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

ROBERT M BELL rmsbell200 at YAHOO.COM
Mon Dec 24 16:58:18 UTC 2018


Thanks Mark,

Excellent comments.

You point out many things that need attention. Do most physicians even understand?

I do not have all the information needed to effectively triage the way forward. 

If I were “King" I would leave it to the SIDM experts and their colleagues to decide!

I totally agree with your statement about a Mission and Defined Goals.

Tackling one or two things at a time and we can better move forward.
>  
Rob Bell

> On Dec 23, 2018, at 9:40 PM, gusackm at comcast.net wrote:
> 
> Rob:
>  
> I’m sure Mark is looking for Bluntness.  If we are going to move this forward, we have to work things out between us regarding these matters.
>  
> So, first, autopsy data:
>  
> I agree completely.  I’m a pathologist so I know just how poor present autopsy practice is today.  Since there is no money in autopsies – only lots of time and trouble – few pathologists do more than a superficial autopsy in the clinical setting.  Clinicians rarely attend the autopsy or read the report on their deceased patients.  Findings are forgotten and the final cause of death is often miscoded.  As for Forensic pathologists; they are too overburdened to do much with cases that come to them without obvious evidence of homicide, suicide, or accidental death.
>  
> Next, laboratory testing:
>  
> The Clinical Laboratory:
>  
> We suffer from numerous challenges.  Just as a small example below:
>  
> Accuracy and precision is often determined only during the initial validation of a new instrument or methodology.  Only laboratories that achieve ISO 15189 certification utilize their QC data to do ongoing calculations as recommended in the Clinical Laboratory Standards Institutes [CLSI] EP23 document which, although a landmark in the field, is not followed by most laboratories.  Worse, this information should be presented with the lab result so the clinician can make an informed judgement as to how much reliance they will place on it in the diagnostic process.  Worse.  Clinicians should be presented with the initial metrological data at validation and asked the question:
>  
> “Is this an Acceptable Risk using this particular implementation of the test?”
>  
> Then there is the matter of sensitivity versus specificity (and we are not even considering incidence and prevalence) and the proper use of a test for either screening and/or diagnosis.  Furthermore, as we attain higher and higher sensitivity – for example, Troponins – we are faced with a whole new diagnostic domain of subclinical ACS for which we have no answer regarding how to manage.
>  
> Next, Anatomic Pathology:
>  
> In short, the scientific basis for most diagnostic criteria for many major diagnoses is slim-to-none.  And even where well established, the standardization of application is not present leading to significant differences in both diagnosis and staging from lab to lab.  In fact, my own experience is that even the best experts will often call difficult borderline cases differently at different times.
>  
> As for AI and its application in differential diagnosis engines?  I’m a solid supporter of this.  I started in the field in 1973 at Amherst College exploring LISP which was still under development at the computer science department at nearby UMASS.  Later, I played with Forth, Knowledge Pro, and used Turbo Prolog extensively in model medical student teaching applications.  Later, I discovered an object oriented database language that had surprisingly powerful AI features called Paradox Application Language [PAL].  I’ve even invented associative database technology to provide a database structure that can model neural networks without programming.  However, all this requires high quality data in large quantities to work reliably and, as IBM has recently found out, it’s hard to get.
>  
> As for differential diagnosis engines.  I designed and programmed my first in medical school early in 1980 under the supervision of one of the founders of this field – Dr. Yamamoto.  The program was in FORTRAN and was supposed to differentiate polycythemia vera from other causes of increased RBC.  What we found was that we could successfully codify the diagnostic logic but could not find the actual clinical data in the twenty patient charts we pulled with that diagnosis to test the program.  Upon investigation, we found that three out of twenty patients did have the requisite data in private practice charts and we were able to enter it in successfully.  The rest?  Nowhere to be found.  So, how was the diagnosis established in the first place?  Patient follow up revealed at least five did not have polycythemia vera!
>  
> So, given the serious problems we face, I would be very grateful if you and others would discuss a central MISSION STATEMENT regarding reducing Diagnostic Error in Medicine from which we and other might develop a set of Strategic Goals and Measurable Objectives to achieve those goals.
>  
> I have the honor to be, respectfully yours,
>  
> Mark Gusack, M.D.
> President
> MANX Enterprises, Ltd.
> 304 521-1980
> www.manxenterprises.com <http://www.manxenterprises.com/>
>  
> From: ROBERT M BELL <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> 
> Sent: Sunday, December 23, 2018 3:37 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>?
>  
> Hi Mark and everyone,
>  
> But with the limited autopsy data and other limited end point data, would it not be better to focus on the lab testing, radiological improvements, etc.?
>  
> This making the assumption that with less error in testing it is likely to lead to more accurate diagnoses, and that could be better than anything SIDM and the list serve are doing at the moment.
>  
> Throw in Differential Diagnostic practices and research, and also Artificial Intelligence that is on its way, and I think we could be far more more successful than we currently are.
>  
> Since SIDM was established do we have any idea/guess of the number of patients saved from an incorrect diagnosis?
>  
> I would think that at this time the the cognitive and system-related breakdowns you mention are far too complicated for us to make any significant headway.
>  
> I really think a new Mission and Goals are needed that proves to ourselves that we are helping patients.
>  
> Apologies for being a little blunt. 
>  
> Rob Bell, M.D.
> 
> 
>> On Dec 23, 2018, at 9:33 AM, Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>> wrote:
>>  
>> If we limit this discussion to diagnostic errors, one important way errors have been identified and counted is from autopsies, based on the number of major discrepancies (dx errors that would have changed management) in 10-20% of the cases.  This was the basis for the claim by Lucian Leape, Don Berwick and David Bates that there are 40,000 – 80,000 deaths/year from diagnostic error.  I’ve never quite followed their math, because there are over 2.5M deaths per year in the US.  So autopsy discrepancies are one way to count and some have described this as the gold standard.  Clearly there are many limitations to autopsy-derived data, just as there are for every other way to count.
>>  
>> But the key statement in their publication is this:   “Hospitals cannot be made safer by counting bodies”.  Their point was that the real work is to identify and study the cognitive and system-related breakdowns that contribute to these errors, and address these. 
>>  
>> Mark L Graber, MD FACP
>> Chief Medical Officer; Founder and President Emeritus, SIDM
>> Senior Fellow, RTI International
>> Professor Emeritus, Stony Brook University, NY
>> <image001.jpg>
>>  
>>  
>> From: Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>> Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>> Date: Sunday, December 23, 2018 at 9:25 AM
>> To: Listserv ImproveDx <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>?
>>  
>> Apropos to Dr. Brush comment on MI:
>> What is the n for the study that lead to the headlines on medical error being 3rd leading cause of deaths?
>> What were the definitions of error used; are they externally valid.
>> I'll await an answer; it's interesting.
>>  
>> This topic is important for the same reason the vaccine-autism non-link should infuriate parents of children with autism:
>> It diverts precious resorts, so the reasoning better be good.
>>  
>> What is the reasoning/math behind "3rd leading cause?"
>> References, please, and be sure to include the original article.
>>  
>> tom
>>  
>> On Sat, Dec 22, 2018 at 5:16 PM John Brush <0000001664901ea2-dmarc-request at list.improvediagnosis.org <mailto:0000001664901ea2-dmarc-request at list.improvediagnosis.org>> wrote:
>>> 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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>>  
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>> 
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>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> 
>> To learn more about SIDM visit:
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>>  
>> <Leape - Counting deaths due to medical errors.pdf>
> 
>  
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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