Self-assessments, other alterations will change dynamics 180 degrees’
Submit your organization’s deficiencies to your accreditation organization? Excuse me? That’s exactly what the Joint Commission on Accreditation of Healthcare Organizations is expecting you to do after a self-assessment halfway through your three-year accreditation cycle. You’ll also have to submit a plan to correct the deficiencies. The good news: There’s no penalty, and even the final scores after the three-year surveys won’t be released.
In the past, the focus of Joint Commission surveys often has been on scores and surveys, and the incentive was to not share information with the Joint Commission, admits Russell Massaro, MD, FACPE, executive vice president of accreditation operations at the Joint Commission. The change will not be easy, Massaro acknowledges. "There is a history of the old mindset, which may create anxiety. It’s such a different thing: to share information with the Joint Commission," he says.
The Joint Commission’s program, titled "Shared Visions — New Pathways," is scheduled to be in place in 2004. However, organizations at the midpoint of their accreditation cycles as of January 2004 and beyond (those due for survey in or after July 2005) will receive the self-assessment tool in or after July 2003. Organizations will have three to six months to complete the assessment and to plan corrective actions for any deficiencies.
The Accreditation Association for Ambulatory Health Care in Wilmette, IL, isn’t planning any dramatic changes to its accreditation process at this time.
The dynamics of the Joint Commission’s accreditation process will change 180 degrees, Massaro says. "Normal human behavior causes people to focus intensively on getting a good score and being ready for the survey. Sometimes, unintentionally, they were using the process to continually improve," he says. "In the future, we won’t be publishing scores, and the accreditation process will be incentivized to share info with the Joint Commission and assist in developing good methodologies."
At the time of the survey, if recommendations are given, facilities have 30 days to submit a statement of correction before the final report, Massaro says. To some extent, it’s a leap of faith, he acknowledges. "But if they examine the process, and see the elements, they’ll see it’s safe to move in that direction," he says.
Accreditation costs should go down, Massaro maintains. First, the Joint Commission is planning to reduce the number of standards and the documentation requirements of those standards, he says. "Second, the new process should enable a more continuous process and convert what is a tidal wave of preparation the year before survey into constant trickle of activity to ensure you’re in compliance all the time, which should reduce ramp-up’ [just before the survey]," Massaro says.
One facility that participated in the pilot test of the new process says it absolutely makes sense. "It’s going to force surveyors to stop getting excited about the muffin they found in the freezer [for example] and focus on what is actually the process that puts patients in the system. They’ll be looking at the quality of care delivered," says Angie King, RN, CPHQ, quality management director at Tift Regional Medical Center in Tifton, GA. While it takes additional time to perform a self-assessment, it’s a critical component of continuously improving your care, King maintains. "It’s a far more educational process for the staff" than simply gearing up for a survey, she says.
The new survey also may be more time-consuming, King says. She points to a new "tracer" system whereby surveyors will pull a patient’s chart and trace the services the patient received through the system. This tracer system will include surveyor visits to the areas where the patient received services and questions to the staff.
The tracer system may help surveyors gain a greater understanding of the differences between surgery centers and hospitals, says Kathy Bryant, executive director of the Federated Ambulatory Surgery Association (FASA) in Alexandria, VA. For example, because of hospitals’ size, variety of cases, and staffing, their policies and procedures often need to be much more in-depth than the ones of surgery centers, Bryant says. "Hopefully, this will be another opportunity to work in tandem with the Joint Commission to educate surveyors," she says.
Overall, she is withholding her endorsement of the new process. "The devil is in the details, which in this case, is implementation," she says. "Clearly, the idea to be focused more on how care is developed rather than a bureaucratic review of policies and procedures is more realistic, but until we see how it’s actually working in the process, it’s difficult to say it’s an improvement."
Here are suggestions on how to prepare for the new accreditation process:
• Be more aware of the continuum of care. The new process of "tracing" patients at the survey is likely to involve ambulatory surgery, Massaro and King say. For example, a surveyor is likely to pick up an ambulatory surgery record and use that record to trace the patient through admission, presurgical screening and evaluation, pre-op tests, operative, recovery, and discharge, Massaro says. During these processes, the patient experiences informed consent, patient rights to test results, infection control, and pain management.
"The key here, instead of sitting with groups of staff and talking about how they do those things in general and spot checking records to validate, the new process will take a large number of records and review what actually happened to patients, and interpret that in terms of standards," Massaro says.
At Tift Regional, the surveyor traced an ED pediatric patient who was admitted for outpatient surgery, King says. In the outpatient surgery area, the surveyors looked at processes, she says. "A lot of questions revolved around areas such as consent," King says. Also, the staff were questioned about the anesthesia interview sheet, she says.
This is a dramatic change from past surveys, where surveyors typically focused on inpatients, King warns. The new focus will be on the continuum of care, she says. "When they leave that department, it’s not like the job is over," King says, and she points to the fact that some outpatient surgery patients end up being admitted. Also, same-day surgery departments will be forced to look as the patient as more than a procedure, she says. For example, a basic screen of a morbidly obese patient or a nursing mother may indicate the need for nutritional support, King says. Patients who have no one to care for them at home may need the intervention of social services, she says.
• Continually prepare for the survey. At Tift Regional, a Continuous Survey Readiness program involves monthly "ambassador rounds" throughout the facility, including outpatient surgery. Infection control, quality, plant engineering, biomed, and patient care staff make the rounds. Safety areas, such as the oxygen shut-off valves, are checked, and staff are questioned about items such as what to do during a fire drill. "It lets the staff be comfortable asking questions," King says.
In addition, new employees are given a handbook that is divided into the same sections as the Joint Commission standards. "It’s like the manual but greatly simplified, in that it explains: This is what [the standards] mean to you,’" King says. For example, in the Performance Improvement chapter, the department explains its methodology and how it works at the hospital. Further, Tift Regional works with the Marietta-based Georgia Hospital Association to have a surveyor consultant come in for several visits and provide ongoing advice.
• Expect physicians to be more involved in the process. The Joint Commission aims to have physicians more involved in the new survey process. For example, physicians will be more involved with plans for correction after the self-assessment or on-site surveys, Massaro says. "The designs of systems, improvement models, or new system of care in response to deficiencies found — the design of those models and improvements need strong physician input from the get-go," he says. Also, the Joint Commission says physicians are likely to be involved in the tracer process, when the tracing involves their patients. "We’re not peer reviewing the care received by that patient," Massaro says. "We’ve never done that."
• Surgery centers that are surveyed under the ambulatory and hospital manual will see an elimination of the redundancy. For hospital-owned surgery centers that have found themselves accredited under the ambulatory manual as well as the hospital one, they now will be considered part of the hospital organization, Massaro says. "In the future, at the leadership conference that will occur, we’ll address common standards that apply to different components of the organization and survey them once," he says. After that conference, specialist surveyors can focus on specific units, such as the ambulatory surgery center, and the standards that apply to that center.
To be prepared for these changes, know the standards and know how they’re surveyed, King advises. "Be comfortable with your own processes," she says. "Within your own department, practice talking about how patients move through here, so they understand it’s not just a lap chole coming through the system."
Massaro agrees that the focus should be on patient care processes. "Worry less about the survey, more about operations, and you’ll do well with accreditation," he advises.
[Editor’s note: In future issues, Same-Day Surgery will address your most pressing concerns and questions regarding accreditation by the Joint Commission or Accreditation Association for Ambulatory Health Care. If you have questions, please send them to Sheryl Jackson, Same-Day Surgery, American Health Consultants, P.O. Box 740056, Atlanta, GA 30374. Fax: (404) 262-5447. E-mail: [email protected].]
Sources
For more information on the Shared Visions — New Pathways program, contact: Angie King, RN, CPHQ, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Telephone: (229) 386-6119. Fax: (229) 386-6228. E-mail: [email protected].
The October 2002 issue of the Joint Commission publication Perspectives includes an in-depth look at the new accreditation process for 2004. The special issue is available free at Joint Commission Resources’ web site: www.jcrinc.com/perspectives. Click on "Past Issues," "2002 Archive," "October 2002, Vol. 22, No. 10 — Free Special Issue on Shared Vision — New Pathways." Printed copies are available for $25 including shipping. To order a paper copy, contact: Joint Commission on Accreditation of Healthcare Organizations, 75 Remittance Drive, Suite 1057, Chicago, IL 60675-1057. Telephone: (800) 346-0085, ext. 558. Fax: (218) 723-9437.E-mail: [email protected]. Questions about the new survey process can be e-mailed to [email protected].
Submit your organizations deficiencies to your accreditation organization? Thats exactly what the Joint Commission on Accreditation of Healthcare Organizations is expecting you to do after a self-assessment halfway through your three-year accreditation cycle. Youll also have to submit a plan to correct the deficiencies.
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