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	James L. Holly, M.D.

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Letters - The Joint Commission Telephone Survey of Joint Commission Performance May 15, 2014 26 Questions

Survey of Joint Commission Performance -
Telephone Questions Ambulatory Care

The telephone Survey will consist of: 26 questions asking you to rate these factors related to your experience with The Joint Commission using a scare of “0” to “10” where “0” equals “very Poor” and “10” equals “Excellent”:

Your recent accreditation experience with The Joint Commission	10

I rated it a “10” although, there are improvements which could be made which would help The Joint Commission gain and maintain a significant market share for Ambulatory Care and Medical Home accreditation in a environment where clinics have options. The Joint Commission has a great deal to offer but with its philosophy of “We Don’t tell anyone where and how well they are doing but we only tell them were they are not doing well and/or are failing,” organizations will gradually move away from The Joint Commission.

Considering all costs (e.g. staff, fees, training, etc.) and all benefits (e.g. Organizational review, possible reduction in insurance premiums, external deemed status, patient care, organizational functioning, etc.) of Joint Commission Accreditation, the value of Joint Commission accreditation to your organization.	5

The answer to question 1 is the foundation for the marginal answer to question number 2. In that our organization voluntarily pursued The Joint Commission accreditation without any statutory or regulatory requirement, and In that SETMA’s own culture is to pursue quality and safety for patient’s and excellence in pursuing the Triple Aim, we would pursue excellence with or without The Joint Commission.

The Joint Commission accreditation process on fostering a culture of Continuous Operational improvement within your organization.	5

SETMA would continue to pursue continual organizational improvement with or without The Joint Commission. Overall, The Joint Commission assumes for itself too much credit and implies that an organization’s continuous improvement processes are dependent upon its relationship with The Joint Commission. This seems to flow from The Joint Commission’s history and philosophy which has earned itself a negative reputation and which places its future in jeopardy. If the question were changed, the answer would change. If the question were, “The Joint Commission accreditation process contributes to your organization’s pursuit of continuous quality improvement and to your organization’s commitment to a culture of patient safety and treatment quality.” the answer would be “10.” SETMA would argue that our character and culture fosters quality. The Joint Commission can contribute to quality and safety, but SETMA'

The impact of all aspects of The Joint Commission accreditation process on your facility’s ability to provide safe, high quality care.	5

Again, as the question is phrased, the answer is as it is. SETMA would be SETMA with or without the Joint Commission. Our preparation for the Accreditation site visit was very helpful and the site visit itself, once the surveyors changed from their traditional Joint Commission attitude, was very helpful.

The impact The Joint Commission’s standards on your facility’s ability to Provide safe, high-quality care.	5

Very slight impact. In only one instance did the standards help us.

The performance of the most recent surveyor or survey team that conducted your on-site survey.	10

Once we addressed the negative - you are guilty until you prove your Innocence attitude - we had a very good experience.

The Joint Commission’s on-site survey process on finding all of your known risk areas.	5

The survey team boasted that if there is a problem, “We will find it!” Of course, we knew that was their reputation, but the assumption of deficiencies revealed The Joint Commission’s philosophy that “you are guilty until you can prove yourself innocent.” It is one thing to challenge people to “continuous quality improvement,” which is the basis of your questions above, but it is another to challenge organizations not to have deficiencies. One is positive and the other is negative. I have been told that The Joint Commission is changing, and that is good, because with the historical approach and with organizations having other choices, it could impair The Joint Commission’s future.

The Joint Commission’s on-site survey process in identifying areas of risk in your organization that were unknown prior to the on-site visit.	10

The final report showed partial deficiencies on sixteen things, several of which were trivial. There was ONE which alarmed me and that was in sterilization of an instrument. I only have known The Joint Commission by reputation, but it seemed that our survey was exemplary. The Joint Commission has NO celebratory or congratulatory sprit for those who are doing an excellent job. That is an organizational failure on The Joint Commission’s part. Your certificate reflects that negative culture and as discussed below without changes being made to the certificate, I will not display it in SETMA’s clinics.

The Joint Commission’s on-site survey process on surveyor consistency in the interpretation of compliance with standards.	8

The question itself suggests one of the correctable deficiencies in The Joint Commission. With analysis, the standards should be straight forward and clear and should not require interpretation.

The Joint Commission’s on-site survey process on providing a meaningful assessment of your organization’s strengths and weaknesses	0

The surveyors boasted that The Joint Commission only tells organizations where they are failing but never tells them where they are doing well. We objected strongly to that attitude. They finally said some good things about us but they said they were violating policy in order to do so. As The Joint Commission is very concerned about SETMA’s culture; SETMA is very concerned about the Joint Commission’s culture.

The Overall Cost of Joint Commission accreditation	5

I have no problem with the cost, but when you accredit a 40 provider group in six locations and provide them with one certificate, charging $25 each for additional ones, that is excessive. Disappointment with the certificate (previously sent) I received the Joint Commission Certificate today. It is wrong - it is for the Laboratory which is not yet accredited and there is nothing about Ambulatory Care or Medical Home. Lon, if I may be candid, the certificate is disappointing. It is not attractive and it is so minimalistic for instance It gives the date in 2014, and under that it states Accreditation is customarily for up to a 36 months While I am proud of being Joint Commission accredited, I don’t think I would go to the trouble to frame and hang this certificate. Perhaps we could discuss this. James (Larry) Holly, M.D. My intent is not to aggravate you but I think the certificate trivializes the achievement of Joint Commission accreditation. The final edition of the URAC certificate is very nice but it required major changes before it reflected the achievement. Is Joint Commission willing to discuss redesigning your certificate? Second note about certificate As I have continued to review The Joint Commission certificate, my original comments still apply but I wish to offer the following additional comments which resulted from this additional review: We were surveyed for Medical Home but there is no mention on the certificate about Medical Home. The paragraph at the bottom of the certificate starts with the following statement, “The Joint Commission is an independent, not-for-profit national body that oversees the safety and quality of health care and other services provided in accredited organizations.” Below is the definition of “oversee.” While technically the word could apply, it does so only in a paternalistic manner which reflects what I have repeatedly been told is the Joint Commission’s way , i.e., telling people what is wrong and not what is right with what they do or are doing. It also implies by your wording that The Joint Commission is the guarantor of “safety and quality,” while SETMA believes that our commitment and standards are the guarantors of both. There is nothing about your certificate that is congratulatory or laudatory. It almost reads like you are reluctant to offer positive statements for fear that our commitment will waiver. If there is nothing positive about SETMA’s relationship with The Joint Commission but only the absence of the negative, it will be very hard to go through this ordeal periodically, as there are other alternatives. As a former language professor, I am sensitive to words and how they reflect function. I would think that a better phrase would be “establishes standards and surveys.” I do hope that The Commission takes to heart our ideas because I would like to encourage others to benefit from the expertise of The Joint Commission and I would like to display our certificates. I think it is unlikely that that will occur widely except as it is required by other relationships. That is disappointing. When The Joint Commission was required by federal regulators, how you related to “clients” didn’t matter. Now, it does.

The relevancy of The Joint Commission Standards to safe, high-quality care.	7

As a 64-year-old agency, The Joint Commission has spent a great deal of time writing manuals. There is redundancy and some irrelevancy resulting from the duration and diversity of the kinds of accreditation done by The Joint Commission. A thorough review of the manuals with all of the “stake holders” would help eliminate this.

The relevancy of The Joint Commission’s Standards to the health care services your organization provides.	7

This probable should have a lower score as the concerns of The Joint Commission are heavily weighted to its long hospital experience and often does not have a great deal of relevance to ambulatory care.

The Joint Commission’s use of clear and easy to interpret standards.	7

The Commission would strengthen their product if they had non-Joint Commission employees review their standards with them.

The customer service and support you received from The Joint Commission Staff.	10

Courteous and responsive. No complains.

The educative value of the onsite survey	10

We learned; it is my hope that The Joint Commission learns also. I think we could have learned more if the survey was more relevant to the complex tasks we deal with each day.

The benefit derived from having achieved accreditation by The Joint Commission in regard to external validation of organization performance.	10

SETMA has NCQA Tier Three PC-MH (2010-2016; AAACH PC-MH and Ambulatory Care (2010-2017); URAC PC-MH and Ambulatory Care (2014-2017; The Joint Commission PC-MH and Ambulatory Care (2014-2017. We think The Joint Commission has the potential to be one of the best, if you are willing to address some of the issues we have brought up. We wanted to have all four and achieved that. No one of the four could or should stand on its own.

The benefit derived from having achieved accreditation by The Joint Commission in regard to improved staff/employee satisfaction and Retention.	4

SETMA has an excellent employee retention history. Not much was gained from The Joint Commission accreditation in regard to our employee satisfaction. Actually, many of our employees who have had experience with The Joint Commission were aggravated to have to go through what they called “the ordeal” again.

The benefit derived from having achieved accreditation by The Joint Commission in regard to improved patient satisfaction.	4

No measurable benefit. We are heavily involved with HCAHPS and CAHPS.

The Joint Commission as a source of desired learning.	4

Only the future will prove this. So far our learning has mainly to do with Leadership structure and organization but not performance.

The Joint Commission inspiring your organization to excel in providing safety and effective care with the highest quality and value.	2

As the CEO of SETMA and the guiding force behind our seeking accreditation from multiple organizations, I did not find The Joint Commission inspiring. It could be but its philosophy is not geared to be inspiring but often seems to lead to attempts to intimidate.

With Respect to The Joint Commission’s Center for Transforming Healthcare, the relevancy of customizable solutions and tools for improving patient safety provided for use by your organization on the Targeted Solutions ToolTM website.	0

Have no experience with nor knowledge of this.

The impact of these solutions on the quality and safety of care provided.	0

The impact of all aspects of The Joint Commission’s services (including accreditation and certification). JCR (including education programs, publications and consulting services, and solutions from the Center for transforming Healthcare, on your organization’s ability to provide safe, high quality care.	0

Considering your overall experience with The Joint Commission, the likelihood of your organization re-applying for Joint Commission accreditation.	10

You may find this surprising with the comments above but I think the Joint Commission has a great deal to offer with changes which should be made.

The likelihood of your recommending The Joint Commission Accreditation proves to a colleague (and two follow-up questions probing for more information regarding your rating).	10

I would encourage others to go through the process. Hopefully, the changes which The Joint Commission may make, the experience will be more positive and more helpful. Ask you for your comments on how The Joint Commission can improve the Value of accreditation. See above *Asking you for your comments on how The Joint Commission can continue to improve the accreditation process. See above*

Related Letters

	Joint Commission March 7, 2014 Additional Thoughts about the Joint Commission Joint Commission Surveyors Comments about SETMA Leadership: Character Traits Needed for Healthcare Transformation - The need for change by The Joint Commission

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