Joint Commission 2009 scoring changes: How will they affect you?
Joint Commission 2009 scoring changes: How will they affect you?
A lot is still uncertain about how changes will affect accreditation
Effective July 1, accredited hospitals will be scored on both the 2009 accreditation standards and the additional requirements released by The Joint Commission in March to bring the accrediting body more in line with CMS Conditions of Participation (CoPs). But that's not the only thing that will be different in the scoring and surveying process.
In January, all elements of performance (EPs) were classified as direct impact or indirect impact requirements to reflect the potential impact on quality of care and patient safety as the result of non-compliance with the EP. Previously, organizations were required to provide evidence of standards compliance only for requirements for improvement (RFIs) but not supplemental findings; now they must provide evidence of standards compliance with both direct and indirect impact findings.
For direct impact findings, you'll have 45 days in which to turn in your evidence of standards compliance, and with indirect impact findings you'll have 60 days. Evidence of compliance with EPs requiring a measure of success must also be submitted. In addition, the B classification for EPs is gone and EPs are classified either as A or C. In April, changes were made in the classification of some standards and EPs.
The criteria for determining either conditional accreditation (CA) or a recommendation for preliminary denial of accreditation (PDA) have changed as well. "As you'll recall before, we had program-specific thresholds based on a count of not-compliant standards at the time of survey. If you hit a predetermined number, it would result in a recommendation to the accreditation committee for conditional accreditation," says Phavinee Thongkhong-Park, PhD, RN, The Joint Commission's associate director, accreditation-certification evaluation methods and education in the division of standards and survey methods.
In the new methodology, thresholds — based on a count of not-compliant direct impact standards — serve as screening points for more intensive Central Office Review of the survey findings. In the hospital accreditation program, several bands of screening points have been established to account for differences in size and complexity of surveyed organizations.
The number of surveyor days will be based on the band classification, which also will correspond with the number of non-compliant direct impact standard findings that would result in further review. For instance, hospitals that are classified as band 1, noncompliance with seven direct impact (indirect are not figured in here) standards would trigger a "screen" for more intensive review. And surveyor days would last between one and four days. (Editor's note: See The Joint Commission Perspectives, December 2008.)
That means the findings for that organization would be subject to a more intensive review by The Joint Commission's Central Office — unlike before, when a certain number meant a conditional accreditation decision. Now the survey findings will be reviewed and the "severity" of the findings will help the accreditation committee determine the level of accreditation. So if an organization reaches the threshold, it could result in accreditation with RFIs or a recommendation for an adverse accreditation decision.
"The degree of the observations and their impact on patient safety, whether they're an isolated instance of noncompliance or a systemic problem — these factors will be used to determine whether CA is warranted after review by The Joint Commission Central Office," says Thongkhong-Park.
What can you expect to see when the surveyors leave your hospital? The report will no longer include a preliminary accreditation decision because the decision goes to The Joint Commission for review. But "The Joint Commission will continue to leave the preliminary survey report," says Thongkhong-Park.
If there is noncompliance with one or more direct impact requirements, the report would show what it traditionally has for noncompliance with the specific Joint Commission requirements. Beginning in July, the report also will include references to the associated Medicare Conditions of Participation and standards. The format of the RFI is similar to the CMS principles of documentation.
Thongkhong-Park says cross-referencing The Joint Commission standards and EPs with the associated Medicare Conditions of Participation helps organizations identify observations associated with Joint Commission requirements and the CoPs.
The Joint Commission says immediate threats to life situations are those in which patients, staff, family, etc. are put at jeopardy as the result of the situation (e.g., inoperable fire alarms or fire suppression systems). Once identified by the survey team, the president of The Joint Commission is consulted. If he, or his designee, concurs that an immediate threat exists, the organization's accreditation status will immediately change to preliminary denial of accreditation and will remain as such until the situation is resolved and a survey is conducted to validate the corrective action. The organization's accreditation status would change from preliminary denial of accreditation to conditional accreditation and would remain at that level, usually for four months, until a second survey is conducted to evaluate the sustained implementation of the corrective action.
Another change: If your hospital has home care and long-term care components, accreditation decisions of those specific components would not affect the accreditation status of the entire organization.
What are your peers saying?
Paul Green, MS, RN, CPHQ, director, performance improvement at Scripps Memorial Hospital La Jolla in San Diego, questions just how the scoring changes are going to impact organizations going forward.
"We don't know quite how that's going to play out. It's been a difficult year for accredited organizations to sort of judge where they're at and sort of anticipate what your outcome of the survey is going to be," he says.
"I've been doing this for over 20 years with The Joint Commission, and we've always been able to, when we did our PPRs or our mock surveys, we were always able to sort of be able to predict how scoring was going to come out. We knew what the thresholds were for conditional accreditation or provisional denials."
Does he anticipate a bigger workload as a result of the changes in scoring methodology? "It really has increased the workload" of hospitals, he says — since now accredited organizations must supply ESCs for both direct and indirect impact findings.
"We always took the supplemental findings and took them under consideration and learned from them and used them within the organization but we didn't have to go through the formality of putting together a plan that had to be submitted to The Joint Commission with approval by The Joint Commission," he says.
Juan Inurria, system executive for quality & patient safety at Memorial Hermann Healthcare System, says, "If you're falling out [of compliance], that's a lot of additional work. Obviously, you don't want to fall out. Where the challenge is, is that most hospitals do not normally pay close attention to the CoPs on a day-to-day basis. So for the hospitals typically accredited by The Joint Commission, the focus is Joint Commission standards. And so sometimes the hospitals may not be as familiar with the language of the CoPs, and more importantly with the interpretative guidelines from CMS for the CoPs."
Scoring the changes
• Accreditation status decision criteria.
"The theory behind the new [scoring] model The Joint Commission is following is really getting closer to CMS' CoPs," says Inurria. "And they're really looking for those that put a patient in jeopardy. And that really carries more weight than anything else. You can be non-compliant in one of those and literally your accreditation can be removed immediately [with a finding of an immediate threat to life]."
And determining CA status now "is really left to the discretion of the surveyors and eventually the headquarters of The Joint Commission on how they are going to put all of those together into a potential conditional accreditation."
• Number of EPs.
Green adds that The Joint Commission "did reduce the number of standards, but greatly increased the number of EPs." This increases hospitals' workload even more, he adds, as each EP requires that you show evidence of compliance and is scored, whether it's classified as a direct or indirect impact or is associated with a measure of success. The Joint Commission says EPs that before were "bundled" have now been separated out as distinct requirements for clarity. "So instead of that being one EP, now it's three," Green says.
"I'm not trying to criticize The Joint Commission because I do think they're doing the right thing. I think what I'm trying to express is that until we get used to this, it is more work and it is more confusing."
• B classification gone. EPs labeled A or C.
As far as the elimination of the B classification in scoring EPs, Green says, "actually that does make intuitive sense. That actually does simplify it a bit." And Inurria concurs that the B category had led to some confusion. Removing that classification "takes away some of the gray area in the long-run that I think is beneficial," he says.
Kurt Patton, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission, says, "The biggest surprise to me was there was no explanation with the [scoring changes released in April by The Joint Commission]. And I think an explanation is warranted because it helps the accredited organizations understand why things are changing.
"For example, looking at the number of issues from the life safety code and environment of care, it may be that CMS has said, 'In order for you to maintain your deemed status, you need to align with us to a greater extent.' And I think the accredited industry would say, 'OK, we understand that.' However, it may be that they're just making mistakes in the assignment of EP category and then in thinking about it later, they're looking at them and saying, 'Oh, I see that doesn't make sense. That ought to be an A or a C.' And I think that's a greater flaw."
He says in other areas — for instance with draft standards — The Joint Commission has a public process allowing industry comment. But no such process for scoring decisions exists. Category A, he says, "means, by and large, it should be a yes-or-no situation; you have a policy or you don't have a policy. Or you do it 100% of the time or you don't do it 100% of the time. The Cs mean we're looking for you to do it 90% of the time. So the C should be performance-based issues; we even have lots of observations."
As far as the recent scoring changes, he says, with many of the environment of care-related standards, it seems the changes are most likely a result of The Joint Commission trying to be more in line with CMS. He adds that many of the scoring changes in medication management, moving from A to C, "make sense. Because when you read those, they seem to be performance-based issues. The ones in the performance improvement chapter, they went from Cs to As. And As actually seemed more appropriate for those also, because they refer to having a review and analysis process; not that you use your review and analysis process at some predetermined frequency. So that made sense that there's not going to be a numerator or denominator. You either have a process or you don't have a process."
Survey preparation
As far as survey preparation, Green says, the processes at his hospital, surveyed April 6, didn't "so much change other than increasing our stress factor about not knowing... It's one of those things about being one of the first organizations that comes out of the chute. So you're getting scored on new standards, an increased number of elements of performance, and a scoring methodology where there's no benchstep in terms of people having undergone it."
In the end, he says, the survey went fine. The surveyors were focused and collegial. What was different was that he says usually surveyors will give you an idea of how your organization fared. Not this time. And while he usually receives accreditation results within two days, this time around it took two weeks.
For his part, Inurria says 10 hospitals from the Memorial Hermann system have been surveyed this year, and all went fine.
"I found the surveyors to be pretty realistic and reasonable in reviewing the particular standards that they feel were non-compliant and really have had no problems in having the dialogue and maybe even being able to turn around their initial findings if we present to them more evidence or clarification," he says.
Asked if he thinks The Joint Commission's move to be more in line with CMS will help the organization "kill two birds with one stone," so to speak, Green says: "Yeah. Well, I do think it's good that it's more in line with CMS, especially as the industry is starting to see more CMS activity, especially here in California. From a provider standpoint, we have situations where we had Joint Commission come in and they review it and everything's fine. And then CMS comes in and takes a look and says, 'Nope. You're out of condition.' So that's sort of an unfair place for us as providers when we've been doing our due diligence and doing what we're supposed to do."
His advice to quality improvement professionals is to spend time reading the beginning of the standards manual and trying to understand the "new sort of survey methodology and the scoring methodology... And if you have problems understanding it, seek help and advice either from The Joint Commission or from other resources about how it's going to play out."
Field review on staffing effectiveness
Patton refers to The Joint Commission's ongoing field review of staffing effectiveness requirements, which will be open for comment until July 22, 2009. "Just the fact that they were tweaking the PI standards relative to staffing effectiveness caused me to be a little bit amused because the industry has thought those were rather useless for years, and there's been talk at The Joint Commission about doing away with them. And here we're sort of fine-tuning them before probably eliminating them."
Inurria says, "they're looking at dropping the traditional EPs of this kind and maybe looking at measures that are more outcomes oriented and maybe more evidence-based oriented. The challenge is that... it's very difficult to have national studies and operational definitions that are reliable and that statistically really you can correlate your staffing effectiveness and skill mix and so on and so forth to outcomes." He says there is not enough literature to correlate a particular indicator with a particular outcome.
And even though his health system does track such things as decubitus ulcers and near misses and tries to tie those to the staff on the unit at the time, "to actually make all of this a national expectation, that's going to be a challenge," he says. "I think at the end, every hospital will have to develop its internal methodology." But even though The Joint Commission is getting pressure to drop them and despite the challenge of tying them directly to outcomes, he doesn't see them going anywhere.
It's clear that many areas of confusion for what is coming from The Joint Commission exist. Green says, "it's been a difficult year for accredited organizations to sort of judge where they're at and sort of anticipate what your outcome of the survey is going to be." Are more changes coming? Green thinks so. Laughing, he amends his previous statement: "It's always a tough year to be in health care. It's never an easy year to be in health care."
Effective July 1, accredited hospitals will be scored on both the 2009 accreditation standards and the additional requirements released by The Joint Commission in March to bring the accrediting body more in line with CMS Conditions of Participation (CoPs). But that's not the only thing that will be different in the scoring and surveying process.Subscribe Now for Access
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