LD.4.260 – Patient Safety and Leadership

Those of us who work in hospital departments directly related to investigation and mitigation of adverse patient care events, whether that’s a department of Clinical Risk Management, Quality, Legal, or Patient Safety, need to take note of the 2009 Joint Commission Leadership Standards, as some new requirements have been added.

The 2009 Elements of Performance for LD.4.260 are noted below:

LD.4.260  The hospital implements an integrated safety program throughout the hospital.


Elements of Performance

1.  There is a hospital-wide, integrated, patient safety program.

2.  One or more qualified individuals, or an interdisciplinary group, manages the hospital-wide safety program.

3.  The scope of the program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, good catches) to hazardous conditions and sentinel events, which have serious adverse outcomes.

4.  All departments, services, and programs within the hospital participate in the safety program.

5.  The hospital creates procedures for responding to system or process failures, such as continuing to provide care, treatment or services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.   

6.  The hospital: Defines responses to various types of potential adverse events.

7.  The hospital: Conducts proactive risk assessments.

8.  The hospital: Makes support systems available for staff members who have been involved in a sentinel event.  (I’m glad to see this element added as a formal requirement this year.)

9.  The hospital: Analyzes and uses information about a system or process failure to improve safety.

10, The hospital: Provides systems for internal and external reporting of a system or process failure.

11,  The hospital: Provides governance at least once a year, with written reports on all system or process failures, on the number or type of sentinel events, on whether patients and the families were informed of the adverse events, and on all actions taken to improve safety, both proactively and in response to actual occurrences.   

12.  The hospital: Disseminates lessons learned from root cause analysis to staff who provide services or are affected by the situation. 

13.  The hospital: Encourages external reporting of significant external events, including voluntary reporting programs in addition to mandatory programs.


Poliner Decision Reversed by Fifth Circuit Court of Appeals

The Poliner case generated much attention and concern when a jury awarded $366 million in damages to a Texas cardiologist who challenged a peer review action. (The damages were later reduced to $22 million.) 

On July 23rd the Fifth Circuit Court of Appeals reversed the district court’s decision, holding that the actions of the hospital and its Chair of Internal Medicine were protected under the Health Care Quality Improvement Act.  Horty Springer has posted the full text of the court’s decision on their web site: Poliner v. Texas Health Systems.  

Thanks to Nena Ickes, CPMSM, CPCS, from 3M Health Information Systems, for this breaking news tip.   

Previous MSSPNexus posts about Poliner 




Joint Commission Loses Unique Deeming Authority Provided by Law

The Open Congress Blog reports on the recent passage, despite Presidential veto, of H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008.    
Most of the focus about this bill has centered on potential cuts to physician reimbursement. The Kaiser Network reports, “A 10.6% reduction to Medicare physician fees will be delayed for 18 months because legislation (HR 6331) became law on Tuesday after both chambers of Congress voted to override President Bush’s veto of the bill.” 
However, this new law also removes the unique deeming authority that the Medicare statute has specifically given The Joint Commission’s hospital accreditation program since 1965. 
This does not end Joint Commission’s deeming authority, it simply means that after a two year transition the organization will have to apply for deeming authority just like any other accrediting body that wishes to seek deemed status. 
The Joint Commission released a brief statement about the change in the law:  http://www.jointcommission.org/NewsRoom/statement_07_16_08.htm 
See also:  
The Verdict is In: Joint Commission Loses Its Statutory Deeming Authority – Advocate Alliance.net

Briefings on Joint Commission from HcPro
Kaiser Daily Health Policy Report

Joint Commission 2009 Standards Preview

I have been, as a friend of mine says, ‘burning the candle at four ends’ lately.  Thus, the lack of posts.  

I’m a bit late in reporting it, but the Joint Commission has posted their 2009 standards online until the release of the printed standards manuals.  There has been a considerable expansion of the Leadership chapter. 
They are available here in pdf format: http://www.jointcommission.org/Standards/SII/default.htm

Credentials Committee Decision Blocked in Federal Court

A decision by the Credentials Committee of Brigham and Women’s Hospital has been blocked in federal court according to a report published in the Boston Globe. 
US District Court Judge Nancy Gertner ruled Monday from the bench that Dr. Sagun Tuli could make a strong case that “inappropriate animus” played a role in the committee’s order last fall that she undergo an evaluation or she probably would not be allowed to practice at Brigham and Women’s after April 15. 
Tuli’s lawyer, Margaret M. Pinkham, said she was aware of no comparable US case in which a federal or state judge had blocked a credentialing committee from taking action concerning a doctor. 
“Courts are very unwilling to interfere in the peer-review process,” she said, “but this is a very unique case.” 
Read the article “Female Doctor Need Not Take a Test of Fitness to Keep Her Job.”