Options available when legal issues arise
Even before the new survey process goes into effect, the Joint Commission on Accreditation of Healthcare Organizations has created options to the self-assessment portion of the survey. The periodic performance review (PPR) is an integral part of the new accreditation process that debuts this year, but health care attorneys and risk managers are afraid that information uncovered in this proprietary self-assessment may be discoverable information in some cases where the organization is facing a lawsuit.
The concern does not apply to all states equally, says Harold Bressler, general counsel for the Joint Commission. In fact, the law is not clear in any state, which means that different attorneys in each state might interpret their risk differently, but there was enough concern that the Joint Commission put together a task force to develop options to the PPR, he adds.
The Legal Issue Task Force comprised representatives from the Joint Commission, the Chicago-based American Hospital Association (AHA), and state hospital associations from Alabama, Connecticut, New Jersey, and South Carolina, Bressler says.
"The greatest concern came from hospitals, but the options we developed are applicable to all organizations, including home health agencies," says Michael Kulczycki, ambulatory accreditation program executive director for the Joint Commission. Although the PPR is not a public document, and, in fact, surveyors don’t have access to the PPR, some organizations were concerned that an opposing attorney in a legal action may be able to obtain the information, he explains. "The PPR is designed as a no-harm’ method for home health agencies to conduct a self-assessment as to compliance with accreditation standards and correct any deficiencies prior to their standard survey," Kulczycki points out. "We created these options for the times that an organization may be vulnerable to a legal action," he adds.
Option 1
Option 1 is designed to address the "waiver of confidentiality" that could be implied if the home health agency, or other health care organization, shares self-assessment information with the Joint Commission, explains Maureen Mudron, Washington counsel for the AHA. Option 1 enables the organization to:
- perform the midcycle self-assessment and develop a plan of action and measure of success for areas in which accreditation standards were not met;
- attest that the foregoing activities have been completed but, for substantive reasons, advice has been given to the organization not to submit its self-assessment or plan of action to the Joint Commission;
- discuss standards-related issues with Joint Commission staff without identifying specific levels of standards compliance;
- provide measures of success to the Joint Commission for assessment at the time of the complete on-site survey.
Option 2
The second option addresses concerns that different states describe protected information specifically enough to make the information included in a self-assessment fall outside the protected classification, Mudron says. Under Option 2, the organization can:
- decline to conduct a midcycle self-assessment;
- undergo an on-site survey that is approximately one-third the length of a full survey at the midpoint of the organization’s accreditation cycle;
- develop and submit a plan of action for deficiencies found in the midcycle survey;
- provide measures of success at the time on the complete on-site survey.
"Organizations choosing the second option will have to pay a fee to cover the costs of the survey, but we have not yet decided what those fees will be," Kulczycki states. If an accredited organization chooses one of the two options to the PPR, it is not necessary to give reasons, he says. The choice is made on-line through the Joint Commission’s self-assessment form, with the person filling out the form stating that the organization chooses one of the options, according to Kulczycki. "The chief executive officer of the organization must also attest to the choice of the option rather than the PPR," he adds. "These options were developed to address a worst-case scenario for a Joint Commission-accredited organization," Kulczycki explains. "We don’t expect a large number of organizations to choose them, but we want them to be in place so that we don’t jeopardize the PPR process for everyone," he says. "PPR is a convenient and important tool for health care managers to audit their continual compliance with standards."
[For more information on PPR options, contact:
• Michael Kulczycki, Executive Director, Ambulatory Accreditation Program, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5290. E-mail: [email protected].
• Harold Bressler, General Counsel, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5672. E-mail: [email protected].]
Even before the new survey process goes into effect, the Joint Commission on Accreditation of Healthcare Organizations has created options to the self-assessment portion of the survey.
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