Merger presents JCAHO survey opportunities
Survey creates team spirit; details get attention
Within six months after two or more hospitals merge, the Joint Commission on Accreditation of Healthcare Organizations requires a new survey, regardless of when the previous survey was conducted at any of the individual hospitals. Some directors of quality management may look at this as a frustration, a mammoth amount of work, or both. Margaret Reinert, RN, BSN, MSN, sees it as an opportunity to forge friendships with former competitors, learn new perspectives on preparing for the triennial event, and validate old methods.
Reinert is the director of outcomes research and quality management at Via Christi Regional Medical Center in Wichita, KS. In October 1995, St. Francis Medical Center, St. Joseph's Medical Center, and Our Lady of Lourdes Hospital merged to form Via Christi. St. Joseph's already owned Our Lady of Lourdes, but after the merger the two became more consolidated. Besides changing the letterhead on her stationary, Reinert had to start preparing for a systemwide Joint Commission survey -- an arduous but positive process.
"I would describe a Joint Commission survey following a merger as a methodology to expedite," Reinert says. "It's a way to get things done. I see it as a real plus. If you were going to start from scratch and build a health care facility or a health care system, it is a nice methodology to make sure you have all the different elements in place. I see [the survey] preparation for our new merged organization as a methodology to make sure we have all the elements addressed. It is a tool to help us facilitate the merger." (See what the Joint Commission expects, p. 52.)
Merging methods
Preparing for a Joint Commission survey after a merger is neither for the fainthearted nor for just one person. Merger plans must be sketched out, and those in charge of the survey must determine which areas will be merged and which will not by the time of the survey. Presentations of how these areas will continue to merge must be created for the surveyors. Representatives from the merged entities, who were former competitors, must come together and work in a coordinated fashion.
At each of the three campuses in the Via Christi system, representatives are assigned one or more of the 15 chapters from the Joint Commission's Accreditation Manual for Hospitals. The group totals 30 overall, and each member reports what his or her campus is doing regarding each function. Reinert warns that such a group can be unwieldy, but it is necessary.
"We don't want to have all these different policies on conscious sedation," she says. "Someone needs to change those policies to make sure we are all together. It's the same with restraint issues."
Reconciling and consolidating the policies and procedures for three hospitals takes many months. Via Christi will not have all areas covered when the Joint Commission surveyors pay a visit this summer. The surveyors will want to see which areas have been covered and which are left to address. Reinert is developing a time line for areas that will not have been consolidated by the time of the survey.
Surveyors will also want to see how the merger will impact the system's departments. "In a merger, you are not going to consolidate all the departments, so they will want to see a plan of how this merger is going to roll out," she says.
Reinert and her colleagues are working to have certain areas addressed before the surveyors arrive. "We'll hit the hot topics first -- the ones we know they'll be the most interested in," Reinert says. In this group, Reinert puts areas the Joint Commission has been historically sensitive to -- conscious sedation and restraint issues -- and all past Type 1 recommendations received at any of the three campuses.
Merging cultures
Putting together such a large group has worked well from an organizational standpoint, Reinert says. It has also put former competitors on the same team working on the same project. That has worked to get the new, larger quality department started on the right foot.
"With the new merged organization, it is good to get to know your counterparts in the other facilities," Reinert says.
"The survey has made us focus more on coming together," says Jerry Peterie, MD, vice president for quality and outcomes at the St. Francis campus. In February, Peterie had his hands full preparing for an extension Joint Commission survey. Since St. Francis is overdue for a survey due to the merger, the surveyors perform a scaled-down survey by special arrangement with the Joint Commission. In this situation, the extension survey covers all areas, but it is not as in-depth as a regular survey. Primarily, the extension surveys are made so facilities can maintain their accreditation after their previous three-year accreditation period runs out, or they may be made when a facility adds a new service. Extension accreditation surveys are only temporary. A full survey is required to receive a full three-year accreditation. The St. Francis facility will be resurveyed again this summer when the Joint Commission looks at the entire system.
A merger creates many difficult situations, but it offers residual benefits. For example, Peterie has received assistance with the extension survey from Reinert, who has had a great deal of survey experience with St. Joseph's. "She helped us organize [our survey]," Peterie says. "The people at St. Francis are new due to reorganization and hadn't had experience." The staff at St. Francis had begun preparing for the extension survey when Reinert stepped in. "She had meetings with everybody and gave focus to our activity."
While Reinert was able to assist with St. Francis' extension survey, she says she learned from the experience, too. The new organization is greater than the sum of its parts, she says. "You get to pick the best of the best [procedures]," she says. "You may have one process and think it is great. Then you meet with the other group, and they have something that you had not thought of, and that makes a policy that much more strong."
For example, St. Francis had already implemented the intent of the Joint Commission's new environment of care standards -- previously the behavioral health standards -- into all their patient care activities. That was a particular area of interest because many Type 1 recommendations are issued regarding environment of care standards. St. Francis had time lines and proposals on how to implement the environment of care standards for their campus. That format will now be shared at all three campuses.
When Reinert headed up the survey team in years past for St. Joseph's, the team was much smaller, less spread out, and more familiar with each other. One of the first things she noticed when she started preparing for the systemwide survey was there are many more people to organize.
"At first, it takes more time to figure out how to get that larger group together and figure out who is doing what," she says. When communicating information about hot topics, such as ensuring restraint policies are in order, Reinert has a much longer list of people to contact.
Reinert cites other areas that make preparing for a post-merger survey more difficult:
* More Type 1 recommendations. Surveyors will revisit past Type 1 recommendations made to individual organizations and apply the same level of scrutiny on those areas organizationwide. "You have to address everybody's Type 1's and consultative recommendations," Reinert says. "Yours become theirs, and theirs become yours, and you have to be cognizant of that."
* Determining level of care. The Joint Commission expects all the facilities to provide a similar level of care, such as ensuring that all three facilities have similar policies regarding monitoring patients after conscious sedation. Prior to the survey, Reinert and her colleagues have to determine what the level of care will be for Via Christi. "You can do a lot of work establishing one level of care even at a small facility," she says. Doing the same thing on a much grander scale will take an equivalent amount of effort.
On a smaller scale, determining the level of care takes a great deal of communication, Reinert says. It is no different when the size of the facility triples and is spread out over three locations. Reinert is preparing a weekend retreat for the nursing staff to discuss the survey. She expects the biggest topic of discussion will be care levels.
* Three times the documents to review. Some areas of the three hospitals will be consolidated by survey time, others will not. For areas that are still separate, three sets of documents must be prepared. "When they ask for the minutes of [a particular] committee and you haven't merged those committees yet, what do you do?" she says. "You might have to present three sets of minutes."
Reinert stresses that the positives far outweigh the negatives. She is most enthusiastic about building a team out of former rivals. "These people used to be the competition, now they are people we work very closely with," she says. Since the merger process has commenced, Reinert has discovered that some of the rumors about how her crosstown rival operated were untrue. She found many of the problems St. Francis faced in the quality department, especially surrounding the Joint Commission survey, were the same problems faced at St. Joseph's, and the team at St. Francis was approaching them the same way, which Reinert says is validating and reassuring.
"It doesn't become a St. Joe's way, a St. Francis way, or an Our Lady of Lourdes way," she says. "It becomes a Via Christi way. We have created a Via Christi methodology." *
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