Before he became the commissioner of the New York State Health Department and then chairman of the department of health policy at Mount Sinai School of Medicine, Mark R. Chassin, MD, spent 12 years in emergency medicine, working in both small and large hospitals and in community and academic medical centers. His exposure to different hospital settings will serve him well as he moves into his newest position: On Jan. 1, Dr. Chassin, a board-certified internist, assumed the position of president of The Joint Commission. He recently talked to ACP Hospitalist about the current state of hospital safety and quality improvement, why pay-for-performance is not the answer, and how reaching out to global partners may help U.S. hospitals.
Q: Why did you decide to accept the position of Joint Commission president?
A: I've been working in safety and quality for more than 25 years. I became interested because in the last five to eight years The Joint Commission has made such radical improvements to the accreditation process. Through some of its other activities in public policy and in international safety and quality work, it has really positioned itself to be the premiere quality and safety organization in the United States.
The more I learned about the direction that The [Joint Commission's] Board of Commissioners wants to take, the more interested I got. Their view is that accreditation is an important and necessary function for assuring safety and quality, but it is not sufficient by itself to get us where we need to go. I was very encouraged by and enthusiastic about that view, because it is very consistent with the way that I have looked at safety and quality over the years.
Q: What are some of the methods of improvement beyond accreditation?
A: I think accreditation and certification are very effective, when done well, intrying to assure that there is a floor below which health care organizations do not fall. But by itself, accreditation is not enough to motivate good hospitals [and other health care organizations] to be great. What I think we need falls into two broad themes.
Public stakeholders, such as patients, consumers, families, elected officials and consumer groups, are becoming slowly but increasingly impatient with us. They don't understand why bad things happen in good hospitals, why we continue to see wrong-site and wrong-patient surgical procedures. They don't really understand that the state of the art today is that we can't prevent all these things from happening.
The other similar, but not identical, problem is that they don't understand why routine safety processes continually break down. They don't understand why we don't routinely wash our hands. They don't understand why when their family members are admitted to the hospital, they have to tell the same thing to the first nurse, the second nurse, etc.
Those are two different kinds of problems for us to solve, and I think The Joint Commission can be a leader in helping to solve them.
Q: What are some of the barriers to improving hospital quality?
A: We have a lot of challenges. One is a relative lack of capacity in the delivery system for really robust process improvement that goes beyond the approach that we take sometimes, the “special project” approach. We find a problem, we get a team of enthusiasts working on it, they get some traction on the problem, they generate improvement and then they get dispatched to the next fire. If you look back at the problem that they solved last year, you often find that the problem is pretty much the same as before they started.
That is a very common failing in process improvement, because if you don't really imbed the interventions you develop into the routine work and continue the interventions after the team is on to the next job, and if you don't have monitoring in place to make sure they're actually working, the improvement you generated is in jeopardy of failing. That's one of the big barriers to overcome.
We don't have a very good way of identifying proven solutions, evaluating them and then disseminating them very widely to every [useful] place. So what we end up doing too often is inventing the wheel over and over again in each place that wants to tackle a problem like anticoagulation or post-surgical infection prevention. We could do a much better job in making that process much more efficient and much less costly if we had a way of compiling information about those interventions and moving them out to other delivery systems quickly and efficiently.
Another important challenge is that we have very scarce resources for improvement. We are pretty close to being overloaded with measures, if we're not already there. We need to take a step back and focus those improvement resources on those targets where we have the greatest assurance that if we really improve on those measures, we will improve health outcomes for patients. I am not suggesting for one minute that we reduce the level of effort, but we should focus that effort where we can really gain the most health improvement.
Q: How could quality measures in hospitals become more unified?
A: For example, the recent outpatient measures that Medicare put out have some differences in definition with their counterparts on the inpatient side. That's a problem. Hopefully that will be worked out. The National Quality Forum has an initiative called Priority Partners that hopefully will help, but we really have to make sure that those efforts are successful. The discordance creates lots of wasted efforts.
Q: Do you think that pay-for-performance (P4P) programs will help improve outcomes in hospitalized patients?
A: I don't think we know enough to really design P4P programs that will achieve the intended objective. Doctors and caregivers want to do a good job; we just need to help them with the right tools. I am not sure that payment incentives are going to work because they will always have unintended consequences.
Q: How do you expect the role of The Joint Commission to evolve over time?
A: We are on the verge of a global recognition in the developed countries that the quality and safety problems that we face are really similar, if not close to identical. In efforts by the World Health Organization and The Joint Commission, a group of developed countries got together and tried to figure out if they really did have the same high-priority quality problems. It didn't take them very long to figure out that they did. They were pretty much what The Joint Commission has laid out over the last several years—the National Patient Safety goals for the U.S.
There is a remarkable convergence of effort and recognition that these are global challenges, that no one has figured out how to do this perfectly. I think we may see a harnessing of that global interest that is broader than what we can do by ourselves in the U.S., and that we may benefit if this happens in an effective way.
The Joint Commission will continue to be a leader in this. The next generation of standards in accreditation will be influenced by that development. In addition to identifying the targets for improvement, we will start to accredit organizations on the basis of how well they can improve. I think the challenge [of how to improve] will be helped by this international convergence of interest and impetus for health quality and safety improvement.