Condition critical

The Joint Commission’s Mark Chassin tells Natalie Brandweiner about the infection control issues facing the nation.

“The continued prevalence of healthcare-associated infections and their prominence in the healthcare debate has prompted the commission to step up its operations”
-Mark Chassin

Like every other healthcare institution attempting to limit infection, The Joint Commission understands the very critical safety issue currently facing America's hospitals. "Hospital-associated and healthcare-associated infections are a huge problem in part because the landscape of infectious disease is constantly changing, evolving and challenging," explains Mark Chassin, President of the Commission. With various approaches suggested as being the most effective for control and protection, he notes the difficulty for healthcare institutions in understanding and choosing the right prevention program in a climate where the goal posts are constantly changing.

The Joint Commission has a variety of programs, activities and approaches to help healthcare organizations manage these problems, most notably its accreditation standards, which are revised on an annual basis. "The beginning of this year saw some substantial expansion of those requirements, which focus on the planning and execution of comprehensive infection prevention and control plans, including some detailed requirements on instrument sterilization, disinfection reprocessing, and specifically, what hospitals need to do to maintain state-of-the-art infection control and prevention," he says.

The commission also operates another group of requirements, the National Patient Safety Goals, which function in a similar manner, and aim to highlight the most important and difficult areas of patient safety and quality. Many of the standards directly address infection control and prevention issues, including hand hygiene, bloodstream infections and surgical site infection prevention.

"We have also worked to focus our survey process on various aspects of infection prevention and control," explains Chassin. "We have performance measurement requirements under which all of our accredited hospitals have to send data to us, and the one new group that was introduced in 2005 has seen important improvement. It's a group of measurement requirements that address one of the most critical parts of preventing surgical site infection: the proper application of prophylactic antibiotics in a wide variety of surgical procedures.

"We know from research that prophylactic antibiotics are a powerful preventative for surgical site infection. However, the first dose must be administered within an hour of the beginning of the surgical incision. As of the last full year of data from the thousands of hospitals that report to us, the US average across the different procedures in that measurement group was 89 percent of first doses within an hour, and 86 percent stopped within 24 hours, which is the other component of the measurement. Then you have to pick the right antibiotic: It must be appropriate for the procedure, and there are clear guidelines on that. In 2007 across all of the different groups of procedures, from vascular to gynecology to orthopedic surgery and colon surgery, 95 percent had selected the right antibiotics," says Chassin.

The Joint Commission has taken a leadership role among all of the leading organizations in infection prevention and control, including the Infectious Disease Society of America, the Society of Hospital Epidemiologists and the National Foundation for Infectious Diseases, whom it catalyzed to undertake a comprehensive review in 2008, looking at critical infection issues in hospitals. The result of this review was the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, which principally focuses on getting hospitals to make their programs working more effectively. The Commission also produces other resources to educate its members, such as educational conferences and consulting, as well as publishing various booklets and brochures.

Designated by the World Health Organization in 2005, the Joint Commission is the only world collaborating center for patient safety solutions. The WHO's initiation of this global patient safety initiative took hand hygiene as its first challenge, which has been a National Patient Safety goal of the commission for some time.

The continued prevalence of healthcare-associated infections and their prominence in the healthcare debate has prompted the commission to step up its operations, so for the first time it is preparing to engage with healthcare organizations to create interventions to improve safety and quality. "We've created requirements for organizations to improve the resulting improvement of their processes and their outcomes, but in the past we haven't engaged directly with them in solving some of these critical problems," explains Chassin.

"That's what this new activity is focused on. We are launching a component of the Joint Commission called the Center for Transforming Healthcare; it is a separate component, like the Joint Commission Resources, but a subsidiary.

"We're not for profit, so our focus is to use some of the newer tools of process improvement, such as Lean Six Sigma and change acceleration, to begin working with a group of 16 leading hospitals and health systems that have themselves already made the investment in mastering these tools. We can use this systematic approach to solving problems to attack these critical quality and safety problems that every organization has been struggling with.

"The first topic the participating hospitals chose for this effort, which was launched earlier this year, is hand hygiene failures. We're talking about some of the leading hospital systems in the United States, from Hopkins and Mayo to Inner Mountain in Utah, Partners in Boston, New York Presbyterian in North Shore in New York, Cedars, Stanford, Kaiser in California, Exemplar in Colorado, Memorial Herman in Texas. It's a very impressive list. They identified a number of their highest priority problems, and hand hygiene failures got the most number one, high priority votes.

"For about 15 months, the Joint Commission has been undertaking a very aggressive program for our own internal process improvement of adopting strategies and methods, the same tools of Lean Six Sigma and change acceleration. We have our own Lean Six Sigma experts whom we are bringing to this new center's activities to work with these organizations. The hallmark of what's different about this approach is the systematic methodology to solve these problems, which starts with an agreement on reliable and accurate measurement systems and hand hygiene.

"There aren't very good, easy to apply, systematic measurement systems to know what your performance is, and if you can't measure something reliably, you can't improve it effectively. The second issue is once you've got a good measurement approach, to understand these tools with systematic applications and figure out why the process isn't working. That's a step in this Lean Six Sigma approach to solving problems that is absolutely essential in these critical quality and safety areas, where solutions have remained elusive. This leads you to be very precise about what the causes of the failures are in where you're trying to fix the problem," he explains.

Finding the cause

Chassin hopes this approach will pinpoint the major reason why hand hygiene compliance is so hard to achieve, and why the distribution of the causes of noncompliance differs from one place to another. He provides an example of solving the problem of soap dispensers and their location outside patient rooms, noting one surprising major cause of infection in a large number of hospitals is the number of healthcare staff approaching patient rooms with unclean hands.

Unless the process is carefully assessed and the reasons for failure understood, it is impossible to target interventions that effectively manage the high impact causes, nor can improvements cannot be made. Chassin believes this is the key activity that differentiates the Center from others pursuing this methodology.

The second difference is that this methodology is now married with the reach of the Joint Commission. "Our job is to coordinate these projects, oversee them and make sure they're done exactly the same way with fidelity to this method so that we can compile results across all of these organizations," he explains. "Eight of the 16 are participating this first project of hand hygiene, and the remaining eight are just starting the second project.

"Our job is to put the learnings from these initial projects into a knowledge database that we can then take to the other 95 percent plus of hospitals that have not invested in Lean Six Sigma process improvement; every hospital is worried about hand hygiene. Then we view how they're doing on the programs and often find opportunities for improvement. We direct them with very precise guidelines and instructions on how to measure the problem, how to assess what their causes are, and then give them specific interventions developed by the participating hospitals in the Center project to tackle exactly the same cause in locations.

"The reach of the Joint Commission in pushing these very effective interventions out, along with this methodology, translated and jargon-free, so you don't have to do the painstaking, difficult process of learning this stuff: that's the other component of what's different. Obviously there are enough opportunities for improvement across the healthcare delivery system so that everybody who wants to work in quality improvement should feel free to expend their maximum effort. We don't view this as competitive with or replacing anything that's out there: it's complementary and additive."

Flu focus

The Joint Commission has been very involved with H1N1 from the first outbreak in spring and early summer, advising its healthcare organizations on the CDC's most up-to-date recommendations. As a partner with the CDC and being present in its regular briefings, the Commission can communicate the latest information and guidelines directly to accredited organizations. The Commission's infection control and prevention standards cover the needed guidelines, specifically the recommendations of what hospitals need to do to prepare for a large increase in the number of potentially infectious patients.

"We've been among the leaders in preparing hospitals for emergencies, including pandemics. And that's been recognized in a lot of different places, so the need to refresh emergency preparedness guidelines and plans, coordinating with other organizations in the community so that you're not functioning in isolation. We are very much engaged in the planning work, for our organization and our standards have been the most recognized items in this area," says Chassin.

H1N1 is not the only difficult issue that the industry is currently facing. The economic recession has had a notable impact on safety within a hospital environment, and as Chassin points out, whenever times are hard, healthcare organizations are tempted to reduce expenditures that aren't directly involved in the delivery of patient care.

"Fortunately for quality, the Joint Commission Accreditation process and requirements don't change," he adds. "We don't change the way we assess hospitals and other organizations, and we believe it is critical to attend to quality programs even in difficult economic times because backing off them can lead to adverse events and outbreaks of quality problems that can be costly not only in adverse outcomes for the patients, but also for the resources of the hospitals and other organizations.

"We've been pretty effective in making those arguments. There's been an occasional organization here or there that is literally on the verge of bankruptcy that has idiosyncratic problems, but we don't see any significant retreat from the commitment or the safety and quality programs that are necessary."

Implementing a standard performance measurement across the whole spectrum of organizations is no easy feat. The Joint Commission was the first of its kind at the start of the 21^st century to begin a national program of measuring quality in hospitals, and met with huge resistance when attempting to collect the data from hospitals and publicly record it. Chassin explains that back then there were very few measures that anybody could agree on, whereas now there hundreds of measures available, both good and bad.

"Our program was picked up by the American Hospital Association, and hospitals were encouraged to voluntarily report in the middle part of the decade. Then Medicare CMS picked it up and required hospitals to report, but they wanted to get their full annual payment update, so a penalty for not reporting was the Medicare approach. Now virtually every hospital that has appropriate patient services reports a whole panoply of core measure data to us and some of those measures have now reached levels of consistent excellence that are unparalleled anywhere in the healthcare delivery systems.

"For example, some of the surgical site infection measures that came in in the middle of this decade were for heart attack. When that program started, it wasn't uncommon to see 40 and 50 percent rates of performance on things like aspirin and beta blockers. Now the national average for aspirin on arrival and beta blocker on discharge is 97 percent," he says.

The model operated by The Joint Commission demonstrates a good degree of consistency, with the later measures of surgical site infection prevention having a standard level of accuracy. Chassin explains that this program has a lot of stakeholders and therefore must continue to be worked on. The commission works with CMS on a weekly basis to ensure this, to be certain that the specifications for these measures are identical between the Joint Commission and the government.

"The Joint Commission created the program, got the experts around the table, did the evidence summaries, got them to agree on precise specifications with great fidelity to the clinical integrity of the measures," he explains. "The clinicians were all on board. The Joint Commission created the data collection infrastructure to allow the data to be collected across the country in exactly the same way, with high levels of data quality, completeness and accuracy, by creating a network of vendors that have to pass very rigorous tests that the Joint Commission administers. Every hospital knows that the data in California are collected the same way as in New York, Illinois or Texas."

Chassin notes that it was this infrastructure that allowed Medicare to ask for the same data, which is now collected the same way for Medicare's accreditation purposes. with the same vendors; with the hospital's agreement the same vendor then sends the same data to two different places. The Joint Commission works to maintain that data collection infrastructure capacity by ensuring that the specifications are exactly the same. 

He notes that this is not easy - data changes over time, and so does the science; for example, the information about who is an appropriate candidate for a beta blocker ace inhibitor and what is the appropriate antibiotic for preventing infection in colon surgery. "All of that is maintained with great fidelity to the clinical integrity and the evidence, and to making this data collection infrastructure work so that it's seamless for the hospitals that collect the data once," says Chassin.

Obama's Plan for America only vaguely alluded to initiating performance measures, says Chassin. There is discussion of using these measures to drive improvement in a variety of ways, such as arranging new collaborations between doctors and hospitals. Quality will be judged through measuring performances and the commission is focusing on making sure the measures are the very best.

Armed with the experience of conducting such measures for thousands of organizations, the Joint Commission has been contributing knowledge, ensuring that it supports the creation of a quality improvement infrastructure. Chassin points to the example of the Center for Transforming Healthcare, which can take information from the renewed interest in comparative effectiveness research and transform it into practice much more rapidly than before.

"That's part of our involvement in health reform legislative debate - the legislators should not assume that creating new knowledge about what the best thing to do for improving quality and safety is automatically translates into the delivery of care. Often that takes many years and we can't afford those lengthy delays any longer," he says.

The Joint Commission is continuously engaged in processes to improve its own standards and the way it conducts its surveys across all of its programs. "We accredit over 4000 hospitals, but that's less than a quarter of the 16,000 organizations across all the delivery systems that we accredit or certify," he explains. "We actually accredit more homecare organizations now than hospitals."

Internal standards

"We are engaged in every kind of delivery organization that exists out there we developed standards for all of them. There are requirements for safety, which are focused on quality. The standards improvement initiative, which started several years ago, was designed to review all of our requirements, to sharpen, clarify and remove ambiguity from the language, to make sure that the standards were specific to the different programs - ambulatory care, behavior health program, home care - and make sure that we got rid of anything that was redundant or nonessential. 

"That phase of our improvement initiative is coming to an end now with the second group of programs that are going into effect this year, but we're not stopping there. Now we're starting another round of improvement that will focus on understanding exactly what the evidence is behind our requirements, and making sure that we have the highest possible confidence, whether it's really good evidence like the prophylactic antibiotics, preventing surgical site infection, or a very strong rationale to have a good maintenance program for machinery like cardiac defibrillators, to make sure the battery is there when you need it. 

"The highest confidence results when we ask organizations to do the work of complying with National Patient Safety Goals, standards and performance measures. Health outcomes for patients will improve directly as a result of that work. Now we are engaged in that aspect of improving our standards and survey process," concludes Chassin.

Mark Chassin is President of the Joint Commission.

The Joint Commission

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 17,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.