The Joint Commission has long considered its accreditation process the hallmark for the healthcare industry. Based in suburban Chicago, the Joint Commission accredits nearly 80% of U.S. hospitals for participation in Medicare. But its other main business—consulting—has raised concerns about the separation of church and state. The organization came under fire early this year when a Wall Street Journal investigation highlighted the fact that accreditation is rarely pulled for providers even when they violate Medicare requirements. The paper found that just 1% of facilities not in compliance in 2014 lost accreditation. Joint Commission CEO Dr. Mark Chassin contended that denial rates are not true markers of the organization's effectiveness. Chassin recently spoke with Modern Healthcare reporter Maria Castellucci. The following is an edited transcript.
Modern Healthcare: What do you think sets the Joint Commission apart from other accreditation organizations?
Dr. Mark Chassin: There are four things that we do that none of our competitors do. The first one is that we spend a lot of time and effort using very rigorous evidence-based processes to set quality and safety standards for healthcare organizations, and we keep them up to date, which is a critical task given how fast science and medical practice change.
The second is that we accredit across the entire continuum of care. We're probably best known for the hospital program, but we accredit ambulatory organizations, behavioral health organizations, laboratories, home care, hospice, durable medical equipment and nursing homes. That gives us a unique position and perspective on the healthcare delivery system in the U.S.
The third thing that we do that no other competitor does, is we go beyond traditional accreditation standards and survey methods. We spent a lot of time and effort to apply the most modern process improvement techniques to actually create solutions for the most difficult quality and safety problems that have resisted improvement for decades, like hand hygiene noncompliance and preventing falls with injury.
The fourth thing that we do is we spend a lot of time and effort evaluating the impact of what we do and publishing the results in peer-reviewed scientific literature so that everybody can benefit.
That's what sets us apart.
MH: If, as you say, your competitors are just focusing on the conditions of participation, wouldn't it be easier to get accredited by one of them? What about your standards are different?
Chassin: I'll give you an example. We brought the problem of medical-device alarm safety to the world. If you've watched any TV show involving medical care, you've heard all the alarms beeping and buzzing in an ICU. Those alarms are 90% false positives. And over the course of a nursing shift, having all those alarms go off bothers caregivers, and they, unfortunately, lead them to unsafe practices, so we published a Sentinel Event Alert calling attention to the problem several years ago. We then enacted a national patient-safety goal, which is a high-visibility way of bringing the industry's attention to an emerging problem. Now, every hospital has to pay attention to the problem and reduce the number of false positives, do a risk assessment and figure out how to solve this problem so that patients don't die because alarms are turned off. That's an example of one of our programs that goes way beyond.
MH: You are an accreditation organization enforcing CMS rules to stay accredited, but you also have a division that trains organizations to improve their safety and quality. How do you balance that? They are your customers, yet you are also the enforcer.
Chassin: The survey process is only about determining compliance. Our surveyors also have been trained over the last seven or eight years not to be ruthless, punitive inspectors, because our mission is to improve safety and quality. It's not to figure out how many deficiencies an organization has.
When our board reframed our mission in 2009, we realized that the only way we could achieve our mission of improving safety and quality is to do a very thorough and objective evaluation, present the organization with opportunities to improve, and do that in a way that engages the organization so they take in that information and use it to change the way they provide care. That's how care improves. That's how our mission is accomplished.
Our surveyors can't be mean and nasty and punitive. They have to be collaborative, thorough, objective, comprehensive in their assessment, but communicating that in a way that galvanizes the organization to want to improve.
MH: Would there be any flaw in the logic of a health system that determined it knows better than the Joint Commission saying, "I'm just going to hire these other guys because I know what I'm doing"?
Chassin: There are some who have said that. The one thing an organization can't do is to know how it compares with others because they're not there—we are. The opportunity that we have, if we do it right, is to engage with the organization, give them pointers about problems that they have been working on that our surveyors have seen handled in a very positive way differently in another organization, so pointing them to leading practices—not doing consulting, they don't do consulting—but they bring leading practice examples.
MH: How often do you revoke accreditation? What does that process look like?
Chassin: It's a false premise to argue that the denial rate should be looked at as a measure of the Joint Commission's effectiveness. That's absolutely backwards. Our job is to do a thorough, objective assessment against our standards, provide the information to the organization in a way that they take it in and want to change, to walk with them through the change process, through the remediation process, until they are all fixed, and then they stay accredited.
To us, denial of accreditation is a failure and we do it, but we do it in very limited circumstances—when the organization either is unwilling or unable to walk through the remediation process and get to clear all the deficiencies.
Over the last four years, we've denied accreditation roughly to eight hospitals per year. In about half of those instances, it's safety and quality issues. In about half, it's other things like they are going out of business or they're changing to an ambulatory-care organization.
But to put some other numbers behind that, in the first six months of 2017, we did 750 full hospital surveys. There were 15 instances when we found immediate threats to life and that's the worst possible finding that you can have in a survey. That means the surveyors have found pervasive risks to patients that are so risky that they need to be fixed before the surveyors leave, literally. And about half of those are related to infection prevention and control, and about half were related to building safety issues that were just gross neglect. We worked with those organizations, and there are various kinds of processes that we use, including follow-up surveys.
The Wall Street Journal article and others have implied, "If you find something that's so egregious that it's an immediate threat to life, just deny accreditation."
What does it take to deny accreditation? Well, it takes what I said, which is being unable or unwilling to improve. If an organization is working on improving, isn't it in the public's interest for them to be working with an organization like us that can help them improve and get out of their problem?
If we abandon them, nobody's going to help them improve and then the likely event is the organization closes, and access gets to be a problem for a lot of communities.
MH: There's also been some finger-pointing toward the Joint Commission for its pain measures and if those have contributed to the opioid crisis. Is that something you have reflected on, or have there been any changes as a result of the criticism?
Chassin: There's just no evidence that the Joint Commission pain standards of 2001 somehow triggered the opioid crisis. The original pain standards came at a time when there was universal agreement that pain was under-treated. Congress, in fact, adopted a resolution to make the decade, the first decade of the 2000s, the Decade of Pain Management and Research. The Joint Commission standards basically said hospitals should identify pain and manage it appropriately. They never said anything about medication management, let alone opioids. And if you look at the trajectory of opioid prescribing, the trajectory going straight up started a decade before the Joint Commission standards and there was no change in the rate of increase when 2001 happened.
Now, having said that, a couple years ago we convened a panel of experts and we brought to bear all of the existing knowledge about what we could do to help to contribute to the solution. This year, we published a brand new set of pain standards. This is a very detailed set of standards that relates to the use of nonpharmacologic pain management modalities as well as the use of opioids when it's appropriate and avoid them when it's not appropriate.