Joint Commission surveys will change in a big way

It appears the Oakbrook Terrace, IL- based Joint Commission on Accreditation of Healthcare Organizations has heard all the wailing by hospitals across the country and is announcing a major overhaul of the survey process. Under the new system, the accreditation process is supposed to be more relevant to actual patient care and less of a hassle.

The Joint Commission’s Board of Commissioners determined that "now is the time for the Joint Commission to take bold action" and "radically revamped the accreditation process," says John Noble, MD, board chairman. The new plan, called "Shared Visions — New Pathways," goes into effect January 2004.

Dennis O’Leary, MD, president of the Joint Commission, says the new survey process will be more continuous and eliminate much of the "ramp up" before a scheduled survey. A task force is continuing its efforts to review all Joint Commission standards and eliminate those that are redundant or unnecessary, he says.

"We’re consolidating, saying things in a lot fewer words and moving standards to the most appropriate sections," O’Leary says. "We have reduced the number of scorable elements, and that has a significant impact in terms of the burden on accredited organizations."

The new-and-improved system includes these components:

  • Streamlined standards and a reduced documentation burden, with more focus on critical patient care issues.
  • A self-assessment process intended to support an organization’s continuous standards compliance while freeing up survey time to focus on the most critical patient care issues.
  • A system for focusing surveyors on specific areas that need attention during their visit. Organization-specific data are used to highlight those areas.
  • A new survey system with six basic components that will replace the standard triennial survey format. The system starts with an opening conference between surveyors and hospital leaders, which is followed by a leadership interview, validation of self-assessment results, a focus on actual patients as the framework for assessing compliance with selected standards, discussion and education on key issues, and a closing conference.
  • More training, requirements, certification, and an enhanced role for surveyors. Surveyors will have to be certified and recertified every five years.
  • Revised decision and performance reports providing more meaningful and relevant information.
  • The use of ORYX core measure data to identify critical processes and help organizations improve throughout the accreditation cycle.
  • Better engagement of physicians in the new accreditation process.
  • A new approach to surveying complex organizations.

The self-assessment, in which you look for much of what the surveyors would have looked for in the triennial survey, could be the biggest change for health care providers. An accredited organization will complete the self-assessment at the 18-month point in its three-year accreditation cycle, rating its level of compliance with all standards applicable to that organization.

If you find that your organization is not compliant in any standards area, you must detail the corrective actions that you have taken or will take to comply. Once the information is submitted, a Joint Commission representative will contact you to review the findings, approve the corrective actions, and provide advice on taking those actions. At the 36-month point, the time for the triennial survey, surveyors will visit the site to verify that the corrective actions have been taken. The surveyors also will validate the self-assessment by reviewing specific critical areas.

Providers that are at the midpoint of their accreditation cycles or beyond as of January 2004 (meaning they are due for a survey in July 2005 or after) will receive the self-assessment tool in July 2003 or thereafter. Once you receive the self-assessment tool, you will have three to six months to complete it and plan any corrective actions.

The biggest change during the on-site survey involves what the Joint Commission calls "tracer methodology." In short, surveyors will trace the experience of actual patients through your system to determine compliance with Joint Commission standards instead of quizzing staffers and studying representative documents. That system will focus the survey process much on actual patient care rather than theoretical compliance with standards, says Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission.

"In the past, surveyors might have asked what steps you take to prevent wrong-site surgery and the organization would talk about procedures, education, and other steps," he says.

"In the future, we’ll get at the same information but in a different way. We will choose at random from open records a patient who has just had surgery, and we’ll trace that patient through the process. The surveyor will go to the ER [emergency room] and ask how they X-rayed the patient, how they obtained consent, and so on. Then if the patient went to a unit, the surveyor will go there and talk about preoperative preparation. Then they’ll go to the OR and say, When this patient came up, was the site marked? Did you have a time out before you began surgery to discuss whether this was the right patient and what procedure you were doing?’"

All of the questions will be derived from the actual patient’s chart, Massaro concludes.