JCAHO's patient safety standards take effect in July. How will they affect hospitals?
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has revised its guidelines on patient safety. The commission will require hospitals and similar groups to identify and address potential patient safety problems before errors occur. The shift to prevention is based on standards long used in aerospace and other high-risk industries.
"We have built up a medical culture that is counter to patient safety because of the tendency to blame individuals," explained JCAHO safety specialist Richard Croteau, M.D. "We have to change processes and procedures to make it difficult to make a mistake. These are principles found in other high-risk industries and quite transferable to health care."
The new standards take effect in July. Changes start at the top. For the first time, hospital leaders are being pressed to create a culture of safety, said Victor Perini, director of pharmacy at Methodist Healthcare Central Hospital in Memphis.
JCAHO is almost as direct. New language requires health-care organization leaders to create an environment that encourages the identification of errors and the reduction of risk, said JCAHO spokeswoman Janet McIntyre. Health-care organizations must identify high-risk activities and reduce risk before adverse events occur, she said. Organizations must aggregate data related to patient safety, analyze the data to identify risks, apply knowledge-based procedures to reduce risks, and effectively communicate the change to all caregivers and others involved in patient safety. JCAHO wants organizations to share safety data to improve practices throughout the industry.
The guidelines also require hospitals to minimize individual blame and retribution for those involved in an error or in reporting an error. "These standards rely on system analysis to improve patient safety," said Don Nielson, M.D., senior v.p. for quality leadership at the American Hospital Association. "They will help break down a lot of departmental barriers as the organization looks at patient safety across the board."
Those departmental barriers can't fall fast enough, Perini said. Pharmacy-based changes such as pulling potassium chloride from floor stock have dramatically reduced specific types of medication errors, but every significant safety improvement has meant protracted battles with hospital administrators, nurses, and medical staff. "With these new guidelines, hospital leadership will be more willing to be responsive to the kinds of measures pharmacy has been promoting for years," Perini said. "Change will be higher on hospital agendas now that it is a measurable standard and not just a department recommendation."
More than half of existing JCAHO practice standards already relate to patient safety, McIntyre said, but the commission has been looking at new approaches since the mid-1990s. Croteau said the move toward new standards gained momentum in 1999 when the Institute of Medicine reported that medical errors kill between 44,000 and 98,000 patients annually and cost the health system $8.8 billion.
JCAHO's new approach is based on root-cause analysis. Rather than focusing on a specific error, Croteau explained, health care should be analyzing the way services are delivered. The most effective way to reduce errors is to design safety into every procedure, to make it easier to practice safely and harder to make a mistake. "You can't prevent medical errors if you can't understand them," he said. "And you can't understand errors without root-cause analysis. "
Kasey Thompson, director, Center on Patient Safety, ASHP, backs JCAHO's engineering analysis approach. "If health care buys into root-cause analysis, we can prevent a lot of errors on the front end," he said. "There is evidence in other industries that it works."
It's also a tough idea to implement. Like medical tradition, the U.S. legal system is based on assigning individual blame. Without tort reform that shields practitioners from liability, said Croteau, few are likely to admit to errors. Even states that require reporting of medical errors are having problems collecting data. A National Academy for State Health Policy survey in 2000 found that underreporting of errors is endemic in hospitals, even in states that require adverse events to be reported.
JCAHO has a model bill that encourages blame-free reporting of medical errors, but few states have used the language, Croteau said. "The better solution is federal legislation," he said. "Nothing has been passed, but we're cautiously optimistic. Patience for medical errors is running low among many constituencies."
Fred Gebhart. New JCAHO patient safety standards stress prevention.