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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has released its 2004 standards for hospitals []. The complexity of modern information management points to the increased importance of the medical library and the need for leadership by the medical librarian. Recent trends in information sciences and the demand for current, authoritative information throughout the hospital necessitates a new appreciation of the medical library. “The increasing use of the Internet and new information technologies by medical, nursing, and allied health staffs; patients; and the community require new strategies, strategic planning, allocation of adequate resources, and selection and evaluation of appropriate information resources and technologies. To assess the quality of a hospital the library should be evaluated for resources and technologies” []. With the future promising even more aspects of virtual libraries, the librarian remains the gatekeeper to cataloging vast amounts of raw information into the knowledge-based products needed by patrons. The librarian's role may change to accommodate future trends, but the need for quality information management remains strong.

The Joint Commission. Standard NPSG.03.06.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII) 21. Centers for Medicare and Medicaid Services and The Joint Commission.

In recent years, JCAHO has made patient safety a major issue in its assessment of hospitals. It has been looking at sentinel events that it describes as occurring when “The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition” [3]. One such sentinel event took place in June 2001 at Johns Hopkins University. Ellen Roche, a healthy twenty-four-year-old patient, was participating in a clinical study on asthma. She was given a drug, hexamethonium, which caused irreversible lung damage, and she died. When medical librarians looked at this case, it became apparent that this drug had a history of causing lung damage: “medical librarians around the country immediately searched various sources and by using just online resources discovered disturbing information on problems associated with this drug” [4]. If a librarian had done a comprehensive search on hexamethonium, articles published in the 1950s would have warned about possible lung damage. Even if a librarian had done a quick current PubMed search of the literature, reports pointing to the older articles would have been found. The conclusion seems obvious: “This kind of tragedy offers a terrible lesson in the importance of using professional searchers and medical librarians in critical searching situations” [5]. Other factors may have contributed to this tragedy, but clearly in this case, the lack of a librarian's search was an essential factor.

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Medical librarians provide the knowledge-based information resources to patrons in the hospital library. Knowledge-based information is “a new term for an old concept: information provided from in-house collections combined with that from external databases in order to enable evidence-based medicine” []. Hospital libraries house the resources that librarians use to ensure that the information is up to date and readily available. Although managing information is librarians' main job, they are often involved in other duties in the hospital. With hospital budgets being cut, librarians take on other duties, as needed. Some librarians run the audiovisual department, some are in charge of continuing education departments, and some provide resources for patient education. Librarians attend department head meetings and often get involved in many other committees in the hospital. They are also involved in professional organizations outside the hospital. For patient care, librarians provide most of the background information that enables health care workers to make wise decisions based on evidence found in the literature. It is not a highly visible function, but it is essential to quality of care.

Most hospitals strive to meet the standards set forth by JCAHO, and library services are covered in the Management of Information (IM) section in the Comprehensive Accreditation Manual for Hospitals. The standards were updated in 1994 to “shift the emphases away from standards for individual departments to standards for hospital-wide functions” []. The latest standards make no provision that the hospital should have a library or a librarian. Instead, they focus on the functions the library provides to the hospital. In section IM 4.10, we find “The information management system provides information for use in decision making” [] and, in IM 5.10, “Knowledge-based information resources are readily available, current, and authoritative” []. The only mention of libraries is found in “Elements of Performance for IM 5.10. Library services are provided by cooperative or contractual arrangement with other institutions, if not available on site” []. This is hardly a ringing endorsement of libraries and librarians in the hospital.

Once every three years most hospitals in the United States endure a three-day long inspection by JCAHO. JCAHO is not the only accreditation agency, but it is by far the largest and most prestigious. For 2004, the inspection visit is not officially announced ahead of time, but word usually gets out. (This hospital is tentatively scheduled for a visit in March or April 2004.) Anyone who has spent any time in a hospital knows that this visit is highly anticipated and very important. “The JCAHO survey agenda includes an interview for Management of Information and suggests that at least the chief information officer, the director of the library, and the director of medical records attend that meeting” [11]. In my experience, this usually consists of several general questions being asked, with the bulk of time spent on concerns about medical records. Questions for the librarian may include: “How are library patrons needs' assessed?” “With everything on the Internet, how do you decide what to collect?” “How do you deal with pornography on the computers?” The wise librarian knows to get in as many points as possible while answering these questions. The Medical Library Association (MLA) assures us that “Librarians bring. . . skills in organizing, retrieving, analyzing and disseminating information; a focus on providing access; and a strong background in networking and resource sharing” [12]. Librarians should mention that. Sometimes there is a review of the library itself, but this seems to depend on the surveyor. I have found this meeting mostly either not scheduled or canceled due to time concerns. Other librarians have assured me that I am not alone in that observation.

Clearly, there is a danger that, if JCAHO does not specify that a hospital should have a librarian, and only mentions that library services must be at least by contractual arrangement, hospital administrators might decide that libraries and librarians are expendable. When added to the promise of the virtual library (i.e., a library wholly dependent on the resources available and accessible online), the hospital library could become a hard sell. “The system of balancing virtual services with traditional services seems destined to continue for the foreseeable future. . . . However, it is likely that the virtual library will become the gateway that integrates access to most, if not all, of the library's resources and services, both traditional and virtual” [13]. Could a computer and fax machine become the library of the future? What effect would that have on patient care?

If the effect of JCAHO regulations leads hospital administrators to go without a librarian or to close the library and rely on contracts with other libraries, then the quality of care in the hospital will suffer. This could lead to other sentinel events like the one at Johns Hopkins. JCAHO regulations are taken very seriously by hospital administrators, and JCAHO could take the lead in adding a few more regulations regarding librarians and library services. As a template for these regulations, JCAHO could consider the standards published in 2002 by the Standards Committee of the Hospital Libraries Section of MLA. “The Medical Library Association ‘Standards for Hospital Libraries 2002’ have been developed as a guide for hospital administrators, librarians, and accrediting bodies to ensure that hospitals have the resources and services to effectively meet their needs for knowledge-based information” []. This article goes on to list in great detail the standards that should be used in evaluating hospital libraries. The medical librarian is an essential part. “Knowledge-based information in the library should be directed by a qualified librarian who functions as a department head” []. The library itself is described: “The physical library will be large enough to accommodate the library staff, the in-house collection, an appropriate amount and selection of personal computers and other information technology hardware, and seating for an appropriate number of users. A separate office will be provided for at least the professional library staff” [].

Suggesting that JCAHO actually add more regulations to their already quite large manual, to protect libraries and librarians, might be seen as unnecessary. Why should library services be more defined? There is a perception that hospitals, particularly small hospitals, have been cutting costs by eliminating librarians and libraries. If hospitals are eliminating library services, the effect on patient care could jeopardize patient safety. As information sources continue to grow with no end in sight, librarians are best suited to organize, evaluate, and disseminate the information necessary to provide quality health care services. The library houses not just books and journals but a vast collection of virtual resources, all of which must be maintained, so that the information is both relevant and current. Clear library guidelines would ensure that hospitals continue to provide quality care to their patients.

References

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Gluck JC, Hassig RA, Balogh L, Bandy M, Doyle JD, Kronenfeld MR, Lindner KL, Murray K, Petersen J, and Rand DC. Standards for hospital libraries 2002. J Med Libr Assoc. 2002 90(4):465–72.Available from: <http://www.pubmedcentral.gov/articlerender.fcgi?artid=128964>. [PMC free article] [PubMed] [Google Scholar]
Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert [serial online]. 1998 May. 3.. [cited 16 Dec 2003]. <http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/print/sea_3.htm>. [+.++' target='pmc_ext' ref='reftype=other&article-id=385295&issue-id=11768&journal-id=93&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar'>Google Scholar]
Perkins E. John Hopkins' tragedy: could librarians have prevented a death? Information Today 2001 Aug 7. [cited 27 Oct 2003]. <http://www.infotoday.com/newsbreaks/nb010806–1.htm>. [+.++' target='pmc_ext' ref='reftype=other&article-id=385295&issue-id=11768&journal-id=93&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar'>Google Scholar]
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Doyle JD. Knowledge-based information management: implications for information services. Med Ref Serv Q. 1994 Summer. 13(2):85–97. [PubMed] [Google Scholar]
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Medical Library Association. Librarian's guide to a JCAHO accreditation survey. [Web document]. [cited 27 Oct 2003]. <http://www.mlanet.org/resources/jcaho.html>. [+.++' target='pmc_ext' ref='reftype=other&article-id=385295&issue-id=11768&journal-id=93&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar'>Google Scholar]
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Gluck JC, Hassig RA, Balogh L, Bandy M, Doyle JD, Kronenfeld MR, Lindner KL, Murray K, Petersen J, and Rand DC. Standards for hospital libraries 2002. J Med Libr Assoc. 2002 90(4):465–72.Available from: <http://www.pubmedcentral.gov/articlerender.fcgi?artid=128964>. [PMC free article] [PubMed] [Google Scholar]
Gluck JC, Hassig RA, Balogh L, Bandy M, Doyle JD, Kronenfeld MR, Lindner KL, Murray K, Petersen J, and Rand DC. Standards for hospital libraries 2002. J Med Libr Assoc. 2002 90(4):465–72.Available from: <http://www.pubmedcentral.gov/articlerender.fcgi?artid=128964>. [PMC free article] [PubMed] [Google Scholar]

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Accreditation Monthly, July 9, 2005

Dear Colleague,

For those hospitals keeping score, there are no fewer than 13 substantive additional requirements or edits contained in JCAHO's Comprehensive Accreditation Manual for Hospitals (CAMH) Update #2 released in May, 2005.

Recent issues of JCAHO Perspectives have included announcements of numerous substantive changes that, taken together, make it all the more challenging to achieve continuous survey readiness. Since many of the changes are effective immediately or by July 1, 2005, it has become increasingly confusing for hospitals to keep up.

I'd like to address a few of these updates:

First, in the March 2005 Perspectives JCAHO announced the addition of EP 46 and 47 to HR.1.20 for hospitals and critical access hospitals requiring primary source verification of licensure, certification or registration for all clinical licensed staff effective July 1, 2005.

Footnotes following the EPs are highly prescriptive and describe how the new requirement is applicable to CVOs and staffing agencies. Predictably these changes were included in the CAHM Update #2 released in May. However, the May issue of Perspectives announced that the implementation date for the changes is postponed to January 1, 2006. So my advice is to begin to study changes needed to comply with the EPs while awaiting further clarification in an upcoming issue of Perspectives.

Second, the June issue of Perspectives confirms that beginning with full surveys conducted July 1, 2005 organizations 'should' provide the survey team the Measure of Success (MOS) data used to measure the effectiveness of any Elements of Performance (EPs) found noncompliant in the organization's first Periodic Performance Report (PPR) completed sometime between January 1, 2004 and July 1, 2005.

This appears to be the JCAHO's expectation regardless of whether the organization completed the full PPR or one of the alternative options. Although they chose to use the helping verb 'should' in this instance, I suspect organizations should assume they intended to use the helping verb 'shall' or 'must.'

Finally, the June issue of Perspectives clarified Medication Management standard MM.4.10 (review of medication orders by pharmacy) with respect to how oral contrast media used in imaging exams is to be addressed. In April 2004 and again in the January 2005 issue of the journal 'Hospital Pharmacy' Darryl S. Rich, Pharm. D., MBA, and an employee of JCAHO wrote a column titled 'Ask the Joint Commission' in which he answers 'frequently asked questions' including one on whether, since oral contrast media is now considered a medication, will this require a pharmacist to review all orders for oral contrast media prior to it being administered.

His answers sowed some confusion in the field and now the Standards Interpretation Group at JCAHO has weighed in officially to say that the review by pharmacy is required only if pharmacy receives the order and dispenses the oral contrast media. Otherwise, a qualified health care professional (e.g., staff in imaging) operating under a medical staff approved guideline or protocol may review the contrast media for appropriateness.

So while Dr. Rich's FAQs published periodically in Hospital Pharmacy are often very helpful in providing insight into the intent of the medication management standards and offer implementation tips, his column should not be confused with the official JCAHO position on any particular issue.

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Sincerely,

John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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