Preparing for your 2010 survey? Here's some tips
Preparing for your 2010 survey? Here's some tips
As far as its 2010 accreditation standards, The Joint Commission told Hospital Peer Review, there are not many changes. But that doesn't mean there's nothing for you to do, says Ode Keil, MS, MBA, president of Ode Keil Consulting Group.
The fact that there are no big changes "doesn't mean people can just let down their guard. I think the benefit of that is that people don't have to worry about remaking programs. They can concentrate more on sustaining them and it's not just a diversion this year," he says.
He suggests focusing on two types of elements of performance — the A elements, which he says are binary scoring, meaning you do it or you don't, and the direct impact statements. "The direct impact elements of performance count toward the outcome of your accreditation, and I don't think people have really processed that," Keil says. "That's kind of a game changer, when The Joint Commission has applied both an A and a direct impact to a specific element of performance. If you have a single avoidable deficiency, the numbers start running up, and depending on the size of your facility and the number of surveyor days, it has a direct bearing on the outcome as far as the decision goes," he says.
He adds that he still sees confusion about what threshold, or number of RFIs, constitutes a change to conditional accreditation and many hospitals don't understand what bands they fit into. If you don't know, you can call your Joint Commission representative and find out.
He says that while the standards haven't changed materially, the scoring and how it will play out does have a great impact on you. He recommends paying special attention, again, to the classification of the EPs and the "hieroglyphics" The Joint Commission has added and updated to its standards (for instance, if documentation or a measure of success is associated with a particular EP).
A "broad-brush area" hospitals are struggling with, he says, is patient records. And "there's a whole bunch of little components to this," he adds. "It's every aspect of it. It's everything from histories and physicals to invasive procedures with post-op notes, all the medication order business, pain management, every little detail of that. It's still where hospitals more frequently than not get tripped up in the survey process."
The biggest issue Kurt Patton sees in survey readiness is "the failure to rigorously self-assess. The element of performance says the hospital has a written policy that says something. And people say, 'Oh yeah, that's what we do.' But they fail to actually go and say, 'What is that policy? Where did we write that down?' And then they get stuck at the last moment; there isn't a written policy," says Patton, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission.
"The other thing they do when they're self-assessing is they say, 'Oh yeah, we do that.' But again, they haven't concretized it anywhere. So having those written policies that spell out everything that's associated with those elements of performance, I think, is very important."
He suggests more rigorous assessments and taking a more objective approach, which can be difficult, because often the quality personnel are familiar with staff across the house. He suggests interviewing staff and ensuring they know what the policies are. He also recommends checking that policies don't conflict with one another: "Oftentimes, you will have what they call an administrative policy and procedures manual; oftentimes, you will have a nursing policy and procedures manual. And oftentimes, you will have medical staff bylaws, rules, and regs. And sometimes those documents conflict. You need to make sure there's no conflict in those. You need to make sure that people are able to access those documents," he says.
He says look first at the 10 most commonly scored standards, the areas most hospitals are having problems with, which can be found at The Joint Commission's web site. He also says having "chapter leaders" responsible for understanding and communicating what is in specific chapters is a good structure for being survey ready. But the leader "has go across the organization to make sure that their chapter is effectively implemented. If you take a chapter like provision of care, that affects huge parts of the organization. And I can't sit in my office and say, 'Yeah, I think we're compliant with that because I look at my department.' I've got to go all through the organization to figure out is the entire organization really compliant?"
As far as its 2010 accreditation standards, The Joint Commission told Hospital Peer Review, there are not many changes. But that doesn't mean there's nothing for you to do, says Ode Keil, MS, MBA, president of Ode Keil Consulting Group.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.