Help is on the way for JCAHO accreditation
May 1, 2002 4 minutes read
Help is on the way for JCAHO accreditation
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in Oak-brook Terrace, IL, will produce a new accreditation manual for 2003 with the manual available for review in fall 2002, says Diane H. Flynn, BSN, MBA, a St. Louis-based consultant with Joint Commission Resources. There won’t be any significant changes, but requirements for meeting standards will remain high, she says.
This means that there are some standards that make it easy to receive a Type 1 recommendation that requires a follow-up focused survey. "For example, Standard TX.2 addresses having and following physician orders 100% of the time," Flynn explains. If a clinician uses a different dressing than specified on an order, or flushes an IV with 5 cc of saline rather than 3 cc of saline as specified on the order, he or she has not met the standard, she says. If an agency is compliant only 95% to 99% of the time, it will result in a Type 1 recommendation.
Other standards agencies need to focus upon to avoid Type 1 recommendations include:
• Competency assessment (HR.4 and HR4.1)
Because not all home-care employees must have competency assessments, sometimes an agency forgets to assess the competency of those who require them, Flynn says. "Most often an agency forgets to document competency assessment for a supervisor who usually doesn’t make home visits but might occasionally fill in for someone on vacation," she points out. Remember, if the staff member ever makes a home visit, document the competency.
Also, don’t confuse competency assessment with performance evaluation, Flynn says. A competency assessment is documentation that through a written or verbal test, or observation by a competent individual such as a supervisor or a peer, the person has the capacity to do the right thing, she explains. A performance evaluation (HR.7) is documentation that the person did the right thing over a period of time, she adds.
• Performance improvement
"Don’t produce slides, storyboards, or elaborate presentations to demonstrate your performance improvement project," says Flynn. "Limit the presentation to 10 minutes, and keep it clear and concise," she says.
The points to highlight include involvement of staff members closest to the problem that is addressed and data that show an improvement, she suggests.
"I always recommend that an organization work on two or three projects even though it only has to present one," Flynn says. This ensures that at least one will show results that meet the standard, she adds.
Also, be aware that the benchmarking standard (PI.4.2) doesn’t require that an organization benchmark against an outside organization, just that it occurs if it is feasible, Flynn says. This means that you can benchmark against yourself in a specific area by showing statistics over a period of time, which indicate performance improvement.
• Employee orientation
The human resource standard that addresses orientation (HR.5) includes a list of topics that must be covered with new employees, Flynn says. The best way to meet this standard is to use the list as a guide to develop or evaluate your orientation program, she suggests. Also, be sure your orientation session is interactive and gives employees a chance to ask questions. "It is not enough to hand an employee a manual," she says.
• Licenses
"If you do nothing else to prepare for JCAHO, be sure to have current validation of licenses for all of your clinicians (HR.3.1)," Flynn says. "The absence of a valid license is an automatic Type 1 recommendation." This also applies to verification of physician licenses (TX.2.1), which must occur before care is rendered, she explains.
• Contracts
The best way to make sure you meet Standard LD.1.1, which applies to contracts with other organizations or suppliers, is to have someone who doesn’t work with contracts on a regular basis review them, suggests Flynn. "There is a laundry list of items that must be addressed in each contract that should be compared to each of your contracts." Someone with a fresh pair of eyes is more likely to spot items that are not included, she adds.
• Documents notebook
Appendix A of the standards manual contains a four-page list of documents that should be assembled for the survey. "The best way to prepare this notebook is to follow the list and place the documents in the same order," Flynn says.
The assembly of the manual did require a great deal of time but facilitated a smooth survey, says Greg Solecki, vice president of Henry Ford Home Health Care in Detroit. "It has also served as a useful tool for our annual program evaluation."
When you are reviewing policies for inclusion in the survey manual, be sure they reflect reality, Flynn suggests. Don’t write a policy that describes an ideal situation when you know that reality is less than ideal. "You should say what you do and do what you say," she adds.
A final reminder from Flynn, "Don’t forget to place your 30-day notice in local newspapers, offices, and notes to patients. You’ll receive your survey packet 45 days prior to your survey, so address the notification issue immediately to avoid a Type 1 recommendation."
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