Access gets little action in recent JCAHO surveys
‘Tracers' target front line, not bosses
Access directors at two facilities recently visited by surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported little or no contact with surveyors, and an overall experience that was decidedly different from previous visits.
Those accounts reflect the dramatic change in the survey process that took place in January 2004, says Joe Cappiello, BSN, MA, vice president, field operations, for the Oakbrook Terrace, IL-based organization. At that time, surveyors began doing "tracers" — picking up the trail of certain patients and following the course of their care through the facility — as opposed to setting aside blocks of time to talk mostly with hospital leadership.
The new process, he adds, eschews formal checklists and chart reviews in favor of discovering "a sense of the way [hospitals] conduct business day in and day out."
Since JCAHO surveys are a triennial event, two-thirds of all the accredited facilities had been surveyed using the new method by the end of 2005, he says, and the remaining third will experience it in 2006. The latter facilities also will be exposed to another innovation that has some hospital leaders on edge — the unannounced visit.
At Wake Forest University Baptist Hospital, the admitting department prepared extensively for the JCAHO visit, says Keith Weatherman, CAM, MHA, associate director of patient financial services, but had virtually no interaction with surveyors.
"I personally had no contact," he adds. "However, [a surveyor] did walk in to an outpatient area and talked to one of the registrars — asked what her role was and how long she had worked here."
In his past experience with JCAHO surveys, Weatherman says, he was typically called upon to set aside certain times to be available for meetings with surveyors. During this visit, he notes, there were few such formal encounters.
What Weatherman did observe about this year's visit, he notes, is that surveyors were particularly concerned with whether the necessary consents were obtained from patients.
Surveyors also wanted to know whether caregivers asked patients what their primary language was, Weatherman says, and were very interested in how advance directives were handled.
"Another thing I noticed was that they were making sure that signatures were legible," he adds. "There were a couple of charts where the bar code label with the patient's information might have covered part of the signature, and they didn't like to see that."
In anticipation of the JCAHO survey, Weatherman says, his department made sure that policies and procedures were updated, and set up displays showing departmental goals, as well as the organization's focus on the Six Sigma quality assurance methodology.
"We had ‘Joint Commission Jeopardy,' and gave prizes if, for example, employees knew who the [hospital's] safety officer is," he notes. Despite what might have seemed like preparation overkill in view of a JCAHO visit that barely touched his department, Weatherman says he hasn't changed his philosophy.
"If anybody reads this and thinks they're off the hook, I wouldn't advise that [attitude]," he adds. "If it were going to happen again, I'd still make sure we were well prepared."
One of the more humorous accounts of the Wake Forest survey visit, Weatherman recalls, came from the human resources department, where the manager had taken great care to ensure that some 6,000 employee folders were in perfect order.
"[The surveyors] only asked for one chart," he says. "We have a clinical dog for the geriatric area, and they wanted to make sure its shots were up to date."
Privacy notice highlighted
One of the "couple of phone calls" from JCAHO surveyors fielded by Holly Hiryak, RN, CHAM, director of hospital admissions, during the agency's recent site visit to the University of Arkansas for Medical Sciences (UAMS) Medical Center in Little Rock had to do with how her department handles distribution and documentation of the HIPAA privacy notice.
That process, she explained, is documented electronically in the registration system so access staff can track whether or not a given patient has received the notice. The electronic documentation has been in place since about a month before the Health Insurance Portability and Accountability Act's privacy rule became effective on April 14, 2003, Hiryak adds.
"If, for instance, a patient is seen in the outpatient clinic and it is the person's first time there, there is a required field that has to be populated," she says. "If there is nothing in that field, the frontline staff will know [the privacy notice] has never been provided."
At that point, the registrar gives the patient the privacy notice, asks the person to sign an acknowledgement form, and then puts the indicator in the field, Hiryak says. "Then we don't ever have to do it again, unless something changes with the form."
If the patient's first encounter with UAMS is a telephone interaction, the registrar triggers a "mail request," she notes. At midnight, the computer system automatically prints the notice, and then mails it out the next day, Hiryak adds.
The system, meanwhile, changes the designation in the field to "mail sent," she says. "If the patient returns the [signed notice], we scan that in and indicate that it was received."
The JCAHO surveyors also checked with Hiryak — as part of the process of doing tracers, or following certain patients through the different phases of their hospital encounter – to make sure that the Consent for Treatment for those individuals was in place, she notes.
Otherwise, there was no interaction with the access department, Hiryak says. "[The surveyors] didn't stop and talk with my staff at all. From our standpoint, [the visit] was no big deal."
Overall, UAMS Medical Center did very well on the survey, she adds. "What they told us was that for a hospital of our size and complexity, the average number of recommendations for improvement was between nine and 14. We had only six, and we received an unconditional accreditation."
[Editor's note: Keith Weatherman can be reached at [email protected]. Holly Hiryak can be reached at [email protected].]
Access directors at two facilities recently visited by surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported little or no contact with surveyors, and an overall experience that was decidedly different from previous visits.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content