JCAHO expectations same for merged organization
New operation must function as one system
For better or worse, the Joint Commission on Accreditation of Healthcare Organizations does not look at a newly merged organization any differently than a stand-alone operation, says Glenn D. Krasker, a Joint Commission team leader for hospital service teams.
"Bringing formerly independent organizations together represents a whole new set of challenges for the new organization undergoing a survey," he says. "They have to integrate activities and processes within that new single entity."
A newly merged health care organization has 30 days to notify the Joint Commission of the merger. Each organization will maintain its accreditation separately for six months until the new system can be surveyed. In certain situations, a special arrangement with the Joint Commission can be made, but in most cases, the survey will be carried out within eight months of the merger date.
The standards that address organizationwide functions, such as leadership, management of information, and performance improvement, will be the hardest to live up to, Krasker says. Those require flow of information across the organization. While each of the separate entities may have had a coordinated communication system, the new organization probably does not, or likely will have a few kinks in the system.
Krasker understands that a merger process takes time and the integration process may not be finished when surveyors arrive. This does not, however, excuse the operation from meeting Joint Commission criteria.
"If we are surveying an operation as a single entity, they will be found noncompliant with those standards [addressing areas that have not been integrated]," he says. "If one part of the organization is doing something one way, another part is doing it another way, and another part is doing it a third way, that leaves a lot of opportunity for error and miscommunication. That kind of organization will take its lumps when it comes to these transitional issues."
Lay out your time line
Addressing those dilemmas directly with the surveyors will help matters, Krasker says. Presenting information on how far along the organization has come with respect to integration since the merger, and laying out specific steps and deadlines will show that the organization is moving toward compliance.
"[An integration time line] may convince me as a surveyor that the organization is being partially compliant with the standards, in that the organization has identified what the path is to get to the ultimate goal," Krasker says. Most likely, however, the organization would face a focused survey or a written progress report by the Joint Commission to see how well the organization fulfilled its plan. He pointed out that 80% of all facilities encounter follow-up procedures after the survey.
Merging organizations may find more similarities among the different entities than previously thought, Krasker says. Creating a single policy out of three similar policies poses fewer challenges than writing a brand new document. This may make the process easier, he says. *
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