Self-assessments can be used against you

Insurance industry underwriters are relying more on risk assessments when you apply for coverage, but they’re not the only ones you have to please. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, also has some expectations in this area, and risk managers could benefit from knowing exactly what the accrediting body wants.

Some caution is necessary, however, because complying with JCAHO expectations could mean disclosing sensitive material to potential plaintiffs.

Kurt A. Patton, JCAHO’s executive director for accreditation services, says risk managers should use self-assessment as a way to strengthen their programs. JCAHO’s site visits too often are the focus of a risk manager’s attention, when they should be seen more as simply a snapshot of what goes on in the organization every day, he says. He addressed the topic recently during an audio conference sponsored by the American Society for Healthcare Risk Management in Chicago.

Frequently self-assess

Ongoing self-assessments are one of the best ways to ensure compliance with JCAHO standards, Patton says. The periodic performance review, a requirement of the new JCAHO review process, can be a useful tool for assessing risk and improving quality throughout the organization, he notes.

"Very highly motivated, high-achieving organizations do self-assessments periodically between surveys to see how they are doing with compliance with standards," Patton says. "In addition to the self-assessment tools available from the Joint Commission, we also make it possible to have a dialogue with the surveyors in our Standards Interpretation Group, to make sure they are interpreting things correctly and developing an appropriate action plan if they identify deficiencies."

He notes that utilizing those resources will not affect your organization’s assessment when surveyed, even if in the process you report deficiencies to JCAHO. Each self-identified deficiency in the required periodic performance review does require you to develop a plan of action and usually a method for measuring success.

Self-assessments can focus on specific elements that are known to affect quality or threaten patient safety, such as communication failures or the universal protocol for reducing wrong-site surgery, Patton says. Risk managers can use various methods and tools for conducting the self-assessments, he notes, but JCAHO requires some type of periodic performance review.

"It is an accreditation participation requirement, so we do expect organizations to go through that process, roughly between the 15th and 18th months after the last full survey," Patton says. "If an organization identifies a particular deficiency, and they work within periodic performance review to develop an approved plan of action, and then if the Joint Commission comes out to do a random unannounced survey, our surveyors are not going to score that particular problem area because you have self identified it, you’re working on it, and there would be no benefit from our surveyor citing the same issue."

The approved plan of action cannot be overruled or modified by the surveyor on site, Patton notes. But the surveyor may request a review of the plan’s success so far and look at how well you have implemented the specific measures. "In most cases, the on-site surveyor will be using the same measures that you identified in your plan of action," he says. "The standards are written in such a way that the corrective measures for a particular problem should be almost self-evident, and the surveyor’s focus will be on how well you are following through on those."

Because there are concerns about information being transmitted either electronically or on paper to JCAHO saying essentially that you’re not doing something right, some health care attorneys are concerned that the information might be disclosed to third parties in the event of a lawsuit. To address those concerns, JCAHO offers three options regarding the reporting of results form the periodic performance review:

In Option 1, you can affirm that you have discussed the situation with legal counsel and have decided not to participate in the full periodic performance review, but you will go about your own self-assessment, developing plans of action and measures of success as appropriate. However, you will not use JCAHO’s Internet-based tools for conducting the self-assessment and you will not report the results to JCAHO.

"If organizations don’t use the Internet tools and don’t submit the information to the Joint Commission, they will not be able to have specific conversations about the situation with the Standards Interpretation Group," Patton says. "However, they can have more general conversations about the standards and interpretation."

Option 2 is designed for organizations whose legal counsel has advised them not to conduct the self-assessment. The organization can report that to JCAHO and invite JCAHO in to do the assessment for them. The findings from this on-site survey do not affect the accreditation decision. There is no survey report or score, but there are feedback mechanisms for discussing the findings, such as a conference call with the Standards Interpretation Group.

For those risk managers most skittish about possible disclosure of any findings, there is Option 3, in which the organization invites JCAHO in to do the assessment but without using the Internet based tools. There is no written documentation, only a verbal report from the surveyor. The organization can have a phone discussion with the Standards Interpretation Group, but only for general interpretations and not anything specific to that organization.

About 60% of JCAHO-accredited organizations are using full periodic performance review, and 25% are using Option 1, Patton reports. About 9% are using Option 2 and only 1% is using Option 3.

But what about using JCAHO’s Internet-based tools for the periodic performance review and then just not submitting the data? "Technically, you can do that, but it’s something you should check with your legal counsel about to see if they would want you doing that," Patton says. "Remember that if you are working in our on-line self-assessment tools, you are working on a computer that resides in Chicago and you are sending information to Chicago even though you haven’t hit the submit’ button to send the information to our Standards Interpretation Group."

If you are in a state in which discoverability is an issue and your counsel does not want you to submit your review findings to JCAHO, you probably shouldn’t use the Internet tools at all, he suggests.