JCAHO issues reminder on survey process changes
Health care providers will see several policy modifications in 2000 under the Joint Commission on Accreditation of Healthcare Organizations’ Accreditation Process Improve ment (API) initiative, including some that will radically alter the way providers are accredited.
Most of the changes went into effect Jan. 1, 2000, and the Joint Commission recently issued a reminder that the new policies are in effect. These are the changes to the accreditation process:
• Advance notice for random unannounced surveys has been discontinued. Surveys may be conducted at any time between nine and 30 months following the triennial full survey.
• "Accreditation with Commendation" has been eliminated as an official decision category. Recent field research indicated that this decision category was leading organizations to place inappropriate emphasis on achievement of commendation and interfering with the consultative and educational aspects of the accreditation process.
• There are new guidelines for evaluation of peer review and credentialing processes. Survey ors will examine specific issues such as the organization’s definition of the circumstances requiring peer review; the participants included in the review process; and the time frames in which the review must be conducted and results reported.
• Surveyors will receive an enhanced pre-survey information packet that will provide them with more information about the health care organization such as its recent complaint history, if any, and its ORYX data.
• The survey agenda has been revised to allow surveyors the time necessary to address in more depth organization-specific performance issues.
• Scheduled survey dates will be posted on the Joint Commission’s Web site beginning in the first quarter of 2000.
• Pilot testing of the extension of the on-site survey activities to evening, night, and weekend periods, which began during the last quarter of 1999, will continue in the first quarter of 2000.
• A common identifier for all accredited organizations will be created and will be used to improve customer services.
• The focus of the unannounced survey also has been modified. In addition to five pre-selected standards-related performance areas, organization performance will be reviewed in areas indicated after an analysis of certain organization-specific information.
Organization-specific performance areas for review will be selected for review based on an analysis of the organization’s last accreditation survey or any validated complaint or performance measurement data received since the last full survey. For some organizations, the extent of review required for the organization-specific elements of the survey may not allow the time needed to assess all of the pre-selected performance areas. In such cases, only the highest priority, pre-selected elements will be addressed.
The Joint Commission conducts random unannounced surveys for a 5% sample of accredited organizations. The percentage of random unannounced surveys has not changed. The first group of organizations eligible for a random unannounced survey under the modified policy are those that had their triennial survey between July 1997 and April 1999.
Random unannounced surveys will not be conducted for laboratories or health care networks in 2000.
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