Here’s what JCAHO will be looking at
August 1, 1999 3 minutes read
Here’s what JCAHO will be looking at
Network linkage is a key issue
When the Joint Commission on Accreditation of Health Care Organizations (JCAHO) visits a physician office site, the surveyors are checking on compliance with eight network accreditation standards.
Most of the standards deal with whether the network communicates with and oversees the practice sites with which it contracts, according to Gina Val Zimmerman, executive director for network accreditation standards.
Here are some of the issues that the surveyors address:
• Communication and linkage issues. The surveyors make sure the practice site is familiar with the network’s policies and procedures and how they are to be implemented.
• Performance improvement activities. The surveyors determine whether staff at the practitioner site know the network’s performance improvement priorities and if the physician offices participate in performance improvement activities.
"We look at the networkwide process for performance improvement, and how it incorporates physician offices and all other sites where patients receive care," Zimmerman says.
Among the things the surveyors look for is how physician offices receive data and information from the health plan and how they send information to the health plan.
• Patient rights. The surveyors will check to see that staff at the practice sites are familiar with the policies and procedures the network has in place regarding patient rights.
"A big area in the network practice site office relates to respect of the members of the network," Zimmerman says.
Among the areas the surveyors will look at are:
— How does the network handle confidentiality of member information?
— How does the practice site protect patient privacy and security? For instance, the surveyors will check to see if the physician office takes steps to ensure that other patients do not know who is visiting the office and for what reason.
"One issue that has come up in recent years is the possibility of someone walking into the reception area and reading the list of patients who have been treated that day," Zimmerman says. Some physician offices have complied with this part of the JCAHO patient privacy issue by asking patients to sign in on an index card, as opposed to logging in on a list.
— How are the medical records maintained? For instance, the surveyors will check to see if the records are secured in a back office that is locked at the end of the day.
• Grievance procedures. The surveyors look at how the physician officers are linked with the health plan or network. Does the practice site know how to handle complaints and grievances? Is there a toll-free number to call? Does everybody in the office from the receptionist to the physicians know what it is?
• Continuum of care in the practice site. The surveyors examine how well the services the health plan or network provides are integrated. Do the physicians know how to make a referral to another provider? Do the physicians understand what other sites are included in the network? Do the physicians know how to access the referral process? Do they have forms or instructions for referrals? If they need to communicate with the network, do they know whom to call?
• The referral process. Surveyors will examine how the various settings in the health plan or network are linked. They want to know how the patients’ records or other information is transmitted; what information is forwarded with the patient; and how the sites share information.
Are you documenting your education efforts?
• Education and communication. Surveyors want to determine if staff know what types of education they should be providing and if they provide it. Surveyors also look for documentation within the clinical records showing that education was provided.
• Leadership issues. Are the physicians involved in decisions made by the health plan? Do practice sites know how to contact the health plan and how to provide input on strategies and procedures the plan may be implementing?
• Management of human resources. The surveyors want to determine if staff are competent to perform the skills they have been hired to do and if there is sufficient staff to handle the workload. They look at education, training and orientation to the job, competency assessment, and credentialing and licensing of staff.
• Information management. This section of the survey includes determining if medical records are being maintained for each patient and if the physician office is carrying out policies and procedures on documentation set by the network or health plan.
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