Opinion
VIEWPOINT
Mark R. Chassin, MD, MPP, MPH The Joint Commission, Oakbrook Terrace, Illinois. David W. Baker, MD, MPH The Joint Commission, Oakbrook Terrace, Illinois.
Author Reading at jama.com
Corresponding Author: Mark R Chassin, MD, MPP, MPH, The Joint Commission, One Renaissance Blvd, Oakbrook Terrace, IL 60181 (mchassin @jointcommission.org).
Aiming Higher to Enhance Professionalism Beyond Accreditation and Certification the area of health care quality and safety. The days of the solitary physician toiling in isolation are long gone. Increasingly, physicians are practicing in teams within complex organizations, and the quality and safety of health care depend on all team members and the system in which they work. Accrediting and certifying organizations have traditionally helped the medical profession achieve good governance and self-regulation by requiring structures within health care organizations that promote and facilitate system-level leadership by physicians. For example, Joint Commission standards bestow the “selfgoverning organized medical staff” with the responsibility for credentialing, privileging, and evaluating the competency of practitioners; delineating the scope of privileges that will be granted to practitioners; and providing leadership in performance-improvement activities. The Joint Commission also created Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation to make privileging more objective and continuous so medical staffs can better determine if the care delivered by a practitioner falls below an acceptable level of performance. To address the Accrediting and certifying organizations problem of intimidating and inapproprimust develop new programs and ate physician behaviors, The Joint Commission established leadership stanactivities designed to foster, identify, and dards and issued guidance about how publicly recognize consistent excellence to address this important threat to safety.4 Accrediting and certifying orgaprinciples of patient welfare, patient autonomy, and jus- nizations have also played a governing role through rigtice. Other medical societies have similarly focused on orous evaluation processes to protect the public from the behavior of their individual members and worked to organizations and individuals that pose unacceptable inspire them to pursue lifelong learning, scientific prac- risks because of noncompliance with safety standards tice, and ethical behavior. or failure to deliver critical evidence-based processes of However, medicine’s overall record of self- care. How effective these programs and activities have governance is less exemplary. Problematic behaviors been in achieving their stated objectives is unclear, have too often been tolerated within health care orga- due in no small part to the difficulty of rigorously evalunizations and by the profession as a whole. Many stake- ating them. holders suggest that medicine has failed to address Although these tools by which accrediting and pressing societal needs such as poor quality of care and certifying organizations help physicians with selfsafety, lack of access to health care, and the high cost of governance are important, they are inadequate to care. As a consequence, threats to self-governance meet current quality and safety challenges. Physicians have arisen from government officials, private organi- could make a much stronger case for continued selfzations purporting to judge physician quality, and con- governance if they took a more visible and vigorous sumers demanding greater accountability. Medical leadership role in efforts that led to major improvesocieties and other organizations have been more pro- ments in the quality and safety of patient care. In the active recently by supporting health care reform and past, it might have been enough for individual physiidentifying opportunities to reduce low-value health cians to work hard and provide care to patients to the care through the Choosing Wisely campaign.3 Yet the best of their ability. Medicine was far more art than sciability of medical societies to effect change is limited by ence. However, health care today is too complex for a their weak enforcement authority and their focus on single physician’s isolated efforts to be successful. Sysindividual physician behaviors. This is especially true in tems of care are necessary to achieve the highest levProfessions have special privileges in the United States. There are intangible benefits such as prestige, but more importantly, professions have the dearly prized privilege of autonomy. With this privilege comes the expectation that a profession will establish codes of conduct and promote high standards of quality among its members. From the standpoint of creating codes of conduct, the medical profession has been a role model. In 1847, the newly formed American Medical Association met in Philadelphia, Pennsylvania, as the first national professional medical organization in the world. At that meeting, its members adopted the world's first national code of professional medical ethics and established standards for education, training, and conduct.1 More recently, the American Board of Internal Medicine, the American College of Physicians Foundation, and the European Federation of Internal Medicine jointly authored Medical Professionalism in the New Millennium: A Physician Charter.2 The charter established a set of professional responsibilities that inform physicians about how they should practice: to follow the fundamental
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
1795
Opinion Viewpoint
els of safety and quality. The variability in quality and safety of health care remains breathtaking—even in the United States, which spends the most money on it. Poor hand hygiene, transition failures, lack of coordination among clinicians caring for the same patient, wrong-site surgeries, and inpatient falls continue to cause harm. Consistent excellence must become the norm within individual organizations and across the delivery system if the medical profession is to regain its reputation as a responsible steward of health care. If physicians are going to lead health system efforts to drive major improvements, they will need to acquire new skills and take on new responsibilities for quality improvement and safety, whether as part of system leadership or a group of engaged caregivers. Medical societies have emphasized to their members that working to improve quality is part of physician professionalism.2 Accrediting and certifying organizations can work in tandem with medical societies to help make this a reality. But just as health care has changed, the organizations that perform standard accreditation and certification functions will need to change to be effective in this new environment. Traditional approaches to these functions involve an organization marshalling requisite evidence and expertise to establish standards of practice by which a health care organization is judged, typically through an onsite survey. Analogously, organizations that certify physician competencies perform similar functions to develop examinations that judge physician qualifications. In both cases, this traditional approach of comparing performance to standards is able only to find deficiencies, ie, noncompliance with standards during an onsite survey or wrong answers on a test. That approach, by its very design, is inherently unable to recognize or foster excellence. A different set of tools, skills, and programs is required. First among these changes is to state simply and clearly that the ultimate goal is zero harm for patients and health care workers. This means always delivering effective care, freedom from complications of care, and elimination of care that has no value (overuse). Some health systems have embraced this challenge and are well on their way to achieving this goal.5 Second, physicians and organizations should master the tools, methods, and science that businesses outside of health care have proven to be capable of facilitating the magnitude of improvement envisioned by this goal. The tools of Lean, Six Sigma, and change management and the science of high reliability provide just this ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. American Medical Association. History of AMA ethics. http://www.ama-assn.org/ama/pub/about -ama/our-history/history-ama-ethics.page. Accessed March 30, 2015. 2. ABIM Foundation. Physician charter: principles of the charter. http://www.abimfoundation.org
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capability.5 Briefly, Lean tools and strategies identify opportunities to eliminate the steps in a process that represent wasted effort and do not contribute to achieving the goal of the process. Six Sigma tools work to reduce "defects" or poor outcomes of processes. Change management tools are essential to ensure that the improved processes produced by Lean and Six Sigma are successfully implemented and sustained.6 Third, accrediting and certifying organizations must develop new programs and activities designed to foster, identify, and publicly recognize consistent excellence. These new programs should augment and be seamlessly integrated with traditional accreditation functions, which are still necessary and appropriate to establish a level of performance below which organizations and individual practitioners should not be permitted to operate. For its part, The Joint Commission is taking on these 3 challenges. Six years ago, to emphasize that the organization needed to go beyond finding deficiencies in its accreditation surveys, the Joint Commission Board reframed the mission of the organization, which now reads: “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” The Joint Commission has fully adopted Lean, Six Sigma, and change management for all of its internal improvement functions and has, to date, trained 45% of its workforce in the use of these tools. The Joint Commission Center for Transforming Healthcare was established as a separate entity from the accreditation program to work with health care organizations that have also mastered these tools to produce new and more effective solutions to persistent quality problems. Its Center for Transforming Healthcare has embraced these new tools, as well as high-reliability science, and created a series of new programs and tools to engage physicians and health care organizations in this effort.5,7,8 Physicians should demand and lead new efforts to eradicate patient harm and produce consistent excellence across the full continuum of care. This strategy is the best way to ensure society will continue to entrust self-governance to the medical profession. Accrediting and certifying organizations can and should play a major role in this effort by embracing the goal of zero harm and creating new programs that supplement their traditional functions by directly promoting and supporting consistent excellence in the performance of physicians and health care organizations.
/Professionalism/Physician-Charter/Principles-of -the-Charter.aspx#PrimacyNn. Accessed March 30, 2015.
6. Robust Process Improvement. http://www .centerfortransforminghealthcare.org/about/rpi .aspx. Accessed April 19, 2015.
3. ABIM Foundation. Choosing Wisely: an initiative of the ABIM Foundation. http://www .choosingwisely.org/. Accessed March 30, 2015.
7. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf. 2015;41(1):4-12.
4. The Joint Commission. Issue 40: behaviors that undermine a culture of safety. July 9, 2008. http: //www.jointcommission.org/assets/1/18/SEA_40 .pdf. Accessed March 30, 2015. 5. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91 (3):459-490.
8. Chassin MR, Nether K, Mayer C, Dickerson MF; Beyond the collaborative. spreading effective improvement in hand hygiene compliance. Jt Comm J Qual Patient Saf. 2015;41(1):13-25.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
jama.com
VIEWPOINT
Mark R. Chassin, MD, MPP, MPH The Joint Commission, Oakbrook Terrace, Illinois. David W. Baker, MD, MPH The Joint Commission, Oakbrook Terrace, Illinois.
Author Reading at jama.com
Corresponding Author: Mark R Chassin, MD, MPP, MPH, The Joint Commission, One Renaissance Blvd, Oakbrook Terrace, IL 60181 (mchassin @jointcommission.org).
Aiming Higher to Enhance Professionalism Beyond Accreditation and Certification the area of health care quality and safety. The days of the solitary physician toiling in isolation are long gone. Increasingly, physicians are practicing in teams within complex organizations, and the quality and safety of health care depend on all team members and the system in which they work. Accrediting and certifying organizations have traditionally helped the medical profession achieve good governance and self-regulation by requiring structures within health care organizations that promote and facilitate system-level leadership by physicians. For example, Joint Commission standards bestow the “selfgoverning organized medical staff” with the responsibility for credentialing, privileging, and evaluating the competency of practitioners; delineating the scope of privileges that will be granted to practitioners; and providing leadership in performance-improvement activities. The Joint Commission also created Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation to make privileging more objective and continuous so medical staffs can better determine if the care delivered by a practitioner falls below an acceptable level of performance. To address the Accrediting and certifying organizations problem of intimidating and inapproprimust develop new programs and ate physician behaviors, The Joint Commission established leadership stanactivities designed to foster, identify, and dards and issued guidance about how publicly recognize consistent excellence to address this important threat to safety.4 Accrediting and certifying orgaprinciples of patient welfare, patient autonomy, and jus- nizations have also played a governing role through rigtice. Other medical societies have similarly focused on orous evaluation processes to protect the public from the behavior of their individual members and worked to organizations and individuals that pose unacceptable inspire them to pursue lifelong learning, scientific prac- risks because of noncompliance with safety standards tice, and ethical behavior. or failure to deliver critical evidence-based processes of However, medicine’s overall record of self- care. How effective these programs and activities have governance is less exemplary. Problematic behaviors been in achieving their stated objectives is unclear, have too often been tolerated within health care orga- due in no small part to the difficulty of rigorously evalunizations and by the profession as a whole. Many stake- ating them. holders suggest that medicine has failed to address Although these tools by which accrediting and pressing societal needs such as poor quality of care and certifying organizations help physicians with selfsafety, lack of access to health care, and the high cost of governance are important, they are inadequate to care. As a consequence, threats to self-governance meet current quality and safety challenges. Physicians have arisen from government officials, private organi- could make a much stronger case for continued selfzations purporting to judge physician quality, and con- governance if they took a more visible and vigorous sumers demanding greater accountability. Medical leadership role in efforts that led to major improvesocieties and other organizations have been more pro- ments in the quality and safety of patient care. In the active recently by supporting health care reform and past, it might have been enough for individual physiidentifying opportunities to reduce low-value health cians to work hard and provide care to patients to the care through the Choosing Wisely campaign.3 Yet the best of their ability. Medicine was far more art than sciability of medical societies to effect change is limited by ence. However, health care today is too complex for a their weak enforcement authority and their focus on single physician’s isolated efforts to be successful. Sysindividual physician behaviors. This is especially true in tems of care are necessary to achieve the highest levProfessions have special privileges in the United States. There are intangible benefits such as prestige, but more importantly, professions have the dearly prized privilege of autonomy. With this privilege comes the expectation that a profession will establish codes of conduct and promote high standards of quality among its members. From the standpoint of creating codes of conduct, the medical profession has been a role model. In 1847, the newly formed American Medical Association met in Philadelphia, Pennsylvania, as the first national professional medical organization in the world. At that meeting, its members adopted the world's first national code of professional medical ethics and established standards for education, training, and conduct.1 More recently, the American Board of Internal Medicine, the American College of Physicians Foundation, and the European Federation of Internal Medicine jointly authored Medical Professionalism in the New Millennium: A Physician Charter.2 The charter established a set of professional responsibilities that inform physicians about how they should practice: to follow the fundamental
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
1795
Opinion Viewpoint
els of safety and quality. The variability in quality and safety of health care remains breathtaking—even in the United States, which spends the most money on it. Poor hand hygiene, transition failures, lack of coordination among clinicians caring for the same patient, wrong-site surgeries, and inpatient falls continue to cause harm. Consistent excellence must become the norm within individual organizations and across the delivery system if the medical profession is to regain its reputation as a responsible steward of health care. If physicians are going to lead health system efforts to drive major improvements, they will need to acquire new skills and take on new responsibilities for quality improvement and safety, whether as part of system leadership or a group of engaged caregivers. Medical societies have emphasized to their members that working to improve quality is part of physician professionalism.2 Accrediting and certifying organizations can work in tandem with medical societies to help make this a reality. But just as health care has changed, the organizations that perform standard accreditation and certification functions will need to change to be effective in this new environment. Traditional approaches to these functions involve an organization marshalling requisite evidence and expertise to establish standards of practice by which a health care organization is judged, typically through an onsite survey. Analogously, organizations that certify physician competencies perform similar functions to develop examinations that judge physician qualifications. In both cases, this traditional approach of comparing performance to standards is able only to find deficiencies, ie, noncompliance with standards during an onsite survey or wrong answers on a test. That approach, by its very design, is inherently unable to recognize or foster excellence. A different set of tools, skills, and programs is required. First among these changes is to state simply and clearly that the ultimate goal is zero harm for patients and health care workers. This means always delivering effective care, freedom from complications of care, and elimination of care that has no value (overuse). Some health systems have embraced this challenge and are well on their way to achieving this goal.5 Second, physicians and organizations should master the tools, methods, and science that businesses outside of health care have proven to be capable of facilitating the magnitude of improvement envisioned by this goal. The tools of Lean, Six Sigma, and change management and the science of high reliability provide just this ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. American Medical Association. History of AMA ethics. http://www.ama-assn.org/ama/pub/about -ama/our-history/history-ama-ethics.page. Accessed March 30, 2015. 2. ABIM Foundation. Physician charter: principles of the charter. http://www.abimfoundation.org
1796
capability.5 Briefly, Lean tools and strategies identify opportunities to eliminate the steps in a process that represent wasted effort and do not contribute to achieving the goal of the process. Six Sigma tools work to reduce "defects" or poor outcomes of processes. Change management tools are essential to ensure that the improved processes produced by Lean and Six Sigma are successfully implemented and sustained.6 Third, accrediting and certifying organizations must develop new programs and activities designed to foster, identify, and publicly recognize consistent excellence. These new programs should augment and be seamlessly integrated with traditional accreditation functions, which are still necessary and appropriate to establish a level of performance below which organizations and individual practitioners should not be permitted to operate. For its part, The Joint Commission is taking on these 3 challenges. Six years ago, to emphasize that the organization needed to go beyond finding deficiencies in its accreditation surveys, the Joint Commission Board reframed the mission of the organization, which now reads: “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” The Joint Commission has fully adopted Lean, Six Sigma, and change management for all of its internal improvement functions and has, to date, trained 45% of its workforce in the use of these tools. The Joint Commission Center for Transforming Healthcare was established as a separate entity from the accreditation program to work with health care organizations that have also mastered these tools to produce new and more effective solutions to persistent quality problems. Its Center for Transforming Healthcare has embraced these new tools, as well as high-reliability science, and created a series of new programs and tools to engage physicians and health care organizations in this effort.5,7,8 Physicians should demand and lead new efforts to eradicate patient harm and produce consistent excellence across the full continuum of care. This strategy is the best way to ensure society will continue to entrust self-governance to the medical profession. Accrediting and certifying organizations can and should play a major role in this effort by embracing the goal of zero harm and creating new programs that supplement their traditional functions by directly promoting and supporting consistent excellence in the performance of physicians and health care organizations.
/Professionalism/Physician-Charter/Principles-of -the-Charter.aspx#PrimacyNn. Accessed March 30, 2015.
6. Robust Process Improvement. http://www .centerfortransforminghealthcare.org/about/rpi .aspx. Accessed April 19, 2015.
3. ABIM Foundation. Choosing Wisely: an initiative of the ABIM Foundation. http://www .choosingwisely.org/. Accessed March 30, 2015.
7. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf. 2015;41(1):4-12.
4. The Joint Commission. Issue 40: behaviors that undermine a culture of safety. July 9, 2008. http: //www.jointcommission.org/assets/1/18/SEA_40 .pdf. Accessed March 30, 2015. 5. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91 (3):459-490.
8. Chassin MR, Nether K, Mayer C, Dickerson MF; Beyond the collaborative. spreading effective improvement in hand hygiene compliance. Jt Comm J Qual Patient Saf. 2015;41(1):13-25.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
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