Major culture change’ needed; staff must be more involved during surveys
Now that the long-awaited revised accreditation standards from the Joint Commission on Accreditation of Healthcare Organizations have been unveiled, what changes should you make in the way you prepare for surveys?
The new standards, which become effective Jan. 1, 2004, give you a chance to review the changes before they officially are published this fall, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Hospital in Charlotte, NC. "The era of serious continuous survey readiness is here," she says. "This means a daily process of honing the organization to practice what gets preached."
Taken as a three-pronged package, the revised standards, the national patient safety goals, and continuous readiness and assessment will call for a "major culture shift" at your facility, says Frederick P. Meyerhoefer, MD, principal of the Canton, OH-based Meyerhoefer Organization, a consulting firm specializing in compliance with Joint Commission standards.
"Quality managers are definitely concerned that this will require additional personnel resources that will not be met," he says.
If you’re like most quality managers, you’re already seeing an increased workload for Joint Commission preparation, without senior management supporting and acknowledging this trend, Meyerhoefer adds.
"Hospital leadership may not yet recognize the time needed to be continuously prepared, the self-assessment process, and the hovering knowledge that surveys will shortly be unannounced," he says.
In fact, many quality managers may need an altogether different reporting structure to get needed access to senior management, Meyerhoefer says. Most quality managers are concerned about the continuous preparedness that is required, he reports. "I’ve heard no one dispute that the hospital should always be ready, and this is a laudable goal. But the reality from the past is that many hospitals did last-minute crunches to prepare for the survey."
So how much of your time will continuous preparedness really require? Estimates vary widely, according to Meyerhoefer. "One concerning estimate that I’ve heard is that it will take thirty days to do the self-assessment," he says.
The patient safety issues, the revised standards, and increased emphasis on data-supported and evidence-based patient care, which also includes physician and hospital staff competencies, are all at issue, he says. "This puts the role of the quality manager even more in the spotlight," Meyerhoefer stresses. "The role can’t be performed if the hospital doesn’t accept the need for increased support of the quality manager."
To prepare for compliance with the new standards, consider the following:
• More is left to individual interpretation.
It is true that the standards are simplified in their language, but this leaves a lot to interpretation, says Swain. "The burden is on the facility to figure out how the elements of performance apply," she notes.
Just because many standards were combined, that is no guarantee that the amount of time you spend on paperwork and preparation will decrease, Meyerhoefer says. "It remains to be seen how the surveyors will interpret and score the 2004 standards."
There is more room for surveyor inconsistency, and some surveyors are more rigorous than others, says Swain. "The proof will be in the divergence between the facility scoring rationale and JCAHO’s interpretation of their standards."
You should keep a close watch on the interpretations of surveyors as they return, and listen to "survey stories" around the country, she says. "Then tweak as you must."
For now, Swain recommends focusing on your own problem areas first. "Take the standards that have been in noncompliance and start there with your scoring," says Swain. Use the crosswalks provided by the Joint Commission to see where your chronic areas of noncompliance land in the 2004 standards, she suggests.
While the standards are less fragmented, there is concern about how facilities will show compliance.
"I’m a little concerned regarding how an organization will demonstrate compliance with some of the standards, especially in light of the loss of the document review session," says Virginia Hay, RN, CIC, service director for quality care management at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY. "I’m not convinced that brief observations alone will give a true picture."
Champlain Valley will continue to have material together for each standard as if there still was a formal document review session, she reports. "If nothing else, it will serve to help us focus quickly during survey should the need arise."
Since the next scheduled survey is mid-2004, the self-assessment tool will not be submitted, Hay says. "But, we plan to complete it as soon as it becomes available and have it on site for use during the survey," she says.
• There is increased focus on staff interactions with surveyors.
Interviews with staff will be a major factor in determining whether you are compliant, says Swain. "It is clear that the staff need to know why they are doing things."
It’s not enough for staff to give rote answers anymore, Swain says. "The staff need to be able to describe what the aggregate organizational data means and how they interpret it on their unit," she says. "If staff shrug and state, that’s just how we do it’ without regard for the reason, red flags start to go off."
Different areas may have different procedures, and staff need to understand the reasoning behind these, Swain says. "For example, if the fall rate of a unit is higher than any other unit in the facility, that unit will have initiated fall precautions that exceed what might be found in other units," she explains.
To address this, Swain’s facility uses a "rate card" which is different for every unit, posted where staff can easily see it.
The card shows the organizational data for that individual unit, such as infection rate, turnover rate, performance improvement projects under way, and sentinel events affecting the unit, says Swain. "As the values on the rate card change, the staff can see the progress they are making at reducing wound infections or falls, for example."
Staff are the real experts
At Champlain Valley, staff are continually reminded that they are the true experts and should be the ones interacting with surveyors, Hay says. "We will be reinforcing this throughout the mock survey process. We will promote this as a good thing — that the changing survey process will be more interactive with staff." The goal is to have staff step right up to surveyors, eager to show what they do so well, rather than shy away or revert to yes/no answers, she says.
Use of restraints is a good example of the need for discussion at the unit level, she adds. "While it is often easy to let others do the talking, a unit nurse can best describe the alternate strategies she would try in order to avoid using a restraint."
The unit nurse is also the best candidate to explain the policy for time-limited orders, monitoring of the patient in restraints, and documentation requirements, says Hay.
"Once the dialogue is started with the surveyor, that provides a great opportunity to review the hospital approach to ensure a safer environment by reducing restraint use," she explains.
In this case, Hay then would step in and describe the restraint team that developed the facility’s policy, and the restraint reduction initiative that reviews the overall use of restraints and looks for trends that can further reduce their use.
Another prime opportunity for staff involvement would be the assessment of compliance with the Joint Commission’s patient safety goals, says Hay.
"This is a big topic during surveys, and a staff member in any department might be able to speak to one or more of the goals that directly impacts their work," she says.
Hay encourages staff to "seize the opportunity" to talk about different initiatives related to compliance with the goals during mock surveys. "We remind staff that there is ongoing evaluation of compliance, and the results of monitoring get reported to medical staff leadership and the board," she says.
These discussions usually draw in others, and provide an educational opportunity that is more compelling than an article in a newsletter or on a bulletin board, says Hay.
During mock surveys, small prizes such as candy, pens, and stickers are given to staff who actively participate, says Hay. "Active participants offer us the best opportunity to coach and teach," she says.
"For example, we can suggest other examples they could use to respond to questions and remind them of performance improvement initiatives related to the topic," she explains.
Prizes are given not only for those answering a question correctly, but also to individuals who are willing to describe a system of care being reviewed, says Hay. "We take this opportunity to coach them through so they will feel comfortable discussing our care processes with a real surveyor," she says.
• Increased emphasis on the medical staff.
This is a subtle but significant change in the medical staff standards, Meyerhoefer says. "There is an increased emphasis on the medical staff’s leadership and responsibilities in the quality and safety of patient care," he notes.
This increases the role and responsibility of the medical staff leaders and will call for increased time commitments, involvement, and knowledge of their roles, he says. "Because of the changing nature of the medical staff and [their] relationship with the hospital, this may be difficult to obtain," he says.
In most hospitals, the number of active physicians is decreasing continually for several reasons, Meyerhoefer explains.
Many primary care physicians have fewer hospitalized patients due to increased ability to care for higher acuity patients in their offices, and inpatients also have a higher acuity and now frequently are admitted to subspecialists such as cardiologists, he says. "Thus, there are fewer incentives to devote time to medical staff activities," Meyerhoefer says.
There also is tension between the hospital and the medical staff regarding coverage of the emergency department, and physicians are expecting remuneration for performing on-call responsibilities, he notes.
All this results in fewer physicians willing to take leadership roles, says Meyerhoefer. "Even now, many medical staffs and their leaders don’t fully understand the safety goals and their importance to the hospital and the physician’s role in implementation," he adds.
The most successful quality managers have found physician champions to carry the banner for performance improvement activities, advises Meyerhoefer.
This calls for a lot of one-on-one attention from the quality manager, he says. "It also means that the quality manager must have the necessary data gathering and analytical tools to present the information to physicians. They can’t waste the physician’s time or give the physician the illusion that their time is being wasted."
[For more information on the new JCAHO standards, contact:
• Virginia Hay, RN, CIC, Service Director, Quality Care Management, Champlain Valley Physicians Hospital Medical Center, 75 Beekman St., Plattsburgh, NY 12901. Telephone: (518) 562-7323. Fax: (518) 562-7397. E-mail: [email protected].
• Frederick P. Meyerhoefer, MD, The Meyerhoefer Organization, 1261 White Stone Circle N.E., Canton, OH 44721. Telephone: (330) 966-6717. E-mail: [email protected].
• Paula Swain, MSN, CPHQ, FNAHQ, Director of Clinical and Regulatory Review, Presbyterian Hospital, 200 Hawthorne Lane, Charlotte, NC 28204. Telephone: (704) 708-6591. E-mail: [email protected].]
Now that the long-awaited revised accreditation standards from the Joint Commission on Accreditation of Healthcare Organizations have been unveiled, what changes should you make in the way you prepare for surveys?
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