Does your home health meet EC standards?
Hospitals often neglect home health standards
As more and more hospitals expand into the home health care industry, risk managers need to ensure that their safety departments are meeting the Joint Commission on Accreditation of Healthcare Organization's environment of care (EC) standards specific to home health care agencies.
These standards are different than the Joint Commission's EC standards for inpatient facilities, but many hospitals either do not recognize the differences or are trying to merge their EC programs for their home health units into their inpatient program.
Without first reviewing the Joint Commission's standards for each type of operation and evaluating the ability of your institution's inpatient and home health operations to fit into one program, you may be making a mistake, risk management experts warn.
"Hospitals are really struggling with these EC management plans [for home health]," says Leslee O'Brien, RN, MSN, CPHQ, a health care consultant with QualEd in Santa Ana, CA. "They are not that difficult. But it is a matter of finding out the intent of the Joint Commission for each setting and going forward from there."
Some hospitals may be able to meet the Joint Commission's EC standards for both operations under one management plan. But that should be done only after the hospital risk manager determines how closely linked the hospital and the home health operations are, whether they have shared resources, and the physical proximity of the operations.
"They must look at what processes they put in place to reflect the home environment because typically their policies and procedures only reflect a hospital setting," says Debra Payne, RN, BSN, CRRN, associate director of the department of standards interpretation at the Joint Commission. "Part of the environment-of-care standards is making sure that it is appropriate for the setting. Each standard applies to the patient's home and [hospitals] have to make the leap to addressing those issues. Hospitals have trouble making the association with that environment."
While it is possible to meet the Joint Commission's standards by using one EC management plan for both inpatient facilities and home health care operations, O'Brien advises hospitals to use caution.
"I would not recommend it because how they manage the environment is really different for home care than for hospitals," O'Brien says. "The seven plans on managing the environment need to be specific to either the hospital or to the home."
JCAHO requirements for home health
To see if your EC management plan is meeting both sets of the Joint Commission's standards, cross-walk, or compare, the standards. While the Joint Commission's stated EC standards for home health closely approximate those stated for hospitals, they are different in their applications.
"You need to look at both manuals," Payne advises. "We have core standards throughout each of the accreditation programs. Risk managers will find that they can integrate their home care EC management program, but they need to make sure it addresses the home care setting."
One notable difference between the two manuals is what is included in the definition of the environment in the home health setting. Under the Joint Commission's standards, the environment of care includes both the setting in which the care is delivered to the patient, such as the home, office, or school, and the site of the home health care organization itself, including offices, warehouses, vehicles, and pharmacies.
Management of these environments involves five sets of activities, according to the Joint Commission. They are:
* Designing a program to manage the environment of care. The home health agency should identify the physical characteristics and processes of the different environments. The hospital's plan for this standard should include programs for educating staff and patients about the physical characteristics of each environment and about processes for monitoring and reporting on the environment.
* Teaching staff and patients. The hospital must teach both its staff and patients how to manage the environment where the home health care is delivered, and also for staff, where they are based. The Joint Commission's standards also require that the hospital's home health staff be able to demonstrate job skills that are specific to each employee's work environment.
Similarly, patients should be taught any skills that are necessary for them to function within their home or work environment with the home health equipment or devices. This should include learning what to do on a daily and an emergency basis.
* Implementing processes to manage the environment of care. Under this standard, the Joint Commission looks at whether all of the processes for working, teaching, monitoring, and reporting are being implemented according to the hospital's EC management plan for its home health system.
* Measuring and assessing. The plan should include processes to measure the effectiveness of the hospital's EC management system for its home health operations.
* Improving the management of the environment of care. Action should be taken to address any deficiencies and to continually improve the environment of care.
Review processes
Once the manuals have been reviewed and the differences flagged, the risk managers need to review the processes their hospital created to meet each standard and determine whether it is appropriate and feasible for the home care setting.
O'Brien suggests beginning the review process by talking to staff members in your home health operations to find out whether different processes need to be created or modified. "Work directly with the people who are out-performing the home health function," she says. "Find out what is different, what is alike, how they can fit together."
For example, security must be addressed in the EC management plans differently for inpatient facilities than for home health operations. While hospitals may satisfy this standard for their inpatient facilities by having an emergency call button, this type of system cannot be implemented in the home health environment.
"In certain cities, you have to look at the safety of the staff from the standpoint of going into unsafe neighborhoods," O'Brien says. "You may need policies that do not allow the provider to go into an area after certain hours or without a partner or without a cellular telephone. That is not an issue in a hospital where if you have an argumentative or hostile patient you call security."
Another example of the differences hospitals need to consider in their EC plans is emergency preparedness for home health. Triage systems need to be in place in the event of a disaster since patients on ventilators at home may run out of oxygen if a home health aide cannot reach the patient because of the occurrence, O'Brien notes.
The plans need to address the education of patients about what to do in the event of a disaster. "The patients need to know that they may not hear from someone from the agency for a period of time and what they can do in the interim," she says.
Risk managers also should evaluate the different educational needs of home health care staff when reviewing their EC plans. Education and orientation programs on environment of care for home health staff should be specific to that environment.
Home health nurses also may need to be better educated on EC issues because of the greater number of safety risks in the home, O'Brien says.
While it probably is not necessary to design new mechanisms to gauge the performance of the systems in place in the home health environment, Payne reminds risk managers that whatever systems they have in place must be effective.
"When they design the system, they need to say, 'We are looking at safety and defining incidents," she says.'"Then they need to consider whether they will get the data they need to assess whether their plans are effective."
Payne recommends testing the assessment plans before making them part of any hospital's EC plan for inpatient or home health operations. The data also need to be benchmarked to determine the continued effectiveness of the assessment mechanism and to see what areas need to be improved, she says. *
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