Wow, the Joint Commission Moves Slowly


Heparin errors and patient harm have been in the news quite a bit the last few years. So what are hospital regulators doing about it?

Let's look at the time line here:

2006: Heparin error kills 3 babies in Indianapolis

2007: Heparin error harms twins in L.A. (Dennis Quaid's kids)

2008: Regulator says hospitals need strict heparin rules

Really? It took until NOW to get some guidelines and recommendations out to hospitals?

“The Joint Commission issued a safety alert saying hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children's units.

The alert said 28 deaths are among 32 reports of drug errors involving blood thinners that it received between 1997 and last year.

“We know that there are many more (deaths) and … that's the reason for issuing this alert,” said Dr. Mark Chassin, president of the Oakbrook Terrace, Ill.-based commission.”

Here's more on the guidelines from the official Joint Commission site.

If an alert like this really makes such a difference, how many people were harmed in the 10 months since the well-known Quaid case? So either this was a really slow response, or the Joint Commission and it's pronouncements just don't matter too much. My local paper posed questions about the value of accreditation, considering that many hospitals with horrible patient conditions (the now-closed King/Drew Medical Center and JPS Hospital) were all accredited.

Christine Cahill, a government inspector, walked in to the operating room of a Los Angeles county hospital and found a technician cleaning a surgical instrument. He told her that he had just washed it, but she noticed no water in the sink, so she questioned how he had cleaned it, and he said he had used a cleaner that was in a bottle on the shelf.

“Give me a Q-Tip,” she said. She shoved it into the hollow bore of the instrument.

“Out came this crud,” she recalled. It was dried-up fragments of bone and blood.

At one out of every three hospitals Cahill surveyed for the federal government in California from 2004-06, she said she found egregious deficiencies that put patients' lives at risk. Yet these same hospitals, within a year before her review, had received passing grades from the Joint Commission, America's top healthcare evaluator.

It gave its most prestigious honor – its trademark Gold Seal of Approval – to Martin Luther King Jr./Drew Medical Center, where Cahill found the filthy surgical instrument.

And the commission also awarded that top honor, symbolizing that a hospital has met the most rigorous standards for patient care and safety, to John Peter Smith Hospital in Fort Worth in spring 2006 – the year before an independent consultant documented pervasive problems that put patients at risk.

The Joint Commission says they are using Lean…. let's hope they can reduce the cycle time for getting “alerts” and new recommendations out into the hospital world. It seems like they also need to take a step back and think about the “value” they are providing for hospitals or patients.

Coming over from the manufacturing world, this all reminds me of the “ISO-9000” industry that has built up over the past few decades. Having ISO-9000 certification is often a “check the box” activity where the piece of paper on the wall (or the flag flying in front of the factory) means NOTHING about the quality of product that's being shipped.

What do you think? Am I (and others) being too harsh on the Joint Commission?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Most of the Joint Commission guidelines lay out a process better than what is really happening at the hospital. They can be a little out dated, a little too prescriptive and even turn people off from looking for a better process, but operating at their standards would raise the quality of care in this country.

    My hospital just went through a Joint Commission survey. It was interesting to watch managers and leadership try to achieve compliance in much the same way I used to cram for a test in college; with more information that can be handled, no focus on the real details, no thought for lasting results, and juiced up on an overdose of caffeine.

    Both Joint Commission and hospitals have room for improvement by adjusting our approach.

  2. What good are these JaCo recommendations and requirements if they aren’t “what’s really happening?”

    My hospital, too, has reminders on all of the PC screens… the focus is on passing the test. Why aren’t these visits unannounced, I wonder? We should be ready for a visit ANY day if we’re doing things right.

    We’re reminded to know where the exits and fire extinguishers are… this is smart and required EVERY day, not just for the surveyors. They’re reminding us to keep dirty and clean lines separate. This shouldn’t JUST be for the inspection. Where are the reminders the rest of the time? If we’re not normally doing these things right, are we suddenly going to get it right for the inspection??

  3. Here's a clinical comparison — providers handle emergency better after taking an ACLS course (advanced cardiac life support course). Real emergencies almost never follow the algorhytms but who cares. It gets you thinking about the process.

    Rather than focusing on passing the test I think JaCo needs to set standards for process and review them regularly. Preferribly lean & six sigma. Where both quality and process are tantamount. Getting people to focus on process rather than results is the better way.

  4. What about the JCo bullshit where the hospital pays their consulting arm to come in just before the real survey to tell you what to fix?

    Is the point to be good for our patients or to pass the dang survey?

    What a racket.


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