What JCAHO says it’s doing to address OIG’s concerns
?Accreditation with commendation’ gone?
When deciding how to respond to the Health and Human Service’s Office of Inspector General (OIG) report on hospital accreditation, officials at the Joint Commission "literally went down the list of recommendations" and attempted to match each point to an existing JCAHO initiative, says Paul Schyve, MD, senior vice president at the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
In other words, the first response was not to develop new programs in reaction to the report but to advance the notion that — even before the report was released — the Joint Commission was already taking steps to correct the problems the OIG identified.
In some cases, such as the random selection of records during the survey process, the Joint Commission did, in fact, take action before the OIG said they should, notes Mary Jane Shevlin, MA, CPHQ, director of quality improvement, utilization, and risk management at Pascack Valley Hospital in Westwood, NJ.
"It’s already being done," she says. "The hospital now usually does not know what records the surveyor is going to look at. Medical records as well as medical staff files are being randomly selected."
Not like the old days
That’s a change from the old days, says Schyve, when surveyors "would say something like, I want to see 10 records of patients with X condition who were admitted in the last three months.’ Obviously, that leaves the organization with the ability to do quite a bit of choosing of the records. Under our new policy, surveyors give very specific indications of what records they want to see. So, it’s now in the hands of the surveyor rather than in the hands of the organization what to pick and choose."
Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, adds that, in the past with medical record review, staff were able to do the audits themselves, then "hand the sheets in to the surveyor. Now, [JCAHO] is asking the surveyor to take a sample of the medical records and re-audit them to validate the reviews that were performed by staff."
The one Joint Commission initiative that seems to have been greatly influenced by the OIG report is currently the center of a debate: Should JCAHO scrap the overused "accreditation with commendation" category or revise it somehow to make it more meaningful, as the OIG recommends. Currently, an oversight task force and a separate board of directors committee are studying what action to take regarding the category. Schyve says JCAHO should reach a final verdict by the end of the year.
One of the OIG report’s most stinging criticisms of the Joint Commission was that its standard survey process simply wasn’t capable of adequately detecting patterns of substandard care or uncovering individual practitioners with questionable skills. Shevlin says she isn’t so sure the criticism is valid. "Unless they have a surveyor who will look through every single personnel file of the hospital’s caregivers and every single medical staff file, I don’t really know how you know what methodologies you can put in place to detect substandard patterns of care."
Janet McIntyre, a spokeswoman for the Joint Commission, says that the introduction of outcomes measurement into JCAHO’s ORYX initiative should help surveyors keep better tabs on patterns of substandard care. Once ORYX is fully implemented, surveyors would have access to hospital "profiles" based on those ORYX performance measures.
Getting more background on hospitals
The Joint Commission says it’s trying to get more background information to surveyors in other ways as well. "We are currently developing a process in which surveyors will clearly have a lot more organization-specific information in terms of where the strengths are, and particularly where there may be issues that need to be looked at more intensely during the survey process," Schyve says.
JCAHO surveyors already make a point of reviewing the findings of registered state agencies who have recently surveyed the hospital, Shevlin points out. "If the Department of Health has been here to see the hospital, they look at that."
Along with having much greater access to "contextual information" about the hospital, JCAHO surveyors will also have greater latitude in addressing issues specific to individual hospitals, rather than merely taking a cookie-cutter approach, Schyve says. "Surveyors need to know that they have the freedom in the survey process to follow through on things that they see. It’s like finding a loose thread, pulling on it, and asking, Where does it go?’ — rather than simply noting that there was a loose thread and quickly moving to the next issue on this list."
Schyve says surveyors have already been instructed to vigorously follow up on concerns raised during surveys. "Obviously, as we move forward with our project to provide more contextual information up front to the surveyor, we will also give them more guidance in this," Schyve says.
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