Hospitals: What will be the JCAH’s approach to its work in the future?
O’Leary: Traditionally, the Joint commission has focused on the procedural aspects of care. It is a process-oriented approach, rather than being outcome-oriented. But there is no meaningful experience in correlating good process with good outcomes. Other organizations are looking at outcomes by accumulating data that can be interpreted in different ways. But these organizations, most particularly the peer review organizations, do not necessarily have the ability to interpret the data correctly. And although the JCAH has neither the data base nor the immediate ability to do so, it has more resources and experience than anyone else, by orders of magnitude, to qualify it for this work.
Hospitals: Can the Joint Commission service as a more neutral guardian of quality than those who have sought to take on that role so far?
O’Leary: If the Joint Commission can’t, then I don’t think there is a neutral party out there. Everyone else has a vested interest. I think the JCAH can develop that capability if it decides to do so. But it is not going to be easy at all. We talk a lot about quality, but the tools we have in hand for objective, scientific review of quality are very modest.
Hospitals: The Joint Commission’s authority is enhanced by the fact that we all know there are less pleasant alternatives. Does that give the JCAH enough credibility to carry out its mission?
O’Leary: The credibility issue is an absolutely critical concern to me. I don’t think credibility can be maintained strictly on the thesis that if anything happens to the Joint Commission, its activities will be turned over to the government. I do think that if the JCAH disappeared, pressure on state and federal government to develop detailed review programs far beyond what they have now would be enormous. But I don’t think that’s enough to carry the Joint Commission into the future.
My personal feeling is that the JCAH, as the standard-bearer of high-quality health care, must not only set standards, but also must help providers meet those standards. The organizaton cannot write standards and walk away without having a remote idea of how a provider is supposed to meet them. There are several standards about which that perception exists, whether it’s true or not.
I hope that the Joint Commission will move further in the direction of making itself an educational resource and seek to do so in a broad perspective, not just in a narrow, hospital-focused perspective. Hospitals are still very important, and certainly the most complex care we render is provided in hospitals, but an increasing amount of care is moving out of hospitals, and I don’t think the JCAH can ignore that and maintain relevance.
The question is, when you look at an organization, what is it you are accrediting? Is it the hospital alone, or its satellites, or its nursing home? And if you only accredit elements that are part of a vertical delivery system, and not parallel independent services, then it doesn’t make sense. If you draw the boundaries at the hospital wall and have nothing to say about the ambulatory surgery center or the diagnostic imaging center or the birthing center or the home care program or the nursing home, you are ignoring a critical element of quality of healthcare, which is continuity.
It is clear that these alternative sites of care are going to be subject to state regulatory scrutiny. I don’t think that’s the best approach, because with state regulation, there is a program for hospitals, and a separate one for ambulatory surgery centers, and a separate one for hospices, and those medical programs often have no relationship to each other. That’s where the Joint Commission approach differs significantly, because a key element of the JCAH program is to promote continuity of care as the patient moves among different sites.
Hospitals: Should the Joint Commission, then, be the center of health services accreditation?
O’Leary: I think if the JCAH does its job well, that will serve both the professional and public interests best. Fragmentaton of the accreditation process doesn’t serve anybody’s interest. I don’t think the Joint Commission needs to control all the elements of accreditation. I think we can assume that other groups and agencies will maintain or develop capabilities in accreditation. The JCAH might end up working with some and competing with others. That doesn’t bother me particularly. I think te Joint Commission, with its tradition, is well positioned to compete.
Hospitals: How deep will the JCAH’s involvement be in the cost-vs.-quality issue?
O’Leary: The Joint Commission cannot be immune to purchaser concerns about the cost of health care, the efficiency with which it is delivered, and whether it is appropriate or not. But I don’t think we can or should be co-opted into having that as the central concern. The JCAH’s central concern should be to ensure quality. But there is need for a dialogue with the people who are paying the tab, because to stand in splendid isolation simply won’t work.
Hospitals: What do you see as the Joint Commission’s future role in credentialing issues?
O’Leary: First, credentialing and delineation of privileges are properly performed on an individual basis. It depends on what education, training, and experience the individual has. This is the basis of the qualitative judgment, not whether the individual belongs to a practitioner category, such as a cardiologist or a podiatrist or a nurse practitioner.
My experience is that when credentials committees get down to reviewing individuals, they do it pretty well. But they also tend to get into bitter philosophical discussions, which get you nowhere reasonably quickly.
The second problem is that hospitals, in theory, at least, can only provide for so many practitioners of a given type. A hospital has a limited number of operating rooms, cardiac catherization facilities, procedure rooms, and dialysis stations, and it cannot absorb an infinite number of practitioners. So the hospital, with appropriate consultation from the medical staff, must make reasonable and defensible prospective judgments about its capacity and its perceived needs.
The peculiarity, of course, is that hospitals are experiencing low occupancy, and you could argue that if beds are empty, hospitals should be able to absorb an infinite number of physicians because they will never reach capacity. But there are other resources involved.
Hospitals: There have been antitrust threats to the JCAH. Is this a continuing shadow on its activities?
O’Leary: That shadow is there, but I’m not afraid of shadows. You never eliminate them. Anybody can sue you. If you go around worrying that you’re going to get sued, you become paralyzed.
The Joint Commission went through this thought process during revision of the medical staff standards, because there were antitrust suits on the table for many millions of dollars. The JCAH board does have a fiduciary responsibility to ensure that the organization does not expose itself to unnecessary risks, so there has to be some sensitivity. But you can moderate the risk and still create meaningful standards.
Hospitals: Another thorny issue is malpractice.
O’Leary: It remains to be seen what the Joint Commission chooses to do, but it certainly wouldn’t surprise me to see it become a resource in the area of risk management. Risk management is so closely tied to quality assurance that the difference is possibly only semantic.
Hospitals: What do you see as the major health care quality issues facing us right now?
O’Leary: People are very worried about quality of care, but are unable to measure it in terms that would be acceptable to a spectrum of parties. Insurers are concerned, because although they compete on the basis of price, they are also competing on the basis of quality. They are nervous about the quality issue; some will want to talk to the JCAH about what kind of meaningful measures they ought to be looking at to ensure quality services and patient satisfaction.
Undercare is potentially the most significant problem we face, but we have limited ability to measure undercare. Continuity of care between different service sites is a complex and difficult problem, and an important one. And as new types of services are developed, how do we ensure that they meet service standards? Home care is probably the classic example of that.
Hospitals: What will the JCAH be accrediting in the future?
O’Leary: In other words, the Joint Commission on Accreditation of What? I don’t know whether the organization should or will change its name. I don’t think that will be an issue until the JCAH decides upon its future directions. But I know for a fact that for some people, the name “Joint Commission on Accreditation of Hospitals” suggests that all the Joint commission does is accredit hospitals or, more importantly, that all the Joint Commission should be doing is accrediting hospitals. I think that becomes a problem for the organization, if it is accrediting more than hospitals–which it is.
Another issue is the composition of the JCAH board. That’s enormously sensitive, but it is highly germane to the credibility of the organization. In the District of Columbia, I was a member of a private-sector task force trying to draft District regulations relative to nonphysician practitioner membership on hospital medical staffs.
The task force also included a nurse, an antitrust lawyer, a psychologist, and a social worker, among others. The physician and hospital members took enormous heat for suggesting the Joint Commission standards as a starting point, because of the composition of the JCAH board. I’m not saying that the Joint Commission could or even should change its board composition, but eventually the board will have to confront this issue.