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

Mark Gusack gusackm at COMCAST.NET
Sun Dec 23 19:52:54 UTC 2018


I agree completely with John and wish to take this a few steps further.  Actually many steps further.

 

Although I don’t wish to rain on all those researchers and professor’s parades,  the underlying data presented in so many of the journal articles I read is even more unreliable than what he intimates.  At the 2017 DEM I presented a series of four posters that covered this problem from the terminological, nosological, ICD10 coding, death certification, and epidemiological point of view.  Then, to make matters worse, I added in the issue of lack of data in the literature on the percentage of signs, symptoms, and laboratory/radiologic findings present for any particular diagnosis not to mention what degree of overlap there is between these findings.  That is, data on prior probabilities that John discusses in his book ‘The Science of the Art of Medicine.’    

 

In preparing that fourth poster I began with Euler diagrams (No.  Not Venn.  Those are different.  What we were told in high school were Venn diagrams are actually Euler diagrams…) and found that, once one got above two or three clinical findings for any one diagnosis the number of combinations and permutations took the entire diagnostic effort out of the realm of possible for a single mind and into the realm of computer computations.  Worse, if you added in differentiating between more than two diagnoses the complexity rapidly grew unmanageable as these rose exponentially.

 

So, in the end, we are very fortunate that our profession is able to make so many correct diagnoses!

 

The solution to all this is a massive, difficult, and costly effort that everyone seems to be side stepping as they address single, minor issues of diagnostic error in the literature that I read (which is most of it).  What we MUST DO if we wish to make any headway in significantly Reducing Diagnostic Error in Medicine is to:

 

*	Standardize diagnostic terminology
*	Clearly define diagnostic nosology
*	Rationalize the horribly disorganized counterproductive ICD coding system
*	Standardize training and competency criteria for ICD coding by medical support personnel (GIGO!!!!)
*	Revamping and standardizing death certificate completion which has been shown to be very misleading and drifts over time regarding the meaning of what is entered on the certificate
*	Developing an eHR that enforces all this right from the start through sophisticated associative database technology
*	Developing a nationwide (or, even, worldwide) centralized epidemiologic database into which the deidentified eHR data can be entered automatically so that it can be used to refine diagnostic approaches not to mention verify the effectiveness of disease treatment which is, in the Scientific Method, the Check on the initial findings and, in part determines if the experiment (diagnosis) is valid.  In fact, it may reveal new diagnoses we never thought existed or, new ways to make a diagnosis more reliably to protect the patient from an adverse outcome [SAFETY], more rapidly to reduce patient suffering and inconvenience [QUALITY], and more efficiently to reduce cost [UTILITY].  That is, to implement Integrated Systems Management [ISM] into the diagnostic process to assure that all bases are covered.
*	Finally, we must completely revamp medical school and post medical school training to emphasize cognitive skills along with the competency to read journal articles critically, since much of our problem is highlighted by John’s discovery that a single article that is completely flawed regarding the data it includes, has led to a completely inappropriate conclusion being drawn by the medical field in general.  And, this is not an isolated event.

 

I know that what I am saying is insulting to many and very inflammatory for most.  However, I have been involved in these matters as far back as 1975 working as a clinical engineer at the GWU Medical School implementing an EKG program called ECANGO and learning about the logic of diagnosis as well as differential diagnosis engines from my boss, Dr. William Yamamoto.  It got me interested in diagnostic error.  Since that time, I have seen no real progress over close to half a century!

 

The time to change all this is NOW!

 

Mark Gusack, M.D.

President

MANX Enterprises, Ltd.

304 521-1980

www.manxenterprises.com <http://www.manxenterprises.com> 

 

From: John Brush <0000001664901ea2-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> 
Sent: Saturday, December 22, 2018 3:49 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
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
 <http://www.isabelhealthcare.com/> 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  <mailto:ruth at ryan-graham.com> 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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