Critical Path Network

Hospitals getting more RFIs in 2006: What problems are surveyors finding?

New process is better at uncovering areas in need of improvement

Since the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) unannounced survey process began in January, the average number of requirements for improvement (RFIs) given to hospitals has increased to 6.9 as of April 2006, compared with 5.8 in 2005.

"It's not a huge difference, but RFIs have gone up, about one RFI increase per organization," says Linda Murphy-Knoll, vice president of service operations for JCAHO's division of accreditation and certification operations.

The trend could be due to the use of tracer methodology, which takes surveyors to the actual point of care with patients, and also the fact that surveys are now unannounced.

"It's obvious to everyone that we will find more, versus looking at policies and procedures in a room," says Murphy-Knoll. "I think that in the past two years, the surveyors have just gotten better at doing tracers and pulling threads. They find something, become interested in what they have found, ask more questions, and find more RFIs."

JCAHO's new process is part of the reason for the additional RFIs, says Judy B. Courtemanche, president and CEO of Courtemanche & Associates, a consulting firm specializing in regulatory compliance and outcomes management, based in Charlotte, NC. "There is the element of surprise, and the tracer process reveals process gaps more quickly than previous survey methodologies," she says.

Scoring also is more severe: Three instances will earn an RFI in most cases, but in some cases only one infraction with a required element of performance can generate an RFI.

"There are also increasing performance expectations from JCAHO," says Courtemanche. "An unrelenting emphasis on medication management continues to generate RFIs. There is also a JCAHO requirement that surveyors note findings regardless of potential scoring."

In addition, technology alerts JCAHO to areas in need of improvement, even if findings are not discovered by surveyors, notes Courtemanche. At the same time that JCAHO has better prepared surveyors with more intensive survey tools, organizations are struggling to keep up with the continual regulatory changes coming their way, she says.

"Preparing entire organizations to respond to the possible surveyor tracer has required unplanned resources of time and money just to stay afloat," she says. "Organizations that have always performed well are finding the new approach difficult to prepare for. The results are often an unexpected shock."

Leaders must change their approach to accreditation from a one-year ramp-up to adopting continual compliance strategies that render their organizations survey-ready at all times, says Courtemanche. "Organizational philosophies must embrace regulatory compliance as a basic operating tenet."

Health care professionals can advance this process by staying informed and keeping their leaders informed, she says. "Leaders do not want to hear that the new survey process is producing unexpected results and that they could lose their accreditation. Leaders want to hear how the organization can standardize its approach to assure predictable outcomes," she says.

The RFIs are coming for medication reconciliation and other National Patient Safety Goals and Environment of Care (EOC) standards, according to Susan Mellott, PhD, RN, CLNC, CPHQ, FNAHQ, CEO of Houston-based Mellott & Associates, a consulting firm specializing in health care performance improvement. "With the advent of unannounced surveys, the hospitals cannot prepare for survey like they did before," she says.

It's important that new standards are implemented prior to the date they become effective, says Mellott. "They must be proactive rather than reactive. They must also have members of the facility do tracers every month to assure that the processes are working," she says.

Here are some trends in RFIs received by organizations in 2006:

• Use of unauthorized abbreviations. Organizations are required to identify a list of abbreviations they will not allow to be used in daily medication-related documentation, and at a minimum must use the JCAHO's list of nine abbreviations, although they can choose to add additional ones.

"What we are finding is that it is really a cultural barrier," says Darlene Christiansen, RN, LNHA, MBA, JCAHO's executive director for accreditation and certification operations. "Licensed independent practitioners who have been in practice for a number of years were taught to use certain abbreviations. It's a matter of reeducation and reinforcement about the reason behind this, which is safety for the patient, because there have been medical errors made and sentinel events that have occurred when those abbreviations were used."

Organizations have been receiving RFIs for failing to educate contractual employees about unauthorized abbreviations. "That can become challenging if there is a large group involved with a rotational schedule, but you have to work with the contractual service to develop an ongoing education plan," says Christiansen.

• Medication reconciliation. Although most organizations have a process for medication reconciliation, it's often not comprehensive enough, says Christiansen.

In 2005, organizations were only required to have developed a process to reconcile a patient's medications, but as of Jan. 1, 2006, surveyors are looking to see that the process actually has been implemented.

"It begins at the patient's point of entry into the organization, and continues on through the continuum of care," says Christiansen. "Each time the patient changes the level of care, medication reconciliation is critical."

The point of entry is the most critical and most challenging part of the process, whether the patient comes through the ED or direct admissions, says Christiansen. "You may have a nonresponsive patient without family members immediately available, which poses a big challenge for the caregiver who needs to provide medication."

Surveyors want to see that staff obtain a complete medication history, not only for prescription drugs, but over-the-counter and herbal medications as well.

"The difficult piece is to be more comprehensive," Christiansen says. "If the patient is able to contribute, you can get much of the history from the patient. But even then, you may have to prompt the patient with questions. A patient may forget to mention that they take aspirin every day or other over-the-counter medications."

• Communication during patient hand-offs. Surveyors want to see a process in place to ensure that caregivers communicate with each other with an opportunity to ask questions, when passing care on from one shift to another, or one care provider to another.

"We are not asking that the process be documented, but we want to ensure there is a process in place. When surveyors come through and do their tracer methodology they need to observe that process," says Christiansen.

• Life safety code compliance. A life safety code specialist is now present during surveys for hospitals with 200 or more licensed beds.

"So we are seeing an increased focus in EOC, and with that comes additional RFIs," says Christiansen.

"This has been a focus for JCAHO for the past four or five years, but the focus is now more intense. The EOC is a high-risk area for the patient population and for the staff internally," she says.

A common problem is that organizations having construction have not implemented the interim life safety code measures that are required, such as an increased number of fire drills. Another area is that when an organization brings in contract staff to do repairs or construction, they have not been educated on how to ensure patient and staff safety.

"When you are going through construction, you need to protect the patient from any infection control issues — you don't want debris or dust flying around. So education is important," says Christiansen.

• Medication management. This area is another common cause of RFIs, including ordering, filling prescriptions, administration at the bedside, patient identification, verification of the right medication and dosage, and labeling medications.

"As we evaluated safety trends in patient care, the failure to label has indeed increased adverse outcomes to the patient population," says Christiansen. "It was common practice for anesthesiologists to not label medications, so again it was a reeducation that was needed."

The following RFI threshold changes were decided at a March 21 meeting of the JCAHO's accreditation committee and are retroactive to Jan. 1: For large hospitals with an average daily census equal to or greater than 100, it takes 14 RFIs to receive conditional status (up from 10), and 20 RFIs to receive preliminary denial of accreditation (up from 15). For small hospitals with average daily census less than 100, it takes 11 RFIs to receive conditional status (up from 10) and 16 to receive preliminary denial (up from 15). In 2005, 2.2% of hospitals were put on conditional accreditation.

The thresholds are simply a means for identifying organizations that need further scrutiny, says Murphy-Knoll. The JCAHO's board committee considers each organization separately and decides whether to apply the rules for conditional status or denial of accreditation, she explains.

"This is not decreasing the strength or credibility of the survey process. It's just being fair to organizations, assuring that they not be treated differently based on their size," she says. "It is definitely not a weakening of the accreditation process." In fact, based on the changes made in the last few years, the process has been strengthened significantly, says Murphy-Knoll.