Joint Commission seeks continual compliance

Unannounced surveys keep facilities on their toes

It’s not unlike preparing for an exam in school. You know the exam is approaching, and you do a little studying ahead of time, but you usually wait until the last minute to really push yourself to focus on getting ready for the exam.

In the home health world, the exam for many agencies is the triennial accreditation survey. While you still need to make sure you comply with the standards of both the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations and the New York City-based Community Health Accreditation Program (CHAP), Joint Commission-accredited organizations will have to undergo some cultural changes in the way they prepare for a survey.

Not only is the Joint Commission asking you to identify your own deficiencies in a self-assessment process called Periodic Performance Review, but starting in 2006, you won’t know when the surveyors are coming. Organizations that are scheduled for surveys in 2004 and 2005 can volunteer to participate in the unannounced survey program as the Joint Commission tests the process.

"Of all health care organizations, home care agencies have a tremendous amount of experience with unannounced surveys because all Medicare or state surveys have always been unannounced," says Maryanne L. Popovich, RN, MPH, executive director of the home care accreditation division. In fact, she says, the most frequently asked question about unannounced surveys is, "What if I’m not here?"

For agency managers concerned about their absence when the surveyor arrives, Popovich points out that the new survey process implemented by the Joint Commission during the past year, Shared Visions — New Pathways, focuses much more on the actual care provided to patients rather than lists of policies and procedures.

"Because we are committed to better communication with our organizations, we will provide a short, concise list of documents that we will need, so an agency manager needs to make sure the responsibility for those documents is designated to a couple of people so at least one is available when the surveyor arrives," she says.

"One thing surveyors will want to evaluate is how performance improvement activities and leadership actions impact patient care," says Popovich. For this reason, you should make sure there is always someone who knows how to access patient records for the surveyor, she adds.

Another major change in the Joint Commission survey process is scheduled for implementation for home care organizations slated for survey in and after July 2005. "In October of 2003, these home care organizations will receive their Periodic Performance Review tool that is to be used as a self-assessment of their compliance with Joint Commission standards at the 18-month point between triennial surveys," says Popovich.

An organization has 90 days to complete the Periodic Performance Review and submit it to the Joint Commission. Organizations use the tool by accessing a secure, password-protected web site. The tool basically is the same one used by surveyors that lists standards, rationales for standards, and elements of performance. If the organization determines that it is not in compliance, there is a button that can be clicked to submit a brief plan of action to correct the deficiency.

Once the organization submits the Periodic Performance Review, Joint Commission staff members review the tool and then arrange a conference call to discuss the self-assessment within one month. Deficiencies that are identified during the Periodic Performance Review do not affect the organization’s survey results as long as the deficiency is corrected by the time of the survey.

Home health agencies accredited by CHAP have always had to complete and submit a self-assessment prior to their survey, says Terry A. Duncombe, RN, MSHA, president and chief executive officer of the organization. "Our home health agencies use it as a tool to assess their readiness for the survey and to develop a work plan," she adds.

Although home care pilot tests of the Periodic Performance Review still are ongoing, hospital organizations with home health or hospice organizations were involved the first tests.

"The opportunity to assess the organization in a penalty-free environment is very appealing," says Angie King, RN, CPHQ, quality management director for Tift Regional Medical Center in Tifton, GA, and one of the participants in the first pilot test for the new accreditation process. "You either meet the standards or you don’t, and the self-assessment gives you an opportunity to develop the policies or implement a program that will bring you into compliance with the standards," she says.

The best news is that you are not penalized for any deficiencies you identify during the self-assessment phase, she points out. "Once you’ve identified your own deficiencies, you submit a plan to correct them." Then you have 18 months to implement those corrections, King says.

Although the tool is designed so only one person within the organization can submit information, it is set up so multiple people can access the tool to contribute information. This makes it easy for the coordinator of the review to assign different parts of the self-assessment to the appropriate departments. Because the initial pilot test did not address all standards, King did not need all departments, such as Tift Regional’s hospice, to provide information, but that will not be the case when the organization undergoes its actual self-assessment. "I will coordinate the process, but I will have each department provide information on issues from their area," says King.

All departments will be able to use the web site to see what policies or measurement and monitoring information they must provide, she adds. Then, they can enter it directly on the tool for the coordinator to review and prepare for submission, she explains.

"Most home care organizations already have some sort of ongoing self-assessment program, but even if they don’t, completing the Periodic Performance Review should not be a huge burden," says Popovich. "There is more time involved in the transmission of the document, the conference call, and preparation of action plans if needed, but the benefit of making sure that you are compliant well ahead of your survey will outweigh any extra work," she says.

"The greatest benefit is that you won’t be performing your self-assessment in a vacuum," points out Popovich. "During the pilot tests, Joint Commission staff members discovered that some organizations judged themselves noncompliant in some standards when they really had just misunderstood the intent and did not have to correct anything. In fact, the organizations were much harder on themselves than our surveyors were."