Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO) sends unannounced surveyors to hospitals to make certain that
QUALITY OF CARE and SAFETY is being provided to patients and that
PATIENT'S RIGHTS are being respected.  JCAHO touches on two of the
ACGME general competencies:  practice-based learning and improvement
as well as systems-based practice.

JCAHO looks to see that there are POLICIES in place to support 
standards of patient care that involve a (multidisciplinary) PROCESS
to plan care, provide care, monitor and assess outcomes of care, 
modify care, and coordinate the follow-up of care.  

Then JCAHO looks to see if such a SYSTEM is being followed and 
checked for compliance.  For example:

The surveyors observe residents and students (e.g., to see if 
hand washing and isolation protocols are followed and that ID badges 
are clearly visible, but that you are NOT walking around the floors 
with gloves on!) JCAHO surveyors review charts and they may meet
with residents and students to see that they are familiar with
the following:

* Who SUPERVISES whom (The Chain of Command).
* That residents know what they are allowed (and not allowed) to do 
  and that nurses have access to that information (e.g., your basic
  and advanced procedure forms).    
* That residents know how to get ASSISTANCE when they need it.
* That residents know how to get in touch with the ATTENDING (Captain
  of the Ship) in a timely fashion, and that important diagnostic and 
  therapeutic issues are discussed with the attending (including 
  procedures).
* That patient's symptoms of PAIN ("the fifth vital sign") are
  assessed regularly and treated (and that a form documenting this
  including efficacy and patient education is in each chart).  And 
  JCAHO is also interested that other unpleasant symptoms such as 
  nausea and dyspnea are treated.
* That CONFIDENTIALITY is maintained (e.g. computer terminals are not   
  facing the hallway and screen is shut off when not in use, not
  speaking about patients in public places (elevators, cafeteria).
  (Similar to HIPAA regulations.)  
* That there is a PATIENT BILL OF RIGHTS posted on each floor.  This
  includes the right to know who the physicians are, so always wear 
  your ID badge.
* That residents know policies regarding RESTRAINTS.  Particularly 
  that there are NO PRN orders and there must be documentation of 
  alternatives attempted prior to the application of restraints.
    [When involving Behavioral Health, for example, that the 
    physician has tried verbal de-escalation, empathic listening, 
    voluntary time-out in a quiet and less stimulating environment, 
    re-focus of patient's attention, clear instructions to the
    patient regarding the consequences of his behavior.]   
  That orders for restraints are time limited:
  For Medical/Surgical Restraints, the order is limited to 
  a 24 hour time period.  For Behavioral Health, a physician must
  see the patient within an 1/2 hour of ordering the restraint and 
  the order is in effect for four hours for an adult.  
* That all H&Ps are completed in a TIMELY fashion, LEGIBLY, and that  
  all sections are filled out (e.g., ADVANCE DIRECTIVES, HEALTH CARE 
  PROXY, PAP/PELVIC, SMOKING CESSATION).
* LEGIBLY includes a signature with a PRINTED or IMPRINTED name and
  beeper number. 
* That the hospital has CONTINUOUS QUALITY IMPROVEMENT activities, 
  including reporting and review of adverse events. (see Error
  Reduction, below)
* That residents know what to do in case of a FIRE (see the R.A.C.E 
  summary which should be attached to your ID badge) and number to 
  call.
  -Rescue people in immediate danger
  -Alarm via fire alarm box
  -Confine by closing all doors and windows
  -Extinguish fire using fire extinguishers [P.A.S.S.]
   [See smoke -> RACE; Smell smoke -> call Security]
* That residents know various hospital CODES: (Red, Blue, Pink, D).
* That residents know how to respond to a DISASTER code or any of
  the other codes.
* That residents know the "BELL CODE" in their area. 
* That residents can quickly locate the FIRE ALARMS and FIRE 
  EXTINGUISHERS for their area. 
* That when giving INFORMED CONSENT, that physicians provide 
  patients with information regarding the risks, benefits and
  alternatives to the treatment or procedure, in addition to 
  signing of the informed consent forms.   
* That there is documentation from the physician regarding the 
  decision to make a patient a DNR (i.e., discussion with family
  regarding irreversible condition).  
* Inpatient and ambulatory records should have up to date list
  of medications and medical problems (problem list and medication
  list).
 

JCAHO continuously updates its requirements, and many of these 
are listed below, discussed in the year that they were announced.
Recently JCAHO has been focusing on new patient SAFETY standards
that require hospitals to:
* Develop a formal system for staff to report medical errors
  (e.g., a Safety Reporting System).  
* Conduct a "root-cause analysis" of each problem or "sentinel
  event" with the goal of fixing systems that create errors. 
  [A Sentinel Event is an unexpected occurrence involving death or
  serious risk or injury and Root Cause Analysis (RCA) is an intense
  assessment and investigation of such an occurrence to determine the 
  factors that contributed to the cause of an event.  Root cause
  analysis includes a focus on process and system factors.]  
    [see also NYPORTS = the NY Patient Occurrence Reporting/Tracking 
    System and see SPARCS}
* Become prospective in reducing risk, e.g. in part by having
  a Prospective Performance Improvement Project.  For example,
  we are currently collecting data on CHF and Pregnancy Related 
  Conditions.
* Create an annual report for the hospital's Board of Trustees 
  on medical errors and actions that have been taken to prevent 
  them from reoccurring.
* Enhance communication systems to help prevent mishaps.
* Make certain that resident physicians are credentialed for
  any procedures they perform and can document such credentialing 
  if asked.
* Ask that physicians participate in the verification of the 
  operative and procedures sites.
* All unanticipated patient outcomes (e.g., adverse events)
  will be disclosed to patients (and when appropriate,
  their healthcare proxy/guardian/relative) by the Attending 
  Physician (or his/her designee). 

Starting in 2003, JCAHO has announced it wants to see PREVENTIVE
measures to reduce seven different types of ERRORS:
        
 1 - patient misidentification (use 2 identifiers and "time out"
     before surgery)
 2 - wrong-site or wrong-procedure surgery (mark site with patient)
 3 - medication mix-ups
 4 - infusion pump breakdowns
 5 - alarm system snafus (use FMEA = failure mode effectiveness 
     analysis)
 6 - caregiver miscommunication (document, document, document; 
     have verbal orders repeated back to you; eliminate written
     order abbreviations which are easily misinterpreted
     [e.g., QD vs QID vs QOD])
 7 - reduce risk of health care acquired infections (follow
     CDC guidelines, treat as sentinel event complications).

JCAHO helps hospitals by distributing "Sentinel Event Alerts".   

2004 brings a JCAHO focus on "Shared Visions-New Pathways" 
which will lead to more interactions with physicians regarding 
how their patients receive care including how hospitals assess
patients, educate patients and families, respect patient rights, 
provide coordinated care, and promote safety.  This will be 
implemented by following the experiences of actual patients and 
"tracing" their care from admission to discharge ("tracer
methodology").  The goal of the "Shared Visions-New Pathways"
is to support better patient safety and quality of care by:
- Creating a more continuous process
- Focusing on direct patient care

For example, after reviewing the chart of an admitted patient,
the surveyor may return to the ER to trace the initial
assessment of the patient, medication management,
interdisciplinary communication, attention to patient rights
and ethics, documentation of staff competencies 
e.g. credentialing of residents to perform procedures).

Thus, physicians will be asked to participate in the periodic
performance review before the survey and to review data used 
to improve performance.  

In summary of 2004, JCAHO expects to see continuous quality 
improvement: "Doing the right things at the right time
and doing them well."  The "PDCA" cycle describes the steps
taken to achieve progress when addressing a problem which
needs to be improved:

Plan:    Define the problem, analyze it (root cause) and
         propose changes.
Do:      Implement the changes.
Check:   Measure the results and analyze the data.
Act:     Make additional changes as a result of the analysis. 

Performance Improvement activities can include some or all
of the following:  
  hospital wide teams, departmental indicators, medical
    staff appraisal, benchmarking or comparison to other
    hospitals, and patient satisfaction surveys.  

Such Performance Improvement activities are identified at our
hospital by review of sentinel events and near misses,
NYPORTS, as well as feedback from the community planning board,
hospital committees, the Medical Board and other leadership
divisions.   

Current hospital wide patient safety (best practice and
performance improvement) activities include activities to
address core measures of quality care, such as:
1.  Making certain that patients hospitalized with CHF are
    given appropriate discharge instructions.
2.  Making certain that patients are counseled regarding
    smoking cessation.
3.  Making certain that patients with acute MI follow the
    appropriate protocol (ASA, beta blocker, ECHO, 
    ACEI, LDL-cholesterol)
4.  Making certain patients with pneumonia are given timely
    treatment. 
5.  Making certain that patients at risk are given DVT 
    prophylaxis.
6.  Making certain that patients receive
    peri-operative beta blockers to prevent MI.
7.  To comply with 2005 JCAHO requirements, physicians 
    performing surgical or medical procedures must ensure
    verification of:
      a. The correct patient
      b. The correct surgical procedure 
      c. The correct site 

   Thus, prior to a procedure, the physician

   is responsible to: