Watch for these changes during 2006 surveys

Avoid problems with emergency management

When organizations gave feedback on the 86 unannounced pilot surveys done in 2005, many told the Joint Commission that they were happy with the new process overall but that they really needed a few minutes to collect themselves after surveyors arrived.

As a result, JCAHO changed its process so that the surveyors now have a planning session immediately upon their arrival. Now, after the surveyors announce themselves, organizations have that window of time to gather documents and alert staff as needed.

"We used to have an opening session right away, but we found the organizations needed a bit of time to pull everything together," says Darlene Christiansen, RN, LNHA, MBA, JCAHO’s executive director for accreditation and certification operations. "This helps to alleviate some of that anxiety."

Here are other key changes for 2006:

Tracers are being done for emergency management.

JCAHO has had a strong focus on disaster preparedness for the last several years, so this is not a big change in agenda, Christiansen says. But 2006 surveys will have an extra component — tracer activities conducted by the administrative surveyors or life safety code specialist.

The tracers may be based on scenarios identified in the organization’s hazards vulnerability analysis, such as asking staff about the process when a hurricane or airplane crash occurs, and asking for evidence that staff are educated on this process.

"This is being done at all organizations. It may not be clearly defined on the agenda, but it is part of the Environment of Care (EC) review," says Christiansen.

Problems have been identified with plans for improvement for life safety code compliance.

"Previously, when organizations knew we were coming, they had an opportunity to update these and address all areas related to life safety code," says Christiansen. "Now that surveys are unannounced, we are finding that Section 4 of the Statement of Conditions is a problematic area."

This is the area that identifies deficiencies and the time frame to correct them, and also allocates dollars and resources for the plan for improvement. "What we are finding at times is that the organization has not kept to the timeline that they originally documented," says Christiansen. For instance, the organization may have said the problem would be corrected by June 2006 but it is still not corrected during a January 2007 survey, she says.

"We do have an extension process that they could submit to us, but many organizations don’t take advantage of that," says Christianson. The surveyors have to sign off on the plan for improvement, and if the timeline is exceeded, that can result in a scenario that leads directly to conditional accreditation, she explains.

"The EC area is critical to successful accreditation for an organization," she emphasizes.

In general, there is an increase in the number of requirements for improvement (RFIs) given for the EC standards, adds Christiansen. "Part of that is due to the culture change needed to move from survey preparation to continuous readiness," she says. "Sometimes a reeducation and a refocus of the staff is needed, to understand that they need to embed those standards and use them on a daily basis."

It’s important to have ongoing implementation processes related to the standards, as opposed to addressing them once every three years as organizations have done in the past, says Christiansen. That’s where the periodic performance review (PPR) can be a tremendous help, she says.

"That is one of the beauties of the PPR tool, because now it is an annual requirement," she says. "It really reinforces compliance, because organizations are reviewing all the standards each time they go through it. If you really use that tool as part of your performance improvement process, then you are going to accomplish culture change."

There is an additional option for the PPR.

Previously, the PPR was only available to organizations every 18 months for a three-month period, but as of January 2005, it has been continuously available and can be updated every month or quarter. "Effective January 2006, the PPR submission is an annual requirement," says Christiansen.

Organizations previously had three options to submit the PPR tool: Option 1, in which a mid-cycle self-assessment is performed but information is not submitted to JCAHO; Option 2, in which the organization undergoes a mid-cycle on-site survey; and Option 3, in which the mid-cycle survey is performed but no written documentation of the survey is left with the organization.

In 2006, there is now an addition to Options 2 and 3 — to have a full PPR survey, either announced or unannounced. "The organization of course would be charged for that, but the beauty of the process is that it has no direct impact on the accreditation decision," says Christiansen. "The outcome of the survey is for their knowledge and can be used to improve the processes internally. This gives you exceptional insight as to what is going on with the organization."

Only one organization has done this so far, she says. "They felt it was tremendously valuable in providing insight into the organization. It was also valuable because staff knew this survey outcome would not have a direct impact and were very open with the survey team. So a great deal of information was shared back and forth."

A telephone consultation for RFIs is now optional.

Previously, there was a required telephone consultation with JCAHO’s standards and interpretation staff if any RFIs were given, so that the plan for improvement could be reviewed. "The standards interpretation staff still reviews every submission for plans of action or measures of success. But in 2006, that call became optional, unless standards interpretation staff feel it is important to clarify a plan of action or measure of success," Christiansen says.

However, the organization still can request a call for guidance — something that Christiansen highly recommends.

"Take advantage of that and request the call," she says. "We will give approval for processes put in place. And if you have official approval, then during a regular accreditation survey, the surveyors cannot question whether the plan is valid or not — unless the organization has failed to implement it."