11.7 The Joint Commission for High Standards of Care

Hospitals and other healthcare institutions must all comply with state and federal regulations and standards, and each pharmacy department within them must also abide by all state pharmacy board regulations and oversight. In addition, every US hospital (and many other healthcare institutions) seeks initial accreditation and reaccreditation by the Joint Commission to receive reimbursement from Medicare, Medicaid, and private insurance companies. To receive accreditation, every hospital department, including the pharmacy, must follow and document standards for high-quality care and patient safety. That is one reason why contracted compounding pharmacies must follow Joint Commission standards, and the pharmacy technicians in hospitals should be certified.

The Process of Accreditation

The Joint Commission accredits more than 19,000 hospitals, home healthcare systems, and skilled and long-term care facilities. If a hospital meets the standards and is approved, accreditation or reaccreditation lasts for three years.

The Joint Commission acts as a patient and healthcare advocate, making sure that the facility is following the appropriate standards and procedures. The organization sets evidence-based standards of care developed in consultation with healthcare experts, providers, and researchers. Hospitals and their pharmacies must submit documentation that they have met these standards. All departments, including the pharmacy, must submit an up-to-date online P&P Manual following the criteria required by the Joint Commission. They also must offer annual documentation of technician training on the manual and drug updates.

The Joint Commission’s standards for the hospital pharmacy include best practices for reconciling a patient’s profile upon admission to the hospital, processes to improve the safety of medication use and drug infusion pumps, and to reduce medication errors and the risk of hospital-acquired infections, among others. These standards address a number of significant patient safety issues, including the implementation of patient safety programs, the response to adverse events when they occur, and the prevention of accidental harm.

The emphasis of the Joint Commission is on addressing safety issues that are significant not only for patient care, but also for hospital financial viability. Medicare no longer reimburses hospitals for the additional cost of treating preventable medication errors, injuries, and infections. Medicare also no longer reimburses for preventable readmissions to the hospital within 30 days of discharge.

The Onsite Joint Commission Survey

After the application with documentation is fully submitted, the Joint Commission visits the site without warning and evaluates a hospital’s performance in each specific area of care, as compared against the defined standards. The Commission awards accreditation status if the facility meets or exceeds those standards. The facility inspection is sometimes referred to as a survey. It requires extensive, multiday, onsite visits by a surveying team composed of healthcare professionals who are extensively trained, certified, and educated in quality-related performance evaluation. When the survey team arrives unannounced to conduct its evaluation, it is not done to seek problems and be punitive, but to assure patients that the hospital is at all times living up to the required standards or instituting improvements to be in compliance.

The survey team evaluates the facility’s performance data, reviews the P&P Manual for compliance with quality and safety standards, and often interviews hospital personnel. For example, the survey team may discover that a hospital pharmacy recently implemented multiple personnel cuts for budgetary reasons, and some data suggest that it may be leading to a compromise in the care quality or safety level. The survey team will interview personnel to find out if they believe this is the case and what they recommend. The Joint Commission survey team, having noticed any problematic areas, has the authority to require prompt corrective action by hospital administration.

If the Joint Commission finds enough evidence that inappropriate antibiotic use by hospital prescribers may be leading to an increase in surgical site infections, resistance patterns within the hospital, and healthcare costs, the Commission might then request that a plan be put in place to address the situation, such as establishing hospital-wide criteria that must be met for prescribing antibiotics with the pharmacist in charge, flagging any use patterns that do not match these criteria, and providing counsel about alternative therapies. The hospital and its pharmacy would then have a set time period to demonstrate that an improvement strategy has been determined and implemented.

The survey team generally provides a summary report to the administrative staff and employees. In addition, the Joint Commission offers education and guidance to improve the facility’s overall performance. The final accreditation report of each healthcare facility is available on the Joint Commission’s website for public review by any consumer or healthcare professional.

Quality Assurance and Quality Control

Both the USP and the Joint Commission require each hospital and other healthcare facilities to have written policies and procedures for quality standards, training, and documentation of implementing all practices. These are required for hospital accreditation, which is required for insurance reimbursement. Site inspections that include the sterile and hazardous compounding facilities are essential to initial and maintained accreditation. Also required are quality monitoring and improvement procedures.

Quality assurance (QA) is a system of procedures, activities, and oversight that ensures that operational and quality standards are consistently met. Quality control (QC) involves the sampling, testing, and documentation of results that, taken together, ensure that specifications have been met. Where quality assurance is about how a process is performed or how a product is created, quality control is more about the inspections used to manage quality.

Setting National Quality of Care Standards

The Joint Commission not only sets individual facility improvement goals but also sets National Quality Improvement Goals for raising patient care quality across the country for select at-risk patient populations. Hospitals must then report on key indicators of care quality for these specific populations, such as those for heart attack, heart failure, community-acquired pneumonia, and surgical infection rates. The survey team often requests a number of medical charts to randomly review for compliance with the National Quality Improvement Goals. For example, in assessing the hospital performance for the care of heart attack patients, several medication-related factors may be evaluated, measured, and compared with those at other hospitals accredited by the Joint Commission. The clinical pharmacists are commonly the ones responsible for measuring progress in the following areas (and they may ask technicians to help gather the data):

• use of aspirin, prescribed on arrival and at discharge because it decreases the risk of recurrent blood clots and improves survival

• use of certain heart drugs, called beta blockers, within the first 24 hours and at discharge to minimize damage to the heart

• timely use of thrombolytic or clot-buster therapy within 30 minutes of arrival to the hospital or emergency room to reduce heart muscle damage

• use of certain heart drugs, called angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), at discharge if the patient has a diagnosis of heart failure

Comparative analysis is performed at a national and state level by the Joint Commission and is also made available to employers and patients at its website.