Before your hospital's next accreditation survey, add this to your "to do" list: Develop a policy for informing patients when they've received substandard care.
Starting July 1, hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations will be required to tell patients when their treatment outcomes vary from anticipated results.
That requirement is one of several new JCAHO patient-safety standards that take effect next week and have met with mixed reaction in the industry. Some hospital executives have hailed the new standards as an important part of limiting medical errors and keeping patients in the loop about their own care. Others in the industry believe the disclosure requirement could be difficult to codify and may lead to more litigation.
About 800 of the 4,939 hospitals accredited by the JCAHO will be surveyed for compliance with the new standards before year-end. Hospitals contacted by Modern Healthcare said they have at least started to address patient safety and don't anticipate major expenses or operational headaches associated with implementing the standards.
JCAHO President Dennis O'Leary, M.D., acknowledged concerns about a spike in litigation, but he argued that it's more likely patients will steer clear of lawyers if they're told the truth.
"Be honest and share the facts," said O'Leary, who has headed the Oakbrook Terrace, Ill.-based commission since 1986. "Don't ask to be sued."
Disclosure won't be easy
Requiring hospitals and doctors to disclose their mistakes may be fairly complicated, some said, because it will demand a specific policy on when and how to release such information.
"Are people going to have trouble with it? Absolutely," said James Conway, chief operations officer of the Dana Farber Cancer Institute in Boston and a board member of the National Patient Safety Foundation. "The first time (doctors or clinicians) disclose and get beat up for doing it, they're not going to do it again."
Dana Farber has been telling patients about treatment errors and outcomes deviations for five years, Conway said, and it has been involved in "no significant litigation expressly as a result of that."
Suits a concern
Nevertheless, new lawsuits arising out of the JCAHO requirements are "a concern to anybody," said Lisa Cortes, director of risk management and in-house counsel for Scott and White, a healthcare system in Temple, Texas, that operates a 440-bed hospital and 520-physician medical group. Balancing the new disclosure requirement with privacy laws mandated by the Health Insurance Portability and Accountability Act of 1996 will be a significant challenge, Cortes said.
Some patients will appreciate being informed, she said, and others "will try to use it as a hammer." To prevent such a reaction, Scott and White physicians must reach a consensus that a medical error occurred before divulging the information to patients. "Bad outcomes do not necessarily mean a medical error," Cortes said.
The Association of Trial Lawyers of America said the JCAHO's disclosure requirement could reduce litigation by promoting an atmosphere of trust. "People appreciate honesty and being told what's happening to them or what might happen to them," said Carlton Carl, an association spokesman. "The more people know about their condition, the more favorably they view their doctor."
That position is in stark contrast to the fiery debate in Washington over a patients' bill of rights. That debate has centered on the crowded courtrooms and costly litigation that could result from allowing patients to sue their health plans over treatment decisions.
On July 1, six new JCAHO standards become effective, five of which are directed at top executives. Perhaps the most far-reaching standard requires hospitals to implement an organization-wide patient-safety program with executive-level sponsorship and participation.
IOM reports spurred action
Patient safety has become an increasingly contentious issue since the release of two Institute of Medicine reports indicating that as many as 98,000 Americans are killed by hospital medical errors annually and that the nation's healthcare delivery system is "plagued by a serious quality gap."
In the wake of those reports, the JCAHO determined that fewer than half of its quality standards related to patient safety. "It became clear that the timing was right to raise the bar for patient-safety expectations," O'Leary said.
The JCAHO first proposed the standards last April and fielded comments last summer and early fall. The organization had "lots of response," O'Leary said, "because this is not a boring set of standards."
The Centers for Medicare and Medicaid Services, the American Hospital Association and patient-safety groups were also among those that reviewed the standards.
Of particular concern to hospitals, O'Leary said, was a proposed standard that would have required hospitals to prioritize processes with respect to patient safety. Because hospitals perceived that as a "make-work" provision, it was removed from the final set of standards last December.
That move runs counter to some of the latest thinking on error reduction, which is to focus on error-prone or high-risk treatments. Part of the mission of the Leapfrog Group, a coalition of Fortune 500 companies and leading purchaser organizations, is to minimize the errors providers commit during high-risk procedures (May 28, p. 30).
Plan builds on providers' efforts
Nashville-based HCA-The Healthcare Co., which owns or leases 196 U.S. hospitals, is "very supportive" of the new JCAHO standards and their underlying goals, a company spokesman said. "Engaging patients in their care has been a big push for a long time in healthcare," the spokesman said.
The chief challenge for HCA, he said, will not be complying with the new standards but documenting that hospitals are in fact following the rules. HCA anticipates "minimal new costs" associated with that effort.
"I personally don't see a lot of stuff in the (JCAHO) policy that adds significant cost," agreed Dana Farber's Conway.
He participated in a JCAHO panel that debated the standards and said most of the new requirements expand on existing ones, such as hospitals' need to effectively share clinical data.
The JCAHO said one of its main goals in promulgating the standards is to create a "blame-free" culture of safety in hospitals so that caregivers feel free to report errors and educate patients.
"I think it would be nice to look at our culture and make sure we are not afraid to report errors," said Ingrid Flemming, director of risk management and patient information management services at Northern Michigan Hospital in Petoskey.
To prepare for the JCAHO's new standards, the 202-bed hospital is educating physicians, executives and even patients, which represents the bulk of the work that will be necessary, Flemming said.
"Anyone with a solid risk-management program will not have a problem with the patient-safety standards," she said.
The JCAHO's new patient-safety standards won't be reviewed as part of the standards review program that it announced in May.