Joint Commission Safety Goals and Accreditation, do they relate to quality of care>?

Swerlick, Robert A rswerli at EMORY.EDU
Sat Dec 22 21:52:43 UTC 2018


We have to start somewhere. Whatever we do, we need to avoid making too much out of what we find. The hyperbole and sensationalization that may come from any given observation may serve to generate publicity for the organization but I think it is essential to recognize that the initial iterations of quantification of diagnostic errors will be very flawed.

Studies such as the one that John highlighted get lots of press and attention and create the impression of more certainty that really exists. They may ultimately create barriers to develop the sort of measurement tools that we need to get at the foundation of diagnostic error.

RAS

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: John Brush <jebrush at mac.com>
Sent: Saturday, December 22, 2018 3:49 PM
To: Society to Improve Diagnosis in Medicine; Swerlick, Robert A
Subject: Re: [IMPROVEDX] Joint Commission Safety Goals and Accreditation, do they relate to quality of care>?

It is commonly stated that the diagnosis of acute myocardial infarction is missed more commonly in women than men. I wrote a grant on this topic, so I went looking for a reference. I could only find one study that reported the miss rate (Pope, et al. Missed diagnosis of acute cardiac ischemia in the emergency department. NEJM 2000;342:1163). This was a registry that prospectively collected data by following all patients with suspected AMI, even those who were sent home. But even this study doesn’t give the true rate. How about patients with missed AMI in whom the diagnosis wasn’t suspected? We can find cases of missed diagnosis and start to count the numerator, but how do you identify the patients in the denominator? If you can’t define a denominator, you can’t calculate the rate. If you can’t calculate the rate of missed diagnosis, you can’t compare women with men. And also, you can’t use the measure to accredit hospitals, compare hospitals, or drive improvement efforts.
That is the biggest limitation in measuring diagnostic accuracy - defining the denominator. This problem is analogous to measuring fielding in baseball. You can count the errors, but it is hard to determine what counts as an opportunity, so it becomes impossible to measure an error rate.
John

John E. Brush, Jr., M.D., FACC
Professor of Medicine
Eastern Virginia Medical School
Sentara Cardiology Specialists
844 Kempsville Road, Suite 204
Norfolk, VA 23502
757-261-0700
Cell: 757-477-1990
jebrush at me.com<mailto:jebrush at me.com>




On Dec 22, 2018, at 11:37 AM, Swerlick, Robert A <rswerli at EMORY.EDU<mailto:rswerli at EMORY.EDU>> wrote:

I agree with Jason. The inability to consistently measure diagnostic accuracy and misdiagnosis represents a significant bottleneck. This organization has been grappling with this since I have been a member. An organization such as TJC cannot make diagnostic error a priority without having some sort of metric which can be tracked.

Perhaps this is ground where a patient reported tool could make some headway. Perhaps we could simply ask patients whether they know what diagnosis (diagnoses) they carry and whether these have changed over time?

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM<mailto:jason.maude at ISABELHEALTHCARE.COM>>
Sent: Friday, December 21, 2018 5:20 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Joint Commission Safety Goals and Accreditation, do they relate to quality of care>?

Ruth
That’s a great question but will bring us back to the issue of having a measure of diagnosis. Unless we have a measure then TJC are unlikely to focus on diagnosis. As the previous posts have shown, we do not seem to have support/consensus for any measures that have been suggested. I see this as a major hurdle we need to overcome if diagnosis is going to get the attention it deserves from institutions like TJC.



Regards
Jason



Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>





From: Ruth Ryan <ruth at RYAN-GRAHAM.COM<mailto:ruth at RYAN-GRAHAM.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Ruth Ryan <ruth at RYAN-GRAHAM.COM<mailto:ruth at RYAN-GRAHAM.COM>>
Date: Friday, 21 December 2018 at 19:14
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Joint Commission Safety Goals and Accreditation, do they relate to quality of care>?



Hello All,



The Joint Commission or TJC has been much in the news of late, e.g., Wall Street Journal (Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge 9.6.17), AMA News (Trump administration weighing possible financial conflicts in hospital accreditation process, 12.19.18), and now this article by Ashish Jha:
Accreditation, Quality, and Making Hospital Care Better. The JAMA Forum December 18, 2018 Ashish K. Jha, MD, MPH.
JAMA. 2018;320(23):2410-2411. doi:10.1001/jama.2018.18810.
referring to this new study:
Lam MB, Jha, A et al. Association between patient outcomes and accreditation in US hospitals: Association between patient outcomes and accreditation in US hospitals: observational study
Jha concludes from this recent comparative study that accreditation by TJC, the states or any other body is not associated with improved outcomes or patient experience.



He states, “The problem, it seems, is that accrediting organizations are not focusing on what actually matters to patients. The criticism that these organizations spend enormous amounts of energy requiring hospitals to focus on things like signs in the hallway or how documentation is done appears to have some merit. We need to reexamine the standards required for accreditation to ensure that they are promoting what’s actually important: the health, safety, and optimal experience of patients.”



Diagnosis is largely unaddressed by the patient safety goals and measures of either TJC  or CMS.  How can we who are advocates of improving diagnosis participate in this discussion of changing the quality measures used by accrediting bodies?



Ruth



Ruth Ryan RN, MSW, CPHRM
Telephone (504) 256-8797
Email ruth at ryan-graham.com<mailto:ruth at ryan-graham.com>
Save the Date: Diagnostic Error in Medicine Conference, November 10-13, 2019, Washington, D.C.
Save the Date: Australasian Diagnostic Error in Medicine Conference, April 28-30, 2019, Melbourne, Australia













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