Association and the American Hospital Association as well as a number of other awards. Highly active in a variety of professional activities, including PSRO and liability insurance company board responsibilities, Dr. O’Leary has served both as president and as chairman of the board of the District of Columbia Medical Society; he was also a founding member of the National Capital Area Health Care Coalition. Since 1980, he has lectured widely on hospital/medical staff relationships, medical education, and medicine and media relations. In 1986, he completed service as the first chairman of the editorial advisory board for Medical Staff News. Dr. O’Leary is a fellow of the American College of Physician Executives and a member of both the American Medical Association and the American College of Physicians. He became president of the Joint Commission in April, 1986. JOHN R. PAYNE, MD John R. Payne, MD, was born on March 29, 1925 in Salt Lake City, Utah. He served for 33 months in the US. Army during the post-war era from 1946 to 1949. One year later, he received his undergraduate degree from Northwestern University. He completed Northwestern University Medical School in 1953. Dr. Payne did a one-year internship at San Francisco General Hospital. He was an internal medicine resident at the San Francisco VA Hospital and San Francisco General from 1954 to 1957. He was selected Chief Resident during his last year at San Francisco General. Dr. Payne was in private practice for 20 years at Woodland Clinic in Woodland, California from 1957 to 1977. The next year, he moved to Montana where he practiced for another year. Between 1979 and 1984, Dr. Payne was a J CAH Field Surveyor. The next year, he served in that capacity part-time. In 1987, he took on his present role as consultant to hospitals and the J CAHO. Dr. Payne has memberships with the American College of Physicians, California Academy of Medicine and the Alpha Omega Alpha Honorary Medical Society. He is licensed in California and Montana and has published two articles in [I ll . l l l' . . 157 M FACULTY BIOGRAPHIES continued PAUL J. SANAZARO, MD, F.A.C.P. After graduating from the University of California School of Medicine in San Francisco and completing his residency in internal medicine, Dr. Sanazaro entered private practice. He subsequently became a faculty member at UCSF and carried on the consulting practice. He became interested in the relationship of medical education to the later performance of graduates and was invited to direct the Division of Education of the Association of American Medical Colleges. There he conducted studies which identified the elements of physician performance most responsible for patient outcomes. He was then named first Director of the National Center for Health Services and Research and Development. This agency funded projects which led to currently used methods of assessing the quality of care. In 1973, Dr. Sanazaro left government service to direct privately funded national initiatives in quality assurance under the auspices of the American College of Physicians, American Hospital Association, American Medical Association and the American Society of Internal Medicine. These projects established the feasibility of concurrent quality assurance in hospitals and of measuring the performance of individual internists in office and hospital practice. Dr. Sanazaro is a consultant to private and public organizations, state and federal agencies, and medical and hospital organizations in the US. and abroad. He has been a consultant to the JCAHO since 1977, conducting specialized studies of the QA standards and serving as a consultant surveyor. He has published extensively in the field of quality assurance, physician performance and peer review. He is currently emeritus clinical professor of medicine at UCSF and resides in Berkeley, California. W. KEITH SLOAN, MD W. Keith Sloan, M.D., received his undergraduate degree from the University of Illinois and his degree in medicine from the University of Louisville. Dr. Sloan completed an internship at Southern Pacific Hospital in San Francisco, California. He served surgical residencies at St. Elizabeth Hospital in Lafayette, Indiana and at The Ohio State University Hospital in Columbus, Ohio. During World War 11, Dr. Sloan was a medical officer with the United State Navy Reserve. Dr. Sloan now resides in Cape Coral, Florida. He had a private practice in general surgery in Madison, Indiana for over thirty years. He served as a consultant surgeon at the Madison State Hospital in Madison. Since 1979, Dr. Sloan has been a surveyor for the Joint Commission on the Accreditation of Health Organizations. He has been a consultant surveyor for four years. Dr. Sloan is a fellow of the American College of Surgeons and is certified by the American Board of Surgery. W FACULTY BIOGRAPHIES continued DONALD ERIC WIDMANN, MD A board certified psychiatrist, Dr. Donald E. Widmann received his A. B. (Cum Laude) from Harvard College in Cambridge, MA, in 1956, and graduated from Case Western Reserve University School of Medicine, Cleveland, OH, in 1960. He completed a rotating internship at Cleveland Metropolitan General Hospital and a residency in psychiatry at the University of North Carolina, Chapel Hill. At the completion of his residency, Dr. Widmann received first prize in the Anclote Manor Competition for outstanding research by a graduating psychiatric resident. Dr. Widmann’s professional career encompasses vast experience in clinical and administrative areas. In addition to private practice, he has served as a department head and hospital medical director. Dr. Widmann is a past Commissioner of the Divisions of Mental Health and Forensic Psychiatry for the State of Ohio. While serving as Director of the Department of Standards at the Joint Commission on Accreditation of Healthcare Organizations, Dr. Widmann developed the revised medical staff, quality assurance, governing body, and management and administration standards. He oversaw revisions in the survey analysis process, governing body, and management and administration education publications and programs. Dr. Widmann has continued his affiliation with the Joint Commission as a consultant surveyor in the Hospital Accreditation Program. He also serves as a faculty member for the Joint Commission’s surveyor training and field education programs. Dr. \Vldmann’s expertise extends to the areas of quality assurance, medical staff compliance for acute care hospitals and psychiatric and substance abuse facilities. Dr. Widmann is currently a private consultant for hospital and medical staff accreditation and quality assurance. Through his expert consultative and educational services, Dr. Widmann has assisted hospitals and healthcare facilities throughout the United States in achievement and maintenance of Joint Commisssion accreditation. Dr. VVrdmann retired from the Medical Corps, US. Naval Reserve, with the rank of Captain. He is the recipient of the Navy Commendation Medal, awarded for his contributions to the Navy’s healthcare quality assurance and credentialing programs throughout the Naval Medical Command. In addition to his board certification in psychiatry, Dr. Widmann is certified by the American Psychiatric Association in psychiatric administration and is a Diplomate of the American Board of Quality Assurance and Utilization Review Physicians. He was elected to membership in the American College of Psychiatrists in 1989. 159 glUALITY ASSURANCE NATIONAL TRAINING PROGRAM RATEGIC PROGRAMMATIC PLANNING COMMITTEE Scott Beck, BS, ME, CPQA Regional Quality Assurance Manager Eastern Region Fort Howard, MD Joan Cummings, MD ACOS/Extended Care VA Medical Center Hines, IL Agatha Francis Health Oflicer Office of Medical Inspector VA Central Office Washington, DC Ronald Goldman, PhD Health System Specialist Office of Quality Assurance VA Central Office Washington, DC Thomas Harries, PhD Special Assistant Office of Quality Assurance VA Central Office Washington, DC Eleanor Haven, RN Projects Manager Birmingham RMEC Birmingham, AL Dan J ones Chiefi Regional Learning Resources Services VA Medical Center St. Louis, MO Debbie Kinert, RN, MSN, CPQA , CNA Executive Assistant to the Director, Special Projects VA Medical Center Durham, NC Charles Koerber, PhD Committee Co-chair Executive Assistant for the Deputy ADCMD VA Central Office Washington, DC James McElligott Risk Manager Eastern Region Fort Howard, MD V H S R UALITY ASSURANCE NATIONAL TRAINING PROGRAM RATEGIC PROGRAMMATIC PLANNING COMMITTEE continued Roxane Rusch, RN Quality Assurance Specialist Regional Accreditation Consultant Western Region / San Francisco, CA Lynn Ward, RN, EdD Committee Co-chair Program Director St. Louis Continuing Education Center St. Louis, MO Patrick Walsh, PhD National Program Evaluation Coordinator St. Louis Continuing Education Center St. Louis, MO Eliza Wolff, RN, Dr PH Chiefi Educational Programs Division Office of Academic Affairs VA Central Office Washington, DC V H S R A % w W 161 PRODUCTION CREDITS Content Coordination Debbie Kinert Roxane Rusch Project Coordinator Lynn Ward Producers Ray Iggulden Melissa McCanna Program Designer/Writer Melissa McCanna Directors - taped segments Marie Blase Ray Iggulden Engineers Richard Linder Don Saunders Teleprompter - taped segments Deborah Weston Teleprompter entry/administrative and technical support Tina Beckner Ginnie Fraser Judy Gipson Cheryl Hagerty Dana Roberts James Tomlinson Book Design and Layout Jane Clanton Milton Pfeiffer Research John Chesmelewski TVRO Network Jan Crowell Louise Papille Mary Ann Tatman Produced through the facilities of KETC- Channel 9 - St. Louis, MO < D: In W > 162 PROGRAM EVALUATION < {I} a: W > 163 13, m1,,.312.:, , 32.33.23.222: 13.,m.:321w1333333wwwfimfi3yfl, 1, .33....32. ..3..32 1 3.333323%.23M122 ,,1,1:1,.1n,1.,, 1,:1,1,,,1,1,1u11y:.1,y1,1:1,:,1H1311,,31.3:3..1u,132,u133wu11,yfi1,3w 1: 11.311232211132133 ,.1,,1,,1 ,11,,1, 1 ,1,1,1,1,1.3,111.32 ,333.2.,..3.w. 3311..., .,11 3 ., 1 ,1 1,1, 123329333”... 3.1%.1:,.:1,..1,:, :,, :,,,1,.,1:,1,2 umwwmmwgwg mmwfiiwm3§ 13:.w11m2m1: 2.22.. 11 1.1, 1,. . ,1,,11,1:.11,,,1,1,1:11,11,,,.1,11:y11:,1,,1,1..1311.W1311.,1231,,,3.y31311,.:1, , 3:33:33 3::, ,1 1, , 3 :i 33 1 22.1,:2,m1,3,w,:,..,1,31 322332233321. 31311 1 ,1 3. ,, 3" 3 3 3 X3 3 w 2 3 21:, 1.13211 2, 3 1,21,,11 : 1 3.1.1:: . 1.1,,, ,:.:: 1211.11.13 1: ,,.11,,1.13:1.,11.3,1,,1, .131 ,3; 3 3,. 3:- ,13 3,2 .11,1231,2,215,....1,:.3.1%,:3 .,,.35131,,11,,z,m, 1 ,1 :1, . ,1.,333332233w2333.33 33.3mm.w:., , ,1 1 3.2333 2,333.33. .3332. , , , .2... 3-1 3% .33 3:: :':‘3311.,, i1 33 i“. 313 3‘3 ,,1, a S, :3! % §: 3.. 2 W, , 11333323 1:33:11 ,, 23.32.3333 ‘3'? .3: ,3 11,.33:,21, ,1, 332233§22333..3 ,, WW 3 ,3,, 33 S’?‘ 2:. 3e, W 333 3: ‘3". :3 31 32,331. 32333:: . ,:133: 9‘35 §3:323 1 g 3.3, .333 .3 :,~ .3 my. 2.33»: 32:33” E, 23:: 2, 3.31 . é 33,. ,33 5. 3 12:...1,.::,:.:.,:.:11: ,,121,1,11.11..11,,12,:.1,,1,1,1 .:.1.1,,1.,1,:1.1:.1,:.,:.11: 3.3152. 3.331311131112131 1 1 , , :,3 .1, 1 33,33 .11.:.,,1:1.:11., 3 ,,3. 1,121.11”: ,,.1. 3 33,32, 1 3, ,3,. ,,1 1,,1..:11.1,,,.1.W:.,,.,1111,H11. 1 ,.1wy21..:,,.1,,111.y.111,1. 1 1 1.: ,:::3 3.31:3, 3.2 .:1,,,..,,1111.111: 131131.131, 2 2:W ‘3 £3 .51, $33 33: ‘- :33}; “523 “3,3 “$1 2 3 ,3 3 23,331 3.1.1.11. 11 1.,.1,1,11, ,. ,2 2.. 1, 1.1.,1,,, “3’33 53:, 11% 3 3 21 23 :3 3i :2 2331 2: 3" 33’ 3? ‘i’e. 3: 1 33' 2:3 13. 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A. to enable you to better utilize the M&E process to improve patient care. 1 2 3 4 5 6 B. to assist you in describing the clinical service chief’s responsibilities in the M&E process. 1 2 3 4 5 6 C. to assist you in implementing M&E process at your service level. 1 2 3 4 5 6 D. to assist you in integrating M&E into over-all clinical decision-making process. 1 2 3 4 5 6 3. To what degree were your personal objectives for attending this program met? 1 2 3 4 5 4. How would you rate the external consultants as content experts? I 2 3 4 5 6 V H S R A _ MONITORING AND EVALUATION OF CLINICAL SERVICES: MEETING THE J CAHO CHALLENGE Course No. 90-NB continued 5. 9‘ >1 9° To what degree were the VA panel members helpful in focusing on the agency concerns? 1 2 3 4 5 6 How would you rate Satellite VideoTeleconferencing as an effective method for delivering educational programs? 1 2 3 4 5 6 In what way was this activity useful to you? In what way was this activity not useful to you? 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