We Are Not Done Changing

By  |  April 20, 2017 | 

Recently, the on-line version of JAMA published an original investigation entitled “Patient Mortality During Unannounced Accreditation Surveys at US Hospitals“. The purpose of this investigation was to determine the effect of heightened vigilance during unannounced accreditation surveys on safety and quality of inpatient care. The authors found that there was a significant reduction in mortality in patients admitted during the week of surveys by The Joint Commission. The change was more significant in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks, a 5.9% relative decrease. The positive effects of being monitored have been well documented in all kinds of arenas, such as hand washing and antibiotic stewardship. But mortality?

This is an interesting outcome, especially considering a recent ordeal I went through with my dear sister-in-law. She was on vacation in a somewhat remote location and suffers from a chronic illness, which requires her to have a tunneled line through which she receives nocturnal TPN. She presented with high fever and rigors, septic, with a Klebsiella bacteremia. Though I was re-assured somewhat by the words “sepsis protocol” used by the hospital staff, I was utterly dismayed when the hospitalist continued to use her line, even though the culture from the line was positive and she continued to spike fevers and develop rigors whenever the line was accessed.

Overall, I feel like I’m a reasonable person, but the clear lack of interest – or willingness to consider that this might not be a good idea on the part of the hospitalist in charge – incited a certain amount of anger and disbelief in me. She also received an antibiotic that she had a documented allergy to – a clear medical error. I instructed my sis-in-law to refuse access to the line; it was removed, and she ultimately recovered to discharge.

This brings me back to the JAMA study. It’s easy to perceive unannounced inspections as merely an inconvenience, where things are locked up that normally aren’t, or where that coveted cup of coffee you normally bring on rounds to get you through your day is summarily yanked out of your hand. However, during Joint Commission surveys, surveyors are looking at a variety of factors focusing on patient safety areas, such as infection control, medication management, documentation and the care environment. You know, those places where medical errors occur.

The authors suggest that hospitals and health systems look with a detailed eye at which aspects of normal day-to-day activities changed the most during survey weeks to try and replicate those behaviors which have led to increased safety for our most vulnerable, the hospitalized patients. It’s hard to know how locking up inhalers instead of keeping them at the bedside, or scrutinizing care plans and MARs really impact mortality. Obviously heightened scrutiny in tiny arenas leads to greater downstream effects.

Most experts note it would be difficult to create this type of environment on a daily basis; elevating processes to more fixed intent would be difficult to maintain and might create degradation of the positive returns in the long run. But this article has made me think more about some of the day-to-day details and how I can be more cognizant of them when directing care of my very sick inpatients. I am not a big believer of leaving medications at the bedside. How do you know if the patient took them? What if there was a change in their status between the time you dropped those pills off and the point when the patient actually took them? Since you don’t know what time the patient took them, how can you perceive it as an effect of the medications or not? Taking what some may consider small steps like this can help lay the foundation for creating that environment.

I will leave a more in-depth analysis to those individuals who are experts in statistics to comment about the veracity of this study and its weaknesses. But it is amazing to think that just having some type of increased scrutiny saved lives in our hospitals – and could have possibly resulted in a completely different experience for people in similar situations to the one my sister-in-law found herself in.

The Joint Commission is apparently NOT about that coffee cup, but about saving lives of those we love. I think we should analyze what changes in our institutions when those surveyors come around. And realize that the lives of patients and the ones we love are at stake, and that we have an obligation to them that is more important than any inconvenience.

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About the Author: Tracy Cardin

Tracy Cardin
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations. In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.


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