Be proactive in JCAHO’s questions about Y2K prep
Don’t make surveyors look for evidence of a plan
Don’t be caught without a plan. If Joint Commission on the Accreditation of Healthcare Organizations surveyors don’t see ample evidence of year 2000 (Y2K) preparation this year, hospitals may find themselves receiving type I recommendations. That’s why hospitals should bombard surveyors with Y2K information before surveyors even ask, information and compliance managers say.
The intent statements of standards in the "Leadership", "Management of the Environ-ment of Care", and "Management of Inform-ation" chapters in all Joint Commission manuals call for an organizational strategy to address issues that would include Y2K compliance. The Joint Commission advises hospitals to identify and assess the implications of Y2K on their operations, including computer systems, medical equipment, and utility systems; and to determine whether suppliers are also addressing the Y2K issue.
In its surveys, the Joint Commission is trying to judge hospitals’ awareness of potential Y2K problems and to ensure they have developed a plan, says Susie McBeth, associate director in the department of standards for the Joint Commission.
Surveyors are asking questions at interviews such as, "What are you doing to protect and ensure continuing accessibility to information in the year 2000?" she says. "They’ll ask the leaders what resources they have provided for this. How have they educated their staff about Y2K? Have they checked with their suppliers [about Y2K preparation] — what are they doing? Can they still supply you?"
Emphasis on supplies and contingencies
When preparing for 1999 surveys, the Joint Commission said it would focus on evidence that hospitals or health care organizations have a Y2K program in place and are aggressively pursuing a successful conclusion to year 2000, says Dwain Shaw. In 1998, Shaw, who is director of information services and year 2000 project director at the Medical College of Georgia in Augusta, was asked to join the faculty of the Joint Commission as its year 2000 spokesman. He has traveled with peers from several health care organizations doing presentations and educational programs for the Joint Commission.
"The Joint Commission said it would be placing specific interest in supply inventories and project plans and contingency plans," he adds.
In a statement about Y2K preparation, the Joint Commission said it would ask hospitals if they are involved in these activities:
1.engaging in efforts to identify their Y2K vulnerabilities;
2. upgrading software programs and equipment to make them Y2K-compliant;
3.identifying corrective manual alternatives when necessary;
4. considering possible community disaster scenarios related to Y2K in their emergency preparedness planning;
5.developing contingency plans to handle Y2K disruptions, which are not identified ahead of time or are outside the hospitals’ control.
Surveyors will look at any Y2K plan that the hospitals provide, McBeth says. Surveyors, however, will not critique the adequacy of the plan. "It’s mainly that they are looking for the absence or presence of a plan." If surveyors do not make a recommendation on a plan, this does not mean that they are endorsing it, she adds.
Questions asked by the surveyor will be dependent upon his or her technical knowledge. Shaw says. "[Surveyors] who are computer literate will probably get into this [issue]. [Surveyors] who are not will look for the evidence, and if it’s there, that’s great. If it’s not there, they have been instructed to look and dig a bit more for the evidence."
Shaw encourages hospitals to be proactive in their surveys. Don’t make surveyors look for evidence of Y2K preparation; show it as they walk in the building, he says. "It can be something as simple as a countdown sign that changes every day."
Surveyors accrediting Chestnut Hill Healthcare in Philadelphia did not ask to see a formal Y2K plan, says Jane B. Danihel, RN, BSN, corporate compliance officer and risk manager. The plan, however, was included in the documents given to the surveyors for review.
In the information and environment of care interviews, hospital staff were asked what their Y2K plans entailed, what testing has been completed, how they determined if equipment was Y2K-compliant, and what they did about equipment that was not compliant.
Chestnut Hill had formed a Y2K task force two years ago that has since formalized into a committee. Danihel says the surveyors reacted positively to the organization’s activities.
In its survey, the Community Health System in Fresno, CA, wanted to show surveyors that it was treating Y2K like a quality improvement project, says Terri Lutz, RN, director of information systems. Like Shaw advises, she gave surveyors plenty of information about the organization’s Y2K strategy at the beginning of the survey.
"I felt that if we gave [surveyors] enough information ahead of time, before they actually went out and did the survey, they wouldn’t get confused as to what we were doing. They’d be able to validate that we were on track," she says. Inundating surveyors with data up front also made them feel comfortable that the organization was striving to do as much as humanly possible to make sure it finished in time, she adds.
Lutz tried to make the Y2K effort apparent visually, too, such as placing Y2K stickers on computers, which read "Y2K compliant," she explains. "It validates what we are already talking to surveyors about."
Show surveyors you’re serious
Lutz and staff went over the Y2K project with the Joint Commission surveyors, talking about the project’s status, time lines, organization, and chain of accountability. Surveyors responded with questions about contingency planning but didn’t seem interested in ways to validate the truth of the information in the plan.
"I think the main thing they were looking at was to make sure that we were not only aware [of Y2K], but that we were following through with checking all of our equipment and software and that we had a plan in place," Lutz says.
She advises organizations preparing for an upcoming survey to do a presentation about their Y2K plans. "You have to do various performance improvement (PI) presentations anyway. Doing it in a PI format shows that you take it seriously."
The presentation at Community Health System was so comprehensive that the surveyor in the information management interview said that most of his questions about Y2K planning had already been answered. "He talked a little bit about security, and we left. The whole interview lasted about half an hour," Lutz adds.
To prepare for next year’s Joint Commission surveys, especially if more changes are made in the survey process, Shaw recommends that hospitals prepare for the possibility of sentinel events related to Y2K. (See related cover story.)
As defined by the Joint Commission, a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
As part of the preparation, organizations should train a Y2K team in the possibility that a sentinel event does occur or can occur, Shaw says. "I recommend that as part of any organization’s preparations process and to ward off the litigation." If such an event does occur, the team can then do a root cause analysis, which is the procedural follow-up to a sentinel event.
"This gives you a pretty good idea of what went wrong, first of all," he explains. "Secondly, you can cite the training that you have given to this specialty team in year 2000 failures. Thirdly, it will play well in court."
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