SDS Accreditation Update: On-line tool makes self-assessment easy to access
Penalty-free time to fix problems is a welcome benefit
Continual survey readiness, no last-minute crush of work to prepare for a site survey, and a penalty-free period to correct deficiencies that you identify are a few of the benefits cited by participants who underwent a self-assessment during the pilot project of the Joint Commission on Accreditation of Healthcare Organizations’ new approach to accreditation.
A self-assessment is one part of the Joint Commission’s Shared Vision-New Pathways initiative that introduces a new approach to accreditation.
Self-assessment tools are a part of the process for most accreditation organizations, so the Joint Commission move to include self-assessment is not a new idea, says Carol Gilhooley, director of process improvement for the Joint Commission. The Accreditation Association for Ambulatory Health Care in Wilmette, IL, offers a self-assessment tool for its accredited members to use internally to prepare for a survey, but AAAHC does not collect results of the self-assessment.
The Joint Commission’s self-assessment tool must be submitted 18 months prior to the scheduled survey visit so it will be mailed to organizations three months prior to the 18 month-mark, says Gilhooley. For example, organizations that are scheduled for a survey in July 2005, the first time self-assessment will be incorporated, will receive access to their self-assessment tool in October 2003 and have a deadline of January 2004, she explains.
To use the tool, an organization accesses a secure web site that is password-protected, explains Gilhooley. "Basically, the organization is using the same tool used by our surveyors. It lists the standards, rationale for the standards, and elements of performance," she says. "If the organization is not in compliance, the person submitting the information can click on a button to submit a brief plan of action to correct the deficiency."
Because the tool contains the same information used by the surveyor, it is a little like getting the answers to a test, says Thomas P. Moerschel, BSN, MBA, director of performance improvement for Shriners Hospital for Children in Spokane, WA, one of the pilot project participants.
The opportunity to assess the organization in a penalty-free environment is very appealing, says Angie King, RN, CPHQ, quality management director for Tift Regional Medical Center in Tifton, GA, and one of the participants in the first pilot test for the new accreditation process.
"You either meet the standards or you don’t, and the self-assessment gives you an opportunity to develop the policies or implement a program that will bring you into compliance with the standards," she says. The best news is that you are not penalized for any deficiencies you identify during the self-assessment phase, King points out. "Once you’ve identified your own deficiencies, you submit a plan to correct them," she adds. Then, you have 18 months to implement those corrections, she says.
You also obtain the support and advice of Joint Commission staff after submitting a plan of correction, points out Gilhooley. "Within one month of submission of the self-assessment and plans of action, a conference call between organization representatives and Joint Commission subject matter staff is scheduled," she says.
The group discusses the results of the self-assessment and the corrective action plans, she explains. During the conversation, the group members discuss additions or changes to plans and agree upon final corrective action plans that are to be implemented in the 18 months before the accreditation survey, she adds.
While the Joint Commission staff members do clarify information and offer some suggestions, they did not find unidentified deficiencies during the pilot test, says Gilhooley. "We found that organizations are usually harder on themselves than any of our surveyors or staff members would be," she adds.
Although only one person in the organization is given the ability to submit the self-assessment, it is set up so that multiple people can access the tool, says Gilhooley. This system makes it easier for the person coordinating the assessment to gather information from different departments.
There were some initial software setup problems, but they were fixed, and the self-assessment tool worked well, says Moerschel.
Because the initial pilot test did not address all standards, King did not need all departments to provide information, but that will not be the case when the organization undergoes its actual self-assessment. "I will coordinate the process, but I will have the same-day surgery staff provide information on issues such as infection control and surgical-site verification," says King.
The same-day surgery staff will be able to use the web site to see what policies or measurement and monitoring information they must provide, she adds. Then they can enter it directly on the tool for the coordinator to review and prepare for submission, she explains.
"We’ve always had an ongoing self-assessment process in place, but the Joint Commission tool will help many organizations foster a mindset of continual survey readiness, says Moerschel. "It also increases communications between departments on an ongoing basis, because we need everyone’s input to complete the tool."
The greatest benefit will be seen during the site survey, King adds. "Because the self-assessment enables us and the Joint Commission to review policies and paperwork prior to the site survey, the surveyors and organization staff members are free to look at real issues of patient care, patient safety, and quality during the survey," she says.
Resources
For more information on self-assessment, contact:
• Carol Gilhooley, Director of Process Improvement, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5270. Fax: (630) 792-5005. E-mail: [email protected].
• Thomas P. Moerschel, BSN, MBA, Director of Performance Improvement, Shriners Hospital for Children, 911 W. Fifth Ave., Spokane, WA 99210-2472. Telephone: (509) 623-0441. Fax: (509) 623-0474. E-mail: [email protected].
• Angie King, RN, CPHQ, Quality Management Director, Tift Regional Medical Center 901 E. 18th St., Tifton, GA 31794. Telephone: (229) 386-619. Fax: (229) 386-6228. E-mail: [email protected].
Continual survey readiness, no last-minute crush of work to prepare for a site survey, and a penalty-free period to correct deficiencies that you identify are a few of the benefits cited by participants who underwent a self-assessment during the pilot project of the Joint Commission on Accreditation of Healthcare Organizations new approach to accreditation.
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