The new JCAHO pain standards: implications for pain management nurses.

The newly approved Joint Commission on Accreditation of Healthcare Organizations (JCAHO) pain management standards present an important opportunity for widespread and sustainable improvement in pain assessment and management. Unrelieved pain is a major, yet avoidable, public health problem. Despite 20 years of work by educators, clinicians, and professional organizations and the publication of clinical practice guidelines, there have been, at best, modest improvements in pain management practices. Multiple barriers found in the health care system, and among health care professionals, patients, and families, continue to impede progress. In August 1997 a collaborative project was initiated to integrate pain assessment and management into the standards, intent statements, and examples of implementation of JCAHO--a rare opportunity to improve pain management in health care facilities throughout the country. After review by multiple JCAHO committees and advisory groups and critique by an expert panel, the JCAHO Board of Commissioners approved the revisions in May 1999. The revisions are published in the 2000-2001 standards manuals and will be effective January 1, 2001, for all patient care organizations accredited by JCAHO--ambulatory care, behavioral health, health care networks, home care, hospitals, long-term care, and long-term care pharmacies. An evaluation of the impact of the revisions is currently being completed, and education of the JCAHO surveyors and health care professionals is underway. Nurses, especially those with expertise in pain management, are valuable resources as health care organizations change their pain assessment and management processes to meet the new standards.     

Quality assurance to quality improvement: the impact of the agenda for changes

Health care professionals are committed to the continual improvement of the quality of patient care. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has launched a major research and development project intended to improve its ability to evaluate health care organizations and encourage greater attention to the quality of daily patient care. This chapter describes JCAHO's challenge to evaluate capability and performance of health care organizations and practitioners. The intent of JCAHO's agenda for change is to focus on patient outcomes and quality improvement through a more precise and objective evaluation of both clinical and managerial performance. Through the agenda for change, JCAHO and the health care organization will participate in a continuous-flow monitoring system in which clinical and organizational data are transmitted from the field to JCAHO, analyzed, and fed back to the health care organization.     

Industrial models of continuous quality improvement. Implications for emergency medicine.

CQI or TQM programs were developed from industrial models dating back to the 1930s. The original philosophic underpinnings guiding CQI included SPC, in which rigorous statistical methods were used to study industrial flow processes. As originally adopted by the Japanese, CQI is credited, to a significant degree, with the emergence of the Japanese economy as a major world leader. Nonetheless, the original CQI concepts were developed and implemented by American researchers, including Deming and Juran. The application of industrial models of quality improvement to service businesses in general and the health care industry in particular have met with substantial success in a number of different settings. Far from representing a management fad, CQI represents a solid management philosophy with a strong statistical background that stands in sharp contrast to traditional management in this country. CQI recognizes that the majority of defects result from a failure of the processes through which the product or service is generated, as opposed to the workers themselves. To a significant degree, CQI empowers service providers (through the strong commitment of top management) to participate in improving the processes through which products and services are delivered. As efforts unfold to contain health care costs and maintain quality in the face of declining resources, CQI programs are likely to be essential to success. Nonetheless, adopting CQI requires a significant commitment on the part of top management to the training and retraining of health care providers and the recognition that traditional management philosophies and techniques have largely failed to produce the quantum leaps in quality that will be required in the coming years.     

Continuous quality improvement in the ambulatory endoscopy center

What does quality assessment have to do with the practicing gastroenterologist? Why should one spend the time and effort to incorporate CQI activities into an already busy practice? First and foremost, quality improvement should directly benefit the patient by ensuring that they receive the highest quality of care possible. For example, comparing endoscopic use or outcomes, such as procedure success or complications, with national standards or other endoscopists in the same community may identify physicians who could benefit from additional training. Similar analyses may likewise identify outstanding physicians who might serve as resources for other physicians. Surveys of patient satisfaction may reveal deficiencies, which might be unknown to a physician who is otherwise technically excellent; deficiencies that would never have been uncovered by traditional measures of quality. Second, applying the techniques of CQI to study one's own practice can provide a competitive edge when vying for managed care or corporate contracts. In this regard, CQI can be used to document physician or practice performance through tracking of endoscopic use, procedure success and complication rates, and patient satisfaction. Finally, the rising concern among various patient advocacy groups has led to an increased emphasis on quality improvement, and in most cases it is a required activity as part of the accreditation process. Steps to quality improvement There is more to quality improvement than simply selecting and implementing a performance improvement plan. A number of steps have been suggested to achieve fundamental improvement in the quality of medical care [3]. The first is to use outcomes management for improvement rather than for judgment. One of the major criticisms of QA is that it will be used to judge physicians providing care. It is feared that CQI will be used to identify poor performers who will then be punished. This strategy leads to fear and inhibits an honest pursuit of improvement. Second, learning must be viewed as a process. A quality improvement plan that is successful in one setting may not be as favorable in another situation. Clinicians must be able to focus on their individual situations and adapt what others have implemented to their own practice. Third, the most important aspect of the quality improvement is the implementation step. It matters little if elegant studies of endoscopic complications or patient satisfaction are completed if the information is not used to improve the delivery of health care to every single patient. The delivery of medical care continues to evolve. Resources are becoming increasingly scarce and the progressive rise of health care expenditures suggests a need for control. In this zeal for cost constraint, quality must not be sacrificed. This new-found attention to quality must be extended to the level of the individual practitioner to ensure that individual patients' interests are protected and the best possible care is delivered regardless of the economic implications. As providers of health care, endoscopists need to take an active role in these efforts both in understanding and implementing the techniques of quality assessment into their practices. If physicians are not actively involved in data collection and measurement to improve the quality and value of their own work, someone else will undoubtedly assume this role.     

Designing an integrated extracorporeal therapy service quality system.

Reorganization in clinical operations of a national service provider organization, Fresenius Medical Care Extracorporeal Alliance (FMC-EA), provided the opportunity to overhaul and integrate quality systems. Under the new structure, the management of acute dialysis, apheresis, open-heart perfusion, and intraoperative autotransfusion services were combined into an integrated service portfolio supported by a multidisciplinary team of nurses, perfusionists, and technicians. This communication is intended to be a concise review of the literature that establishes the foundation for the new quality system as well as a discussion of the five clinical policies and clinical procedure guidelines that govern clinical behavior in mobile, point of care, acute extracorporeal therapy services. The clinical policy standards are based on recognized essentials and guidelines published by professional organizations, federal and state government agencies, and accreditation groups. The standards list the essential behaviors that clinicians should exhibit during the provision of extracorporeal therapy procedures such as acute therapeutic apheresis. Compliance with the redesigned procedure guidelines and policies will provide the clinical practice platform for continuous quality improvement (CQI) activities, benchmarking, and self-improvement. These practices can lead to improvements in the quality of care, a decrease in medical errors, and a reduction in overall health care costs.     

A National Center for EMS Provider andPatient Safety: Helping EMS Providers Help Us

With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple—quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.     

The road to JCAHO disease-specific care certification: a step-by-step process log.

In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented Disease-Specific Care (DSC) certification. This is a voluntary program in which organizations have their disease management program evaluated by this regulatory agency. Some of the DSC categories are stroke, heart failure, acute MI, diabetes, and pneumonia. The criteria for any disease management program certification are: compliance with consensus-based national standards, effective use of established clinical practice guidelines to manage and optimize care, and an organized approach to performance measurement and improvement activities. Successful accomplishment of DSC certification defines organizations as Centers of Excellence in management of that particular disease. This article will review general guidelines for DSC certification with an emphasis on Primary Stroke Center certification.     

Performance improvement boot camp

Various regulatory agencies require some form of quality improvement program. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) encourages hospital-wide continuous quality improvement (CQI) and performance improvement (PI) to be implemented by all departments.     

Continuous quality improvement in health care

CQI is most effective when it focuses performance on chronic, critical problems and identifies the "vital few" performance benchmarks. CQI in any health care setting depends on early success, on clear lessons learned, and on the feeling of achievement and "moving forward" that this engenders throughout the organization. If there is a secret formula, it is an initial successful project.     

Practical strategies for implementing continuous quality improvement

The strategies for implementing these components will vary for individual health care organizations. It should be apparent that implementation of continuous improvement theories is a complex undertaking which requires a long-term effort to be successful and improve performance.     

Business coalitions on health care. An evolution from cost containment to quality improvement.

Business coalitions on health were unable to achieve community wide savings in health care costs in the 1980s. Some coalitions are using TQM/CQI to achieve high quality health care at a reduced cost. Although too recent to determine its success, the use of TQM/CQI in employer-provider partnerships built on trust and good data systems may be the best hope for private sector health care system reform. Health professionals knowledgeable about TQM/CQI can play an important role in helping their employers make new relationships with health care providers work.     

The Creation of Emergency Health Care Standards for Catastrophic Events

The creation of health care standards by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in a defined area with known events follows a predictable process. A problem area (e.g., hand hygiene) is identified from multiple sources. The JCAHO then calls together experts from around the country, and through debate and the comparison of positions of various people within the health care arena, a new standard informed by these views can be developed. Once developed, it is vetted and becomes established as a Joint Commission standard. But what happens when an event has never happened, cannot be reliably predicted, and, one hopes, will never come to pass? How can one create any meaningful standards? This is the situation when considering a number of scenarios related to disasters and mass casualty events.     

Hospital managed care performance standards

If hospitals do not establish their own managed care direction and contracting performance standards, they will inevitably find themselves in a reactive position. This must be avoided as managed care is one of the few payor segments that hospitals still have the opportunity to influence.     

Accreditation: a "voluntary" regulatory requirement.

Hospitals and ambulatory surgery centers may choose to voluntarily apply for accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), or the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) as appropriate. The facilities must comply with written standards regarding the environment of care, the provision of care, and the quality of care. Regular surveys of the organization's performance by the accrediting agency are intended to ensure the quality of care provided to the patients entrusted to our care. The accreditation process certifies to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program. Perianesthesia nurses should have an understanding of the regulatory agencies that influence daily patient care. This article provides an overview of the 3 accrediting bodies: JCAHO, AAAHC, and AAAASF. These agencies are committed to improving safety by providing standards of care, survey evaluations, and professional consultative and educational services, and they have an important role in our health care environments.     

Reaching common ground: a patient-family-based conceptual framework of quality EOL care

Improvement in the quality of end-of-life (EOL) care is a priority health care issue since serious deficiencies in quality of care have been reported across care settings. Increasing pressure is now focused on Canadian health care organizations to be accountable for the quality of palliative and EOL care delivered. Numerous domains of quality EOL care upon which to create accountability frameworks are now published, with some derived from the patient/family perspective. There is a need to reach common ground on the domains of quality EOL care valued by patients and families in order to develop consistent performance measures and set priorities for health care improvement. This paper describes a meta-synthesis study to develop a common conceptual framework of quality EOL care integrating attributes of quality valued by patients and their families.     

Revitalizing a documentation system.

The nursing department of a 154-bed acute rehabilitation facility, cognizant of the changing trends in health care and responding to feedback from staff, developed and implemented a comprehensive documentation system. The previous system had been fragmented, inconsistent, and inefficient. The development of the new system focused on the complex needs of the rehabilitation client and the equally complex standards required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), and insurance carriers. The final product, which was based on the nursing process and functional health patterns, encompassed the following areas from admission to discharge: providing feedback on clients' functional abilities and progress toward goals, satisfying requirements of the 1990 JCAHO standards, and, finally, using a flow sheet that saves nursing time and increases objectivity. This article describes the system from conceptualization to successful implementation.     

Reflections on quality health care

The author, a JCAHO Codman Award recipient, reflects on her professional career in the area of health care quality and describes how nurses have been leaders in the study and improvement of health care quality. Nursing's contributions to the development of quality of care measures, guidelines, and standardized languages are described and current and future opportunities for nursing are discussed.     

The evolution of standards. From capability of performance to demonstrated performance

Standardization of performance expectations and accountability for nursing care have been an integral part of nursing departments for many years. The Joint Commission on Accreditation of Hospitals (JCAHO) has used the nursing standards manual to evaluate a nursing division's capability to provide quality care. In this article, the way in which a meaningful quality assurance system is developed is discussed. The aspects discussed in depth are (1) development of standards that define performance; and (2) quality assurance measures that audit performance. By following the steps outlined, a nursing department will have progressed from describing the nurse's capability to provide optimum care to demonstrating optimum performance.     

Personal improvement project in nursing education: learning methods and tools for continuous quality improvement in nursing practice

BACKGROUND: All health care providers, including nurses, need to learn how to improve the care they give. Continuous quality improvement (CQI) is a theory and method used in health care to guide improvement. The question is how best to teach it, particularly to nursing students. It was conjectured that a systematic approach to improve study habits and lifestyle would increase nursing students' awareness of how they handled their studies and, at the same time, became acquainted with improvement knowledge methodology. Using the starting point that 'quality is personal', students worked on personal change and improvement. The purpose was to learn methods and tools for improvement in their personal life and enable them to transfer and use this knowledge in their professional work. AIMS: To describe the use of a personal improvement project (PIP) by nursing students and the resulting increased knowledge, skills, and enthusiasm to continue working with CQI. METHODS: Forty-four nursing students worked on a PIP, which they felt was important, and presented their projects to fellow students. The students answered a questionnaire, and their presentations documented the results of their work. RESULTS: All 44 students followed the instructions in a workbook describing PIPs over an 8-week period and answered a questionnaire. Forty-five per cent felt they had made an improvement in their study habits or lifestyle. Eighty-nine per cent reported that this project helped them to start learning CQI, and 75% reported that they could see the benefit of this kind of knowledge in their future clinical practice. CONCLUSIONS: Personal improvement projects seem to be an effective way of introducing CQI knowledge to nursing students. Even those who did not succeed in achieving personal improvement felt they had a positive learning outcome from the project.     

Standards of care and practice: a vital link in quality assurance

In the critical care unit setting, a quality assurance program is based on the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) ten-step model for monitoring and evaluation. The addition of nursing standards of patient care and standards of nursing practice to that ten-step model provides the vital link between patient expectations, staff performance, and quality assurance in that unit.