JCAHO: Spend more time with staff, less with documents

Much of the survey work will occur before the surveyors arrive from the Joint Commission on Accreditation of Healthcare Organizations, and you’ll be doing it. Hospitals will conduct self-assessments midway (18 months) through the accreditation cycle. They will then draft a plan of action to correct any areas identified as needing improvement. The Joint Commission will use several data sources as well as the plan of action to guide the actual survey, which it calls a priority focus process.

Instead of giving scores, the Joint Commission will publish a Quality Report that uses symbols such as checks, pluses and minuses to compare the hospital with other JCAHO-accredited hospitals within the state and nationally. For example, the Quality Report will rate compliance with the Joint Commission’s National Patient Safety Goals. The new accreditation categories will be:

1. Accredited

2. Provisional Accreditation

3. Conditional Accreditation

4. Preliminary Denial of Accreditation

5. Denial of Accreditation

6. Preliminary Accreditation (under the Early Survey Option)

The new survey agenda includes:

Opening conference

Leadership interview

Validation of organization’s implementation and monitoring of plan of action emanating from the periodic performance review (self-assessment)

Visits to care and service areas guided by the priority focus process using the tracer methodology

Surveyors will select charts at random, then will visit units, sites, or departments "in the exact sequence experienced by the patient chosen. Staff in the various units will be interviewed with regard to specifics pertaining to the care of the patient under consideration, and relevant standards will be surveyed as applicable to the particular case."

Environment of care review

Human resources review

Credentials review

System tracers

Specific time slots will be devoted to in-depth discussion and education regarding patient safety, the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and/or other current topics of interest to the organization.

Closing conference

(For more information on the new survey process, go to: www.jcaho.org.)