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Q&A with The Joint Commission's Mark Pelletier

Connecting Patient Experience to Clinical Quality

Q: Can you share a bit about how The Joint Commission standards support patient experience in your view?

MP: It's important to know that The Joint Commission is undergoing a major transformation itself...from an accreditation organization to a performance improvement organization. Joint Commission standards provide a framework for meeting and exceeding the Centers for Medicare & Medicaid Services (CMS) conditions of participation.

They also ensure the environment is safe for patients and that they receive quality care. The standards are rigorous and purposefully so. You would not want an accrediting body just coming in and checking off items on a list.

Quality is the cornerstone of the patient experience, just as it is for The Joint Commission's standards and survey process. That's what we evaluate in our surveys across the care continuum. We also assess the safety culture in organizations. We want to know if individuals in the operating room feel safe speaking up.

If a scrub tech in the operating room sees a breech in sterile practice, will he or she stop the procedure? We interview staff to find out. In addition, we're also focused on increasing compliance with hand hygiene because hospitalacquired conditions cost so many lives.

Q: Does regulatory compliance improve performance in patient experience?

MP: Yes, particularly if accredited organizations take advantage of free best practice resources available to them. Our surveyors have a vast knowledge base and large number of best practices because they evaluate organizations across the country. The Joint Commission Center for Transforming Healthcare is designed to collect and disseminate those best practices through specific tools.

When it comes to hand washing for example, an ambulatory clinic may have different challenges than a med-surg unit. The Targeted Solution Tool® (TST) we offer for hand hygiene looks at what's going on specifically in your organization and proposes a customized solution with a successful track record of closing the compliance gap. We also offer a TST for transitions of care.

Another major focus for us is helping organizations get to zero harm, which should be a goal for all of us. We offer a free high reliability assessment called Oro 2.0 for leaders designed to help them self-identify where they are in that journey.

Q: Studer Group is also coaching The Joint Commission right now. Can you tell us how your work with Studer Group will ultimately impact healthcare organizations you accredit?

MP: It all comes down to engagement. Just as engagement flows from leaders to clinicians and employees for patient engagement, we're focused on increasing the engagement of our 600 plus surveyors so they can better engage with our customers. Our goal is for them to inspire the organizations they work with when they find problems so that an organization who was just surveyed will want to say, "Thank you. We're glad you were here."

Q: Any last thoughts on best practices to improve patient experience?

MP: I'd urge everyone to think about the continuum of care and how to reduce the challenges that result from hand-offs. Many poor patient experiences and medical errors result from lack of communication between providers.

We now offer Integrated Care Certification for organizations that are providing clinically integrated care across the continuum. The goal is to provide the framework for organizations to assure that they deliver patient-centered care that circles all the way back to the patient and family as the patient moves from acute to outpatient to self-care and back to good health.

Mark Pelletier, RNMark Pelletier, RN is chief operating officer, accreditation and certification operations at The Joint Commission

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