What JCAHO means by risk management.

Interview with Marianna Grachek, Executive Director of the Long-Term Care Accreditation Program for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Who should be concerned about risk management? Insurance companies, star athletes...and long-term care facilities. Risk management is an integral component of an organization's performance improvement initiatives, says Marianna Grachek, Executive Director of the Long-Term Care Accreditation Program for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The issue has particular relevance these days, now that JCAHO has begun incorporating specific risk management factors in its long-term care facility evaluations. She shared her thoughts on the implications of this for nursing homes with Nursing Homes Magazine contributing editor Maribeth Galecki.

Galecki: How, in your view, does the concept of risk management apply to long-term care facilities?

Grachek: Risk management is inherent in everything a long-term care facility does in providing resident care. In essence, it means continually monitoring and evaluating the processes and outcomes of care to identify where opportunities for improvement exist. If organizations have a framework for systematically assessing their performance, both in resident care and in organization-wide operations, they will be in a good position to address potential problems in a proactive manner. Designing a risk management model along these lines will enhance the organization's ability to prevent negative outcomes and minimize its exposure to risk.

The concept of risk management, as expressed here, has evolved over a number of years. Not too long ago, the hot business idea - even for long-term care facilities - was "quality assurance." When a negative outcome occurred, the system looked retrospectively to determine the cause, and often it blamed individual workers. There were checklists to figure out "Who dropped the ball?" or "Who's missing the boat?" The concept of "quality assurance" next evolved into "continuous quality improvement," in which the organization tried to define its existing "quality" of services and then enhance it by measurement, evaluation and feedback. The problem here was that "quality" means different things to different people; two different people might give you two different definitions. Meanwhile, the improvement effort may not have been directed at overall system improvement.

The quality movement is undergoing yet another evolution. It is now moving toward a systematic "performance improvement" framework. Developing from this, the Joint Commission's framework for improving organizational performance offers a way for organizations to design systems to accomplish this.

The Joint Commission's framework focuses on 11 key functions that are inherent to managing care and services in a long-term care facility. Monitoring performance in each of these areas will assist facilities in identifying areas of high-level performance and areas needing improvement. The emphasis is more on system-wide evaluation and design, rather than on "who dropped the ball" or whose definition of "quality" prevails.

In measuring its performance against the Joint Commission standards, a facility achieves an ongoing assessment of its progress. The key to this approach is data collection. Data will show where improvement needs to be made and where goals have been achieved.

Galecki: Should all long-term care facilities implement performance improvement in this manner?

Grachek: There aren't too many facilities that aren't already involved in this process to some degree. Regulatory oversight is in place with both HCFA and state regulations that require the establishment of quality assurance committees. Most long-term care facilities are already developing a framework of quality. However, the level of sophistication of these may vary, depending on an organization's resources.

The Joint Commission doesn't require a long-term care facility to have a quality assurance committee. The emphasis is on the effectiveness of whatever performance improvement approach the organization has implemented. Quality assurance audits are a good first step - now, we say, take it to the next level. More specifically with risk management, do an evaluation of risk factors and look for ways to modify and eliminate them. The goal is to identify risks and potential problems before they occur. Then we ask that facilities demonstrate what actions they have taken to improve. Finally, re-evaluate to see if these actions were effective.

Galecki: How does the concept of "sentinal events" fit into the Joint Commission's performance improvement framework?

Grachek: More and more is being written about the role of sentinel events in risk management. A sentinal event is a single occurrence that places the organization at risk. A hospital amputates the wrong leg, for example, or an elderly patient wanders out of a facility and is found dead a few days later. When an event like this occurs, performance improvement calls for the conducting of a "root cause analysis." The organization looks at all its systems and processes to identify what went wrong and how to prevent it from happening in the future. In the case of the elderly resident's elopement, the emphasis would not be on blaming the front door staff for letting him or her leave. Rather, the analysis might look at the security system, the facility's procedures for finding lost residents and its human resources guidelines for placing the right type of staff at the front door. The focus is on the system itself, not on the individual. The thinking behind this is, if the appropriate systems and procedures are in place and continually monitored for performance improvement, the likelihood of sentinal events will be minimized.

Galecki: Besides the obvious benefit of decreasing risk, what other positives can the implementation of performance improvement bring to a facility?

Grachek: One of the key concepts in assuring performance improvement throughout the organization is an "interdisciplinary approach" to problem identification and solving. In the past, each department of a long-term care facility saw itself as a separate entity, acting apart from the others in performing and improving its particular functions. Now the opportunity for system-wide improvement can bring many departments together toward this common goal. To combat the risk of weight loss in patients, for example, Nursing must be involved with patient assessment, Dietary needs to provide appropriate foods, Housekeeping should be included to ensure that the condition of the rooms isn't interfering with eating habits, and so on. Nursing facility departments don't - or shouldn't - operate in isolation. Collaboration among interdisciplinary team members will increase the likelihood that all the variables contributing to a potential risk factor are addressed.

Performance improvement conducted in this way also can help a facility build a cohesive team among its staff. Shared responsibility leads to shared ownership; if the staff buys into the concept of system-wide improvement and its goals, everyone becomes involved. There is less finger-pointing at individual staff members and more working together to achieve top performance and minimal risk.

By the same token, if an organization monitors and evaluates its performance on an ongoing basis, it will also be easy for members to identify things that they do really well. For example, if a facility has a high rate of restraint use and identifies reduction as a performance improvement goal, staff can study why restraints are used and the effects on patients and, as progress is made, create wonderful graphs showing how the restraint use has been dramatically reduced. Perhaps the facility will eventually be able to advertise to the public that it is "restraint-free." This is how data collection helps a facility identify opportunities for improvement and areas of accomplishment.

Galecki: You mentioned data collection as the key to performance improvement. Why is it so important?

Grachek: As is becoming increasingly clear to the industry, one of the reasons long-term care facilities will have to start demonstrating outcomes is the increasing influence of managed care. Third-party payers and their managed care intermediaries are looking to nursing homes to deal with a sicker level of patient, and these payers demand to see outcomes. To show outcomes, you need data. Facilities will have to get good at collecting data simply to stay in business, as well as identify opportunities for improvement and implement and monitor its achievement.

Long-term care facilities are already collecting data on residents through the Minimum Data Set (MDS). Many states are already compiling MDS data to compare facilities to each other in critical areas, such as decubitus ulcers and use of psychoactive drugs. In the very near future HCFA will be requiring data submission, as well. The data already being collected on resident-specific indicators comprise a good starting point, but there are also nonresident care-related data that are not currently being gathered through the MDS. Processes to gather this information will need to be developed.

Galecki: What sort of information can the Joint Commission offer a facility that wants to begin using the performance improvement process for risk management?

Grachek: There are many resources available at our Central Office. The Joint Commission's long-term care accreditation manual provides an excellent framework for structuring systems. It also has sophisticated educational materials available, including field programs, videotapes, audiotapes and reference manuals. If a facility comes to us and asks how to get started, my office can link it with the appropriate resources.

In every aspect of health care, trends point toward increasing use of data collection to satisfy the demands of third-party payers, the government and others wanting proof that a facility is meeting standards of quality. By implementing performance improvement, long-term care facilities can provide this proof, identify areas of potential risk and progress, and decrease the likelihood of negative outcomes. The Joint Commission's Long-Term Care Standards offer one way to accomplish this.

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