Big changes ahead in JCAHO’s survey process, so start working now
Shared Visions — New Pathways’: Better quality but lower scores?
The Joint Commission’s new approach to surveys promises benefits and improvements over the traditional methods, but don’t let your guard down just yet. Those who have tried out the new process caution that you could see worse scores under the new system, and you need to start working right now to get ready for the change in 2004.
The Joint Commission on Accreditation of Healthcare Organizations recently announced a major overhaul of the survey process, one that it promises will make accreditation more relevant to actual patient care and eliminate some of the most troublesome parts of the current survey process. Called "Shared Visions — New Pathways," the new process will require hospitals and other providers to conduct their own self-assessments before surveyors show up, and then surveyors will focus on real patients instead of theoretical compliance with standards. The new plan will go into effect January 2004 for all Joint Commission-accredited organizations.
But don’t wait until then to get ready for the new system. Angie King, BSN, CPHQ, is quality management director at Tift Regional Medical Center in Tifton, GA, one of two hospitals that conducted pilot tests of the new accreditation process, and she says you’ll have plenty to do before 2004. King is wholeheartedly in favor of the new survey process and says it will be a more effective way of measuring compliance with Joint Commission standards, but her experience with testing the new process showed her how much work will be needed.
"I believe initially more work will be necessary by everyone," she says. "Not only is the survey process different, but they’re reformatting the standards. In that reformatting, it’s going to force the person responsible for the Joint Commission compliance to view things along a continuum, which takes more work than what you might be used to. You can’t just go to a department and ask all those standard questions they’ve written books about, because now it’s about a patient going through many departments and whether each one of them did things right."
The new system includes streamlined standards and a reduced documentation burden, with more focus on critical patient care issues; a self-assessment process intended to support an organization’s continuous standards compliance while freeing up survey time to focus on the most critical patient care issues; and a system for focusing surveyors on specific areas that need attention during their visit. A new survey system with six basic components will replace the standard triennial survey format. Physicians also will be more involved in the new accreditation process.
A task force is continuing its efforts to review all Joint Commission standards and eliminate those that are redundant or unnecessary, says Dennis O’Leary, MD, president of the Joint Commission. O’Leary promises that the new survey process will eliminate much of the feverish preparation that comes before every Joint Com-mission survey under the current method and that the new process will relate much more closely to patient care.
King says the revisions will result in "a whole new language, and we have to teach everyone that new language."
The self-assessment will be the biggest change from the current survey method, says John Noble, MD, chairman of the Joint Commission’s Board of Commissioners. Instead of surveyors coming to a facility once every three years to look it over closely, an accredited organization will complete the self-assessment at the 18-month point in its three-year accreditation cycle. Then that facility will submit its own self-assessment ratings by a secure Internet site.
For any areas in which the organization is not compliant, it must detail the corrective actions that it has taken or will take to comply. Then a Joint Commission representative will review the report, approve it or make further recommendations, and possibly provide advice on how to correct the deficiencies that were found. At the 36-month point, the time for the triennial survey, surveyors will visit the site to verify that the corrective actions have been taken.
Providers that are at the midpoint of their accreditation cycles or beyond as of January 2004 (meaning they are due for a survey in July 2005 or after) will receive the self-assessment tool in July 2003 or thereafter. Once facilities receive the self-assessment tool, they will have three to six months to complete it and plan any corrective actions.
Change will take a lot of hard work
When the Joint Commission surveyors show up, the visit should be quite different from anything you’ve been through before. Instead of focusing on documentation and other administrative proof that you’re complying with standards, the surveyors will use "tracer methodology."
Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission, explains that this approach will have surveyors following the experience of actual patients, using their real experiences to investigate how your organization complied with appropriate standards.
"You’re going to find that it focuses more on actual delivery of health care, and the Joint Com-mission is going to provide more of a continuing evaluation of health care quality, particularly with the evaluation of ORYX data," Massaro says.
From King’s experience in the "Shared Visions — New Pathways" trial, she says the survey process will encourage providers to focus more on the big picture and the spirit of Joint Commission standards rather than just proving technical compliance. Organizations will have to scrap the whole idea of "departmentalization" of Joint Commission compliance, in which departments work separately to comply and document compliance, King says. Compliance will be measured more broadly, she says, and that takes away some of the crutches quality managers have used in the past.
"Now they submit a schedule for going from one department to another at a certain time. You can expect them in obstetrics at 10:15 a.m. on Tuesday, so you make sure that obstetrics is looking sharp and has everything in order at 10:15 on Tuesday," she says. "But under the new system, you don’t know when they’ll show up or if they’ll show up. That means you have to make sure everything is ready all the time, which is the whole goal."
King says she is optimistic the system will improve patient care and get more staff involved in compliance, but says quality professionals like herself will be busy, at least in the transition to the new system.
"I have to be more organized, more prioritized, and a better teacher in teaching the continuum, all the parties involved in caring for a patient," she says. "The quality management coordinator has been too compartmentalized. It’s going to be painful to make this transition if you have a hard time with change. If you can embrace change and see the value in the new system, you can enjoy it, but I do think it’s going to be more work."
Elements may show up sooner than expected
King has another reason to spur quality managers on to the new system: She says you might see parts of the new "Shared Visions — New Pathways" system cropping up in your survey experiences before 2004.
The tracer methodology, for instance, has received enough publicity that she expects the Joint Commission to start using it right away in random, unannounced surveys. The methodology is so effective in showing whether standards are truly met throughout the hospital, rather than just in particular departments, that the Joint Commission would be foolish to avoid using it until 2004, she says.
Her hospital is adopting the tracer methodology immediately, partly in anticipation of the Joint Commission using it soon and partly because it helps King break through some departmental barriers, she explains.
"I think doing the tracer system will help the quality management person tear down the silos that develop in a hospital," King says. "Even if you only use the tracer system in a mock survey, it will help staff understand that silos are not going to help us."
For instance, King says she would use tracer methodology during a mock survey to trace a particular patient through the emergency department (ED) to a floor unit. Or perhaps, she would track a patient from ambulatory surgery, through surgery, and then admission.
"I’d go to that patient’s current position, talk to the patient, then start an open record review and back your way out," she says. "You do the survey components in each one, all the way back to the [ED] where they came in. You can see the different routes that patients take, whereas current surveys could just look at a couple of areas and never see most of the areas a patient goes through."
The tracer methodology has a real impact on clinical staff, King says. A patient’s chart or other care notes start to have more meaning when the hospital emphasizes continuum of care and the tracer methodology, she says.
Overall, the clinical staff start to see that Joint Commission standards are more than just academic exercises. "This methodology forces the ICU [intensive care unit] nurse to really look at what the [ED] nurse is sending up with the patient," she says. "It’s not just a verbal report coming up that you can forget once the patient is in your unit. And likewise, the ED nurse has to think this isn’t a patient that I’m done with because he’s gone to the ICU. The continuum of care is everything."
More consistent surveyors and lower scores?
Massaro says the new system includes more stringent requirements for certifying Joint Com-mission surveyors. Surveyors who fail the certification exam must undergo remedial studies before they are allowed to be the surveyor of record, and they only get three tries at passing the certification exam. All surveyors must be recertified every five years.
King suspects that the new training promised for surveyors under the "Shared Visions — New Pathways" program will reduce surveyor variability, a frequent complaint from accredited organizations. But she also thinks the new system could be tougher and result in lower survey scores. Lower scores could result in part from the way the new system will rely on a review of fewer medical records than the current system.
Instead of surveyors sampling a number of records to look for specific points of compliance, the tracer methodology will have the surveyors looking at numerically fewer records as they follow actual patients through the system.
"The impact on records reviews will mean a smaller denominator, which makes keeping records correct even more important," she says. "You’re not going to have a large number of records reviewed, so if you have a problem with a few, you can’t say they’re just a small percentage. The smaller size record review means there’s a good chance for a lower score."
King says quality managers should get to work right away in preparing for the new survey system, first by keeping close track of the information released by the Joint Commission. New details will be released in the coming months about how to do the self-assessment and what standards are being changed.
She also says every hospital or health care organization should make sure that someone "knows the format and standards better than the surveyors when they come rolling in. Know it inside and out."
Though the hospital’s experience with "Shared Visions — New Pathways" was only a test run, King says Tift Regional Medical Center has improved as a result. The hospital tested the new system in June, with Joint Commission surveyors using tracer methodology to check compliance, and then the hospital’s real triennial survey came two months later.
The real survey was conducted under the current, traditional method, but King says the pilot project had lasting benefits. Tift Regional scored 97 on its triennial survey, and the hospice scored a perfect 100. King attributes part of that success to the staff’s trial experience with the upcoming survey process.
"The pilot project helped the staff become comfortable," she says. "Their ease in conversation in August was so much better because they understood it more. They saw how the standards really applied to patient care, that it was more than just whether the record shows a notation for a nutritional consult."
[For more information, contact:
- Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Web: www.jcaho.org.
- Angie King, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Telephone: (800) 648-1935.]
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