JCAHO documentation: What new process requires

Working with documentation review sheets

For every ED professional who’s had to deal with the onerous and time-consuming preparations for a survey by the Joint Commission on Accreditation of Healthcare Organizations, some good news: The Joint Commission has announced a major overhaul of its survey process intended to reduce both the expense and the documentation burden usually associated with accreditation surveys.

Under the new plan, called Shared Visions — New Pathways, hospitals will conduct self-assessments long before surveyors show up, and the surveyors will focus on actual patient care experiences instead of more theoretical compliance with standards.

"In the past, surveyors might have asked what steps you take to prevent wrong-site surgery, and the organization would talk about procedures, education, and other steps," says Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission. Under the new experience-focused process, however, "we will get at the same information but in a different way. We will choose at random from open records a patient who has just had surgery, and we’ll trace that patient through the process. The surveyor will go to the [emergency department] and ask how they X-rayed the patient, how they obtained consent, and so on."

Major components

These are the major components of the new process, according to the Joint Commission:

• Streamlined standards and a reduced documentation burden, with more focus on critical patient care issues.

• Self-assessment process intended to support an organization’s continuous standards compliance while freeing up survey time to focus on the most critical patient care issues.

• System for focusing surveyors on specific areas that need attention during their visit. Organization-specific data are used to highlight these areas.

• New survey system with six basic components that will replace the traditional triennial survey format. The system starts with an opening conference between surveyors and hospital leaders, which is followed by a leadership interview, validation of 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.

• More training, requirements, certification, and an enhanced role for surveyors. Surveyors will have to be certified and then recertified every five years.

• Revised decision and performance reports providing more meaningful and relevant information.

• The use of ORYX core measures data to identify critical processes and help organizations improve throughout the accreditation cycle.

Under the new self-assessment process, ED managers will participate by evaluating their own state of preparedness and sharing what they are and are not in compliance with — "which they should be doing already in continuous survey readiness," notes Paula Swain, RN, MSN, CPHQ, director of clinical and regulatory review for Presbyterian Health Care in Charlotte, NC.

One negative of the self-assessment focus — depending on one’s perspective — is that it makes last-minute "cramming" for an accreditation survey impossible. "There are three ways of doing self-assessment," Swain says. "One is through documents, one is through interview of staff, and one is through observation. When you do those on an organizational level, every manager picks up responsibility for their own part of the organization – their brick, if you will. Then [ED managers] will go in their area and review documentation in the ED."

The tool you’ll be expected to use for documentation, the medical record documentation review sheet, is available on the Joint Commission web site (www.jcaho.org). "Then what they do is also assess any policies that might be affecting the ED. In addition to these nine or 10 elements, if there’s anything on restraints, on point-of-care testing, on initial assessment documentation, any of that stuff, [or if] the policies have been changed, they would add that," Swain says. "Most EDs have some sort of data collection form, so that would be part of it. Then they need to observe the work for the age-specific competencies, things like that. They need to interview staff."

Once each department has completed its own self-assessment, focused on its own set of measures, an overall self-assessment for the facility is compiled, usually by someone in quality or by a designated accreditation coordinator. The overall self-assessment is based on areas of noncompliance. "If I only have one department that isn’t doing it right, we’re probably OK," Swain says. "But if I have a confluence of people who aren’t doing it right, then we have to score ourselves in the "3" range and develop a plan of correction." (For more on the scoring system, see the Joint Commission web site, www.jcaho.org.)

If a plan of correction is necessary, ED managers may be involved again through a round of increased documentation review.

Swain stresses that Shared Visions — New Pathways shouldn’t represent an increased documentation burden for ED professionals who have kept up and adhered to the principles of continuous survey readiness. But "if they’re truly not doing any survey readiness activities, this is going to be different for them," she cautions.

Swain recommends that those managers first seek out the facility’s Joint Commission coordinator and learn what the facility’s individual survey timeline is. "I can’t imagine a place working without a timeline, because there are so many parts to coordinate," she says. "Then I would get the tool they expect me to use so that I’m not missing something and have to go back and do it again. Then, after I establish my baseline, I’ll go ahead and do my graphics and keep my record of how I’m improving, if I’ve found problems."

For an example of how the ED would be involved in an assessment process, Swain cites patient education. "The ED does do patient education," she says. "You usually see it at the bottom of the discharge sheet, but there are other places where they’re liable for patients’ preferences and readiness to learn, etc., which I find missing in a lot of EDs."

From an ED manager’s perspective, an assessment of patient education would include whether the staff had documented the patient’s preference for learning, for instance. "If it shows it’s not there, then that rolls up into the hospitalwide review of compliance, and it would say, We’re in compliance everywhere except the ED,’ so the ED would do the data collection and graphics at a local level and then send that on."

The new plan will go into effect January 2004 for all Joint Commission-accredited organizations.