by Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, Senior Director, Accreditation Education Programs

Saturdays around my house are spent taking care of routine tasks like cleaning, grocery shopping and laundry. The television is usually on in the background with whatever is on HGTV. My favorite is Fixer Upper. While it inspires projects in my own home, it also reminds me of that 1980s movie, Money Pit. Just moments after the dream house that needed a little fixing up was purchased it, it began completely falling apart. While “good bones” are important, inevitably it’s the basic foundation that is most critical. Without that, your project quickly escalates from a simple renovation into a money pit.

The same analogy applies to health care organizations and their focus on patient safety. The roots of patient safety date back to the early 1900s and the Hospital Standardization Program founded by the American College of Surgeons (ACS) and developed by Boston surgeon, Dr. Ernest Codman, in response to the deplorable state of hospital patient records. The program outlined five “minimum standards” focused on quality of inpatient care. 

  1. That physicians and surgeons privileged to practice in the hospital be organized as a definite group or staff
  2. Membership in the medical staff be restricted to physicians and surgeons who are graduates of medicine in good standing, competent and worthy in character
  3. That the medical staff, with the approval of the governing body, adopt rules, regulations and policies governing the professional work of the hospital
  4. That accurate and complete records be written for all patients
  5. That diagnostic and therapeutic facilities under competent supervision be available for the study, diagnosis and treatment of patients

These five simple standards evolved over the years and became the foundation of CMS’ Conditions of Participation for hospitals and other health care programs. They have further evolved into standards defined by voluntary accrediting organizations (VOs) such as The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas (DN). While the standards published by the VOs have increased in number, the basic intent is still very much in alignment with those first five simple standards. 

In my opinion, the third standard, which calls upon the medical staff with the approval of the governing body to adopt rules, regulations and policies governing the professional work of the hospital, is the primary foundation for meeting the standards. A health care organization that can reliably and consistently meet the standards is more apt to be able to demonstrate safe patient care through their outcomes.

It is one thing to define rules, regulations and standards and quite another to implement them reliably and consistently each and every day. Building safe health care processes, just like building houses that stand the test of time requires the following elements:

  1. Sound architectural plans. These include standard work processes defined in policies and procedures that are aligned with the rules, regulations and standards that link to every layer of the organization, including senior leaders, middle managers, front-line supervisors, clinical and operational staff, and physicians.
  2. An ample toolbox. This contains tools which allow everyone in the organization to understand operations, communicate, problem solve and work as a team to ensure consistent, reliable and safe care.
  3. An excellent general foreman. This would be defined by the governing body, CEO and/or senior leadership that is engaged and supportive in meeting standards and finding solutions to problems each and every day

As we celebrate Patient Safety Awareness Week, we are called to remember that “every day is patient safety day.” Building a strong foundation by ensuring the basic standards are met sets the stage for safe care for every patient, every time and will help organizations continue moving forward in their patient safety journey.

About the author. In her role as senior director of accreditation education programs, Jodi Eisenberg leads efforts to help member hospitals develop their continuous patient readiness process, improve their accreditation knowledge, solutions and strategies; and ultimately ensure a focus on quality and patient safety. She has served as faculty for a variety of educational programs and has authored several articles and books related to accreditation and continuous readiness.

Published: March 14, 2017