Consultant: Scoring, PPR requirements still unclear
Consultant: Scoring, PPR requirements still unclear
What you can do to prepare
Do you understand the new Joint Commission scoring methodology? According to Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO/health care consultant, Mellott & Associates in Houston, the changes and their impact are still unclear to many quality professionals, and there is a lot of information still to be gleaned to prepare your facility.
In the last issue of Hospital Peer Review, we discussed the changes, and though The Joint Commission says it has spelled those out, the field remains unclear about many of the elements, Mellott says. One of the biggest areas of confusion is what constitutes conditional accreditation (CA). According to The Joint Commission, as noted in the December 2008 issue of its publication, Perspectives, hospitals are stratified into bands. The bands correlate with the number of survey days and the number of noncompliant direct impact findings that would trigger a more intense review from TJC's central office in which it would decide whether CA status was appropriate.
"The table is very clear to The Joint Commission and no one else," Mellott says. "I think one of the biggest misunderstandings on the health care side — not The Joint Commission side, but the health care side — is people have trouble figuring out which band they would fall into." Previously, there was a set number of findings to trigger CA. It's just not as clear now what your findings might result in. For instance, Mellott says, let's say your facility has 55 requirements for improvement (RFIs), and 10 of those fall into the direct impact category, with the remaining in the indirect impact category.
"Now what does this mean?" she says rhetorically. "And how much weight does direct have more than indirect?
"Well, we in the field don't really know because it's all a computer program that has weights in there and [TJC] hasn't told us yet. All we know is the direct weigh more in the decision than the indirect."
Situational decision rules
Her advice? First, call your Joint Commission liaison to find out what band you fit into. Second, review your standards manual and look at the pyramid in the section labeled "how to use this book."
"At the very top is the immediate threat and at the bottom is the indirect. And [TJC is] describing the immediate threat to life. Everyone kind of gets that. Then the situational decision rule, [TJC] doesn't necessarily tell you that there's very, very few of those," she says. If an organization has one or more situational findings, it can be put into immediate conditional accreditation.
Color coding can help
Situational decision rules are marked in the manual with a solid triangle that has the number two in it. If a standard is direct impact, it's marked with a white triangle with a three in it. Mellott says it's helpful to go through the book and colorcode the different categories. For example, she's colored all the direct impact rules blue and all the situational ones pink. In doing this, she found there were actually only a few situational decisions, and those have not changed from the past. They include:
- how staff function in an organization compared to their licensure;
- complying with the laws and regulations of the organizations;
- maintaining your facility's statement of conditions;
- the interim life safety policy;
- physicians only practice within the scope of their privileges;
- independent practitioners, such as physicians, are licensed.
Previously, The Joint Commission had two ways of scoring. One, Mellott says, was identifying if you were in compliance or partial or insufficient compliance. Then a score was given based on how long you had been in compliance. "They took that out this time. And I like that because I don't think they used it very often and the couple times they were used, they weren't used appropriately or standardized across all hospitals or situations."
So now, she adds, we know if the measure requires a document, The Joint Commission is going to look to ensure there is a document. Direct impact findings are more important than indirect impact findings. If an element of performance requires a measure of success, The Joint Commission is going to look for evidence of not meeting the standard several times before it sites you, and "the magic number" appears to be three, Mellott says.
Still confused about PPR requirements?
The Joint Commission wants organizations to do periodic performance reviews (PPRs) in which you "look at every single standard, rate yourself on them, [and] send Joint Commission a report every year about the time you were last surveyed," Mellott says.
If you were surveyed three years ago in September and by September 2009, The Joint Commission has not yet surveyed you, you're still required to do a PPR, she says. But if they come for the survey in February, you wouldn't have to submit one. "So that's one confusing point," Mellott says. "Secondly, many hospitals and their lawyers said, 'Oh no, we're not sending that kind of information through the mail up to The Joint Commission. There's no way we're giving them all that information. That's too much ammunition, or potential ammunition, if someone outside The Joint Commission gets their hands [on this information.]'"
Because of this, The Joint Commission has put in alternatives, Mellott says. The first is to have TJC surveyors come in and do about a third of what would normally constitute a survey. "So if you're used to three days and two people, you would have someone come down and do a two-day survey. And they will do what they can during that time frame." The surveyor would leave you with a report, which will go back to The Joint Commission. When your action plan is complete, TJC would tell you if it is approved as being compliant with the standards.
The second alternative is to send a surveyor, who would not leave a written report but rather a verbal one and no subsequent communication with The Joint Commission is required. The last option is to tell TJC you have an action plan and when the surveyors arrive, they will ask to see it.
"Interestingly enough, some organizations that are systems have decided they want to spend the money and bring in a surveyor for two days when they could do it themselves. But it's a lot of work," Mellott says.
"So doing it themselves takes a lot of time. You've got to do a cost-benefit analysis to decide which is worth it." Yet another option is to bring in a consultant. Admitting she is biased as she herself is a consultant, she says bringing one in probably will cost less money than having a Joint Commission surveyor. She says a lot of organizations think that if they bring in TJC surveyors, it will give them more leverage if, for instance, there is a question at the time of the actual survey.
Unbundled EPs, standard changes
Where elements of performance (EPs) previously were bundled together, The Joint Commission has broken them out into separate EPs. Does this require more work on your part? Yes and no, Mellott says. It will require more paperwork to separately document each one. "The good thing about it is when you bundle things together, let's say there's five things in one point and you have one of those wrong, you lose the whole question," she says. "This way, you have five chances."
With the 2009 standards, she sees "some standards that have more detail in them. And that detail hasn't necessarily been pointed out to people. And in fact every time I get in there, I find something else that I wasn't aware of. And it's not that it's new; it's just phrased in a different way, or it's pulled out so it's more explicit."
Prepping: What to do
Mellott suggests the following tips to quality improvement directors and regulatory officers:
• Check your data collectors.
"Make sure that the people collecting the data are, No. 1, looking outside of their own department." She says it's common to see one nurse assigned a chapter, and so that nurse looks only at nursing assessments and not at physical or respiratory therapy assessments. Or assigning a lab director to know all about waved testing. "Waved testing," Mellott says, "is a laboratory responsibility, but it's testing that goes on outside of the lab. So if they only look at what they do in their place and don't look at all of the places that are doing waved testing, you're not going to get it. It's about going outside of just one discipline to look at all these standards."
• Check cited standards.
"Look at any published information that Joint Commission puts out on the most frequently cited standards. And focus on those."
• Check National Patient Safety Goals.
"Absolutely, 100%" look at your compliance with the National Patient Safety Goals. "Last year there were two patient safety goals that were phased in over the year. One was the rapid response, and the other was anticoagulant therapy. [Organizations] better be ready to support those two," Mellott says. With rapid response, she clarifies, that doesn't necessarily mean a rapid response team but an early intervention method. She says during one hospital survey, surveyors talked to one person on a clinical unit who didn't know how to call for help if he or she needed it for a patient. That hospital was cited.
When the anticoagulant and rapid response goals came out, she says a lot of hospitals responded, saying, "Oh, we already do that."
"But they don't look at the details," she says. "Because the devil is in the details."
For instance, with rapid response, she says, a hospital she consulted for had a team in place but "they weren't collecting any data on how effective it was. I mean, they had it, and it was working, but they didn't have any documentation that they needed to have for quality."
She says next year, The Joint Commission will target the infection control measures under Goal 7, which are to be phased in by January 2010.
• Get staff involved.
The Joint Commission doesn't "want to talk to anyone but the staff," she says. "They don't want to talk to any managers, the chief nursing officers."
Do you understand the new Joint Commission scoring methodology? According to Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO/health care consultant, Mellott & Associates in Houston, the changes and their impact are still unclear to many quality professionals, and there is a lot of information still to be gleaned to prepare your facility.Subscribe Now for Access
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