6 months for self-assessments, few resources will be needed

Pilot hospitals did assessments in eight weeks

The self-assessment requirement in the "Shared Visions — New Pathways" survey process may not be a shock to anyone who has used self-assessment tools already in preparing for a survey. The Joint Commission on Accreditation of Healthcare Organizations’ version should be familiar and not much more trouble, says Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission.

In the pilot programs, the participating hospitals reported that they didn’t need any new resources to complete the assessment, and most already were completing self-assessments as part of their survey preparation. The pilot hospitals completed their self-assessments in only eight weeks, though they said they would rather have three to six months. To address that concern, the new system calls for the Joint Commission to contact organizations three to six months in advance of their accreditation midpoint with information about the on-line self-assessment tool. While doing the self-assessment, organizations can click on a "references" tool to read the standard’s elements of performance and examples of implementation.

As long as an organization plans appropriate corrective action, the self-assessment will not change its accreditation status, Massaro says. The Joint Commission staff also will work with organizations to develop appropriate corrective actions, again with no penalties. When it is time for the triennial survey, the surveyors will validate the organization’s compliance by looking at a minimum 12-month period in which all the corrective actions were in place. The corrective actions developed with the self-assessment will be used to develop the approach used by the surveyors.