The Joint Commission has established a robust disease-specific certification program, in addition to the accreditation programs that we have all participated in for many years. Of particular interest to the respiratory care community is the certification in management of chronic obstructive pulmonary disease (COPD) The preliminary requirements for this certification were released for public comment in April 2007, and the program was officially announced by The Joint Commission in November 2007. The Joint Commission planned the initial announcement to coincide with COPD Awareness Month, which is held in November of each year. Chronic obstructive pulmonary disease is the fourth leading cause of death in the United States, and more than 120,000 deaths are attributed to the disease annually. Among the country’s leading causes of death, COPD is the only one in which the death rate is increasing. Chronic obstructive pulmonary disease has been diagnosed in 16 million Americans, and an estimated 24 million have COPD—one-third are undiagnosed.1
The Joint Commission accreditation programs, such as hospital, home care, or ambulatory care, are an organization-wide evaluation of care, processes, and functions. The certification programs are an evaluation of care and outcomes of a specific product or service. The Joint Commission has established disease-specific management certification programs for numerous diseases, including chronic kidney disease, primary stroke, heart failure, and bariatric surgery. The disease-specific certification programs are a voluntary review of a clinical program and are not associated with the organization’s accreditation status. Certification is a method to demonstrate commitment to excellence in a particular clinical area.
The Joint Commission developed the certification program for management of COPD in collaboration with the American Lung Association. They utilized the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2006) and the American Thoracic Society (ATS)/European Respiratory Society (ERS) standards for the diagnosis and management of patients with COPD, which were updated in 2005.
When the program was announced, Jean Range, MS, RN, CPHQ, executive director of disease-specific care certification at The Joint Commission, stated, “The Joint Commission’s Certificate of Distinction for Chronic Obstructive Pulmonary Disease recognizes organizations that make exceptional efforts to foster better outcomes for COPD patients. Achievement of certification signifies that the services at these organizations have the critical elements to achieve long-term success in improving outcomes. It is the best signal to the community that the quality of care provided is effectively managed to meet the unique and specialized needs of COPD patients.”2
The president and chief executive officer of the American Lung Association, Bernadette Toomey, stated, “In just over 40 years, key medical and scientific discoveries have deepened our knowledge of chronic bronchitis and emphysema to the point where we can effectively treat COPD. Evidence shows that when health care professionals focus on the whole patient and apply best practice, patients do have the best outcomes. The Certificate of Distinction for Chronic Obstructive Pulmonary Disease recognizes those programs that foster the best patient outcomes and moves us toward the goal of patients having access to this state-of-the art approach. The American Lung Association salutes The Joint Commission and is pleased to be a partner in this program that will decrease the burden of COPD and improve the quality of life for patients and their families.”3
To be eligible for certification in the management of COPD, organizations must be providing care and services to patients diagnosed with COPD in the outpatient, ambulatory care, or hospital setting. There must be a minimum of 30 patients in the program in order to achieve certification. The organization must have a formalized program and a standardized approach to the delivery of clinical care, which must be based on clinical practice guidelines and evidence-based practice.
The certification requirements include specific expectations in the structure, process, and outcome categories. The structure requirements include program and clinical information management, delivering or facilitating clinical care, supporting self-management, and measuring and improving performance. Program management relates to the design and implementation of the program, evaluation of the program, providing access to care, ethical conduct, and resources available to practitioners. Clinical information management is the gathering and sharing of information to coordinate care across care settings, easy access to patient information for practitioners, preserving confidentiality, maintaining data quality and integrity, and integrating data from various sources.
Who Are The Players?
Delivering or facilitating clinical care includes the use of qualified and competent practitioners, delivering or facilitating care using evidence-based clinical practice guidelines, individualized care based on patient need, and improving practice. The following is a list of qualified practitioners who could logically be included in the COPD program. Not all of these practitioners are required for certification, and the list certainly could include other practitioners who provide services to the COPD patient population:
- exercise physiologist
- home care staff
- hospice/palliative care
- medical staff
- nursing staff
- pastoral/spiritual care
- physical therapists
- physician’s assistant
- PFT technicians
- pulmonary rehabilitation staff
- respiratory therapists
- sleep laboratory technicians
- social services
Delivering or facilitating care also includes patient counseling. Counseling should encompass reduction of risk factors, disease prevention, potential treatment options, identification of symptoms, and follow-up care.
Patient assessment is another expectation of delivering or facilitating care. When developing the patient assessment process, the following elements should be considered:
- family medical history
- history of activity limitation
- history of chronic cough
- history of dyspnea
- history of occupational/environmental exposure
- history of smoking/ tobacco use
- nutritional status
- personal medical history
- sputum production/characteristics
- alpha1-antitrypsin deficiency
Supporting self-management relates to collaborative decision making between the patients and members of the care team. The program participants should be actively involved in making decisions about managing their disease. Supporting self-management also includes addressing lifestyle and behavioral changes and educating participants so they can achieve their goals.
Measuring and improving performance in the COPD program requires an organized, comprehensive approach to performance improvement. A formalized methodology, such as a plan-do-study-act (PDSA) approach, should be implemented. As with all performance improvement programs, data collected to evaluate processes and outcomes needs to be trended and compared over time. This information should be used to improve clinical practice. In addition, data quality and integrity must be evaluated and assured, and information on patient perception of care—or patient satisfaction—is required for the disease-specific population and program.
Performance measurement includes two stages of measurement identification and data collection. In stage 1, the organization selects four measures.4 These measures are chosen from the universe of measures available to the organization. Two of the measures must be clinical measures. The remaining two measures can be clinical, functional outcome, financial/utilization, or patient satisfaction. Stage 2 is a standardized measure set defined by The Joint Commission. Monthly data points must be collected and submitted to The Joint Commission after the organization has completed its initial on-site certification survey.
Organizations considering disease-specific certification are usually concerned with the time frame for the application process and preparing for the initial certification survey. The initial on-site visit is announced—unlike the current unannounced survey process for hospital and home care accreditation surveys. Tracer methodology is used during the survey and there is integration of the National Patient Safety Goals. The survey engages practitioners and patients and is meant to be educative and consultative. A 4-month track record is needed for most items. This means if a program is being surveyed on September 1, all certification issues should have been in place since May 1. Certification is received after any recommendations for improvement (RFIs) have been corrected. The survey cycle is 2 years for certification, and the organization is notified approximately 1 week ahead of the on-site recertification visit. One year after the on-site visit, The Joint Commission conducts an intracycle review, which includes evaluation of data submitted to The Joint Commission and an interactive telephone conference with a surveyor from the disease-specific program. This intracycle review is helpful in keeping organizations focused on the ongoing certification requirements.
Similar to The Joint Commission accreditation programs, some standards are more challenging for compliance by organizations than others. In the disease-specific programs, the following five standards have been shown to be problematic. The number after the standard description, in parentheses, is the percentage of organizations receiving an RFI in that particular standard.4
- PM 6 The program evaluates participant perception of the quality of care (15%)
- DF 1 Practitioners are qualified and competent (10%)
- NPSG 10B Develop and implement a protocol for administration and documentation of pneumococcus vaccine (9%)
- NPSG 10A Develop and implement a protocol for administration and documentation of the flu vaccine (6%)
- SE 3 The program addresses participants’ education needs (5%)
Successful COPD programs have included the following elements: staff education requirements, use of spirometry, smoking cessation, risk factor reduction, patient education on self-management, and coordination of care.
Currently, eight organizations nationwide have received the certification in COPD by The Joint Commission.5 Keeping in mind the increase in patients suffering from COPD and the mortality rate for COPD, certification in the management of the COPD patient appears to have great merit. Achieving this recognition from The Joint Commission demonstrates a health care organization’s commitment to excellence in care and service and improving outcomes. This is a great way to demonstrate your ongoing dedication to meeting the unique needs of the COPD patient population.
David Gourley, MHA, RRT, FAARC, is the executive director of regulatory affairs at Chilton Memorial Hospital in Pompton Plains, NJ. He is a former director of cardiopulmonary services at Chilton and former Joint Commission home care surveyor. For further information, contact [email protected]
- Who Gets COPD? National Lung Health Education Program. Available at: [removed]www.nlhep.org/faqs.html[/removed]. Accessed April 12, 2010.
- The Joint Commission Certification Program. Available at: www.jointcommission.org/certificationprogram/copd. Accessed April 15, 2010.
- Joint Commission Launches New COPD Certification Program. Available at: www.aarc.org/headlines/07/10/copd. Accessed May 26, 2010.
- Performance measurement. Available at: www.jointcommission.org/certificationprograms/disease-specificcare/dcspm/. Accessed May 26, 2010.
- Certified Organizations. Available at: [removed]www.jointcommission.org/NR/rdonlyres/27BF1726-F9BE-4ED8-A9AA-15C13ED77E27/0/CertificationMasterList.pdf[/removed]. Accessed June 14, 2010.