JCAHO unveils major changes to survey process

Changes include midterm self-assessments

The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is significantly revamping its accreditation process to answer its critics and sharpen the focus of its accreditation process.

The new initiative, "Shared Visions — New Pathways," will allow hospitals to conduct self-assessments and let surveyors focus on actual patient care experiences.

According to the organization, "Shared Visions" represents agreements among JCAHO and health care organizations about what a modern accreditation process should be able to achieve, while "New Pathways" represents a new set of approaches or "pathways" to the accreditation process that will support fulfillment of the shared visions. The initiative will be implemented January 2004 for all accreditation programs.

Russ Massaro, MD, JCAHO’s executive vice president for accreditation operations, says "Shared Visions — New Pathways" represents the next step in the evolution of accreditation. "It shifts the paradigm from a focus on survey preparation to one of continuous operational improvement," he explains. "In so doing, it enables the accreditation process to become more of a service than a commodity."

The new initiatives include the following:

  • streamlined standards and a reduced documentation burden to focus more on critical patient-care issues;
  • self-assessment process to support organizations’ continuous standards compliance while freeing up survey time to focus on the most critical patient-care issues;
  • priority-focus process that integrates organization-specific data and recommends areas for the surveyor to focus on during the survey;
  • new survey agenda with six basic components: an opening conference, a leadership interview, validation of the self-assessment results, a focus on actual patients as the framework for assessing compliance with selected standards, discussion and education on key issues, and a closing conference;
  • enhanced role for surveyors in the new process facilitated by extensive surveyor training;
  • revised decision and performance reports
  • providing more meaningful and relevant information;
  • use of ORYX core measure data to identify critical processes and help organizations improve throughout the accreditation cycle;
  • better engagement of physicians in the new accreditation process;
  • new approach to surveying complex organizations.

Specifically, the new accreditation process is designed to focus the evaluation to a greater extent on the actual delivery of clinical care; increase the value of and satisfaction with accreditation among accredited organizations and their professional staffs; and decrease costs related to survey "ramp-up" and resource allocation.

It also is designed to shift the accreditation-related focus from survey preparation and scores to continuous operational improvement in support of safe, high-quality care; make the accreditation process more continuous; and increase the public’s confidence that health care organizations continuously comply with standards that emphasize patient safety and health care quality.

In addition, the new survey process will be more continuous and will eliminate much of the "ramp-up" that often takes place before a scheduled survey, says Dennis O’Leary, MD, president of the Joint Commission. "We’re consolidating, saying things in a lot fewer words, and moving standards to the most appropriate sections," he explains. "We have reduced the number of scorable elements, and that has a significant impact in terms of the burden on accredited organizations."

Self-assessment halfway through the cycle

The Joint Commission says a new self-assessment process will be rolled out for ambulatory care, behavioral health care, home care, hospitals, and long-term care in 2004. This process aims to support continuous standards compliance and free up surveyor time during the on-site survey to concentrate on the organization’s critical focus areas and provide practical, educational support.

Accredited organizations will complete the self-assessment at the 18-month point in their three-year accreditation cycle, rating the level of compliance with all standards applicable to that organization. There will be no on-site surveyor visit at the 18-month point.

In the self-assessment, if an organization finds itself not compliant in any standards area, it must detail the corrective actions that it has taken or will take to comply. These actions will be entered into the self-assessment and submitted to JCAHO for review. This activity will not result in any change in accreditation status for the organization.

A JCAHO staff member will follow up with the organization to review its findings, approve the corrective actions, and provide advice or assistance on those actions. At the 36-month point, or the triennial survey, surveyors will go on-site to verify that the organization has implemented the corrective actions as laid out in its self-assessment.

JCAHO reports that during pilot testing, organizations strongly approved of the self-assessment process to help maintain continuous standards compliance. Organizations reportedly required no new resources to complete the assessment, and most already were completing self-assessments using other tools. All the organizations that took part in the pilot completed the self-assessment in the eight weeks allowed. The majority of the organizations indicated that they would prefer three to six months to complete the assessment.

JCAHO says it will contact organizations three to six months in advance of their accreditation midpoint with information on the self-assessment tool, so organizations have adequate time to complete the assessment.

As long as an organization plans appropriate corrective action, the 18-month self-assessment activity, including the report to JCAHO, will not change the organization’s accreditation status. In addition, JCAHO says it will work with each organization, often suggesting appropriate corrective actions.

At the triennial survey, surveyors will validate an organization’s compliance over a minimum 12-month track record with all standards involved in its corrective actions. The corrective actions will also drive appropriate on-site education with surveyors.

(Editor’s note: A special 16-page edition of Perspectives, the Joint Commission’s official newsletter, takes an in-depth look at the new accreditation process and is available at Joint Commission Resources’ web site at www.jcrinc.com/perspectives. Questions may be e-mailed to sharedvisions@jcaho.org.)