Keep the improvement concept steady
Time is the critical element
"Watch out for things that go bump in the night," warns Paula Swain, RN, MSN, CPHQ, of Swain & Associates in St. Petersburg, FL. "As the 1999 Joint Commission standards are implemented without any caps, we see things getting back to tasks.’ Standards are expected to be implemented with gusto from the onset." With much more analysis, statistics in decision making, and numerical considerations this year, she advises that you look around your organization or department to see if improvement is truly a process that includes many topics needing enhancement, rather than merely a punch list of "tasks" to do.
She points out three things to consider when arming your staff with an enforcer for these standards:
1. Keep the concept of the improvement process steady. That is, simply:
• Develop a process that addresses the issue.
• Implement an action plan for those who need to know.
• Evaluate what was developed.
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, expects projects to be completed when it comes for its surveys in 1999. "Don’t just show a good idea heading for improvement," says Swain. The principles in the standards require:
• the need for group analysis of data;
• a shift in the picture presented by the data;
• sustaining of the new direction.
In order to have this level of work accomplished, time is the critical element. Even if your team speed-cycles the improvement process through to completion, the sustaining behavior will need to be measured long after the staff have moved on to the next project. That measure will need to be planned into the project at the onset.
2. Identify performance measures. The 1999 measures are not new, but they have been subdivided into required and optional measures. However, ORYX isn’t in either list. The required list houses the historical medical staff review issues such as blood, drug, surgical case, medical record, anesthesia, nosocomial infections, and others.
The optional list includes issues such as safety plans, performance standards, information systems, leadership effectiveness, important processes, and other issues:
• quality controls;
• risk management;
• staff opinions and needs;
• autopsy results;
• financial data;
• restraint, seclusion if necessary, and care for high-risk populations;
• performance measures related to accreditation and other requirements.
3. But what will the surveyors survey? "We will not know if surveyors will exert their biases about what they like to see measured, or if they will accept the skeleton version of required measures selected," says Swain.
Although there are fewer prescriptive standards from the Joint Commission, there is more accountability on those in the organization who dictate how the resources are used. Decision makers at staff, management, or administrative levels will need to recognize both clinical and operational issues that will meet the 1999 "optional measures."
"Use resources wisely," says Swain, "and pick projects with your eyes open."
The quality office is not the manager of these required and optional measures of improvement; it is but a guide. "Learn about the latitude that the optional measures’ encompass," advises Swain. For example, an "optional measure" is quality control. A lab or radiology technician probably would not consider the quality control program for equipment to be an "optional" measure. Nor do the external regulators, CLIA, or the federal Nuclear Regulatory Agency. In 1999, these and other such "optional" statements by the Joint Commission are required by the organization as "the way we do business."
Corporate Compliance Programs are taking lots of organizational resources in terms of time and manpower. The Office of the Inspector General has been looking at these high-risk areas:
• billing for services not rendered;
• providing medically unnecessary services;
• upcoding and DRG creep;
• billing outpatient services for inpatient stays;
• duplicate billing and unbundling of tests.
"The question is," says Swain, "do you have an established infrastructure? Are the changes sustaining as required by the Joint Commission as well as your facility’s corporate compliance plan?" If the answer is yes, go forward and feel comfortable about your survey. The optional measure, "Performance measures related to accreditation and other requirements," is being met.
[Editor’s note: For more information on using the 1999 standards and compliance programs, contact Swain & Associates at (800) 643-8449, or visit the firm’s Web site at www.snaconsulting.com. Swain & Associates will present a conference titled "Performance Improvement Strategies: Simple, Effective and JCAHO Proven" on the following dates:
• San Francisco — Jan. 21-22;
• Dallas — Feb. 8-9;
• Charlotte, NC — March 11-12;
• Secaucus, NJ — April 12-13.]
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