Guest column
Data processes: JCAHO’s data-driven’ agenda
By Paula Swain, RN, MSN, CPHQ
Swain & Associates
St. Petersburg, FL
Over the past several years, the emphasis on data used to describe processes has largely driven the changes implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. That was most apparent in the changes made to the performance improvement (PI), information management (IM), and leadership standards (LD).
The journal articles and educational sessions stressed graduating data into information to make "informed decisions" in care and management. Some people may have wondered what a survey would look like if it had an emphasis on data. Below are a few ideas that the JCAHO surveyors are projecting for the new year:
1. Data-driven agendas.
More observations will be made to increase the denominator numbers. For example, there will be more observations of patient care processes. Since there is a focus on patient safety, there will be a review of the medication use process. The surveyors will combine many standards by looking at one patient situation. An example would be observing the nurse administer a drug.
There are several processes involved in that function. Determination that the patient assessment (PE) by the nurse shows the patient condition for administration of the drug (TX), i.e., Fosamax, a calcium-sparing drug, that must be given on an empty stomach with water only, and the patient should not lie down for at least 30 minutes. In addition, the surveyor will observe for the nurse completing the patient education (PF) on the drug’s side effects, and that the nurse is competent to administer the medications provided by the unit’s scope of services (HR).
This type of surveying requires much more time than previously required on each patient unit; thus, many more interviews and observations can be carried out.
The open medical record review must be understood by the unit staff as well as those who support the unit through their services, such as the therapies — respiratory, physical, occupational, and speech — and nutrition and other services. Staff assist the surveyor when finding information in the open chart.
Be prepared to have all staff notes easily retrievable in the record. If nutrition staff customarily carry their notes back to the office, make sure there is an integrated document of some type to write an action plan or recommendation. If the other services and nursing cannot find the evidence of the nutritionist’s visit, it is hard to defend an integrated records or collaborative approach to care.
Other types of observation include watching staff, including physicians, wash their hands between patients and questioning staff who are wearing gloves outside of patient care areas. Patient safety is a prevailing concept, so keep answers focused on that as staff are asked questions about separation of clean and dirty — supplies, food, linens, equipment.
In addition, more than one surveyor may descend upon a unit, which adds more to the denominator. The surveyors aggregate their data to provide the final scoring of the observed and interviewed standards.
The new scheduling allows much more time on each unit. Where just a year ago a unit visit might take less than an hour, the new survey process requires twice that time. It is common to see 1.5 hour visits. For example, while moving through a maternity unit, it might take an entire afternoon from 1 to 4.
There also is time in the schedule to allow surveyors to go back and continue their analysis of important findings that surfaced during the first pass of the survey process. These time slots will be listed on the survey schedule as "special interview/issue resolution or patient care visit."
Expect patients and their families to be questioned. Do not be concerned when staff accompanying the surveyor are left outside. That is customary and shows respect to the patient being interviewed.
Finally, ORYX data have graduated from a review of the data alone to an evaluation of the use and response to the data. Data are provided to make a difference — what difference did the organization make. Answers can range from, "we chose to do nothing" to "these are the findings from changes made. . . ." If there were changes based on ORYX, be sure that the findings have been communicated to the area where the change occurred.
It is very common to connect the initial interview information with validation at the unit level. An example might be "length of stay in orthopedics" as an ORYX measure. If stay has changed, be sure the orthopedic unit knows about the change and can speak to "sustaining the gain."
2. Survey process changes.
In the 2001 surveys, look forward to seeing more of the surveyors throughout the day. Visiting staff on other shifts, namely evenings and nights, has proven successful, so the "off shift" will be a methodology used in the future.
Also, four interviews will be eliminated. The patient and family education, continuum of care, medication use and nutrition, and the anesthesia and operative interviews will be incorporated into other interviews. For instance, the querying done in the unit interviews and other specialty interviews such as medical staff leaders and directors will cover some of these topics.
The patient care interview will remain, and findings from the open record review will help fuel the questions. That is, if the surveyor’s experience shows very poor compliance with the facility’s use of the patient education document, it will be addressed here. Also, if the screening criteria are not used and referrals are not made throughout the patient process, the continuum of care questions will be consolidated into the patient care interview.
3. Random unannounced surveys.
Many organizations will not have a planned three-year survey in 2001. Because the window for random unannounced surveys is from nine to 30 months after the previous survey, many organizations will have that type of survey to look forward to. There are a few things that can be prepared for, such as:
• There are fixed elements established by JCAHO. Fixed elements tend to be previous recommendations from other surveys and how the action plan is being addressed. Is the organization finished with the action plan and in the monitoring mode, or has there been no action on the plan at all? Plus, there are always those predictable infection control and management of the environment of care review elements such as cleanliness and fire safety that are fixed elements.
• There are variable elements that take their direction from a variety of areas. For example, JCAHO will come supplied with data from its complaint "hotline" and data obtained by state surveyors. JCAHO reports it will have a conference call with the Health Care Financing Administration to determine the priorities for 2001.
Surveyors will be taken through medication review process training for use with the survey process changes (see item 2). This is consistent with using every opportunity to reduce medical errors and enhance the patient safety in health care today.
4. Assorted other survey issues.
While preparing, keep a focus on survey caps. That is the "training period" allowed by the JCAHO. While in training with a new standard, the scoring is more lenient. For example, pain management has been "in training" throughout all of 2000, and will be fully scored, without caps, in 2001. Also, the new restraint standards are not capped; they will be fully scored in 2001. If a hospital is a critical access hospital — a small rural facility with unique conditions of participation — the survey process will be tailored for it.
An assisted living facility that is part of a hospital will be surveyed with the hospital.
A long-term care facility that has exclusionary criteria of an average length of stay less than 30 days and an average daily census of less than 20 should not pass the Consolidated Accreditation Manual for Hospitals (CAMH). Rather, the unit will have a tailored survey with the hospital, using the long-term care standards.
There will be more in-depth assessment of credentialing and peer review consistent with the changes in the standards introduced during the summer of 2000.
5. Survey day reminders.
Document review session. Do not put more into the document review than that requested in the survey guide book. It is laborious and time-consuming to have to review excess material. Oftentimes, the survey element being searched for cannot be found due to all the extemporaneous material in the manual. Keep a runner handy in case material cannot be found.
The daily briefings are set up for the surveyors to get clarification for their needs, not the facility. However, if there is a question about a finding, or the data have been found for a poorly answered question, disclose it during the briefings session.
The Human Resources interview can be improved greatly by organizing the staff folders prior to the survey. Just separating hiring and benefits data from mandatory material such as performance evaluations and education helps. Organize in chronological order; put the newest material on the top, and put a model personnel file together with tabs and landmarks "Post-it noted." The model can be used as a reference. That way, if any documents are missing, at least the surveyor has a clue as to what he or she is looking for.
Standardize what is being done at the multiple anesthetizing sites. Since all of the sites are going to be reviewed for their consistency and compliance to the sedation and anesthesia standards and patient rights issues, have staff crisscross into each others’ units to see how care is conducted.
By having the staff from other anesthetizing units check on each other, they can see differences in practice. It is then easy enough to recognize the logic of the difference and document it, or change the practice.
Remember, the surveyors see the organization from a bird’s-eye view. That perspective provides insight to an organization that might otherwise be missed. As much as an organization might feel it communicates well internally, it probably does not. Staff in one area will do things their way, and in another area a different track will be followed. Surveyors see this and will use it to their advantage. Although mock surveying helps bring consistency to the process, new policies continue to roll out. Remember to require the policy-makers to define what the implementation and evaluation components of those new policies are.
If there is not a good metric to measure the impact of the new policy, it is likely that a flawed policy will not be identified until a negative event occurs. Improvement means to reduce variation. These are the days of patient safety. Be proactive in your approach; it will surely be noticed by the surveyors on survey days and by your patients everyday.
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