Cancel the triennial stage play’; JCAHO has a new survey process

Get ready for everyday compliance, surprise visits, JCAHO VP says

Ever reflected on the absurdity of gearing up every three years to face the JCAHO surveyor — piles of policies in hand and brass freshly polished — only to heave a sigh of relief and go back to business as usual the next day?

The Oakbrook Terrace, IL-based Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has a program for you, suggests Joe Cappiello, JCAHO’s vice president for accreditation field operations.

Shared Visions, New Pathways, the new accreditation model — effective January 2004, with 2003 as operation development year — is designed to move the process from a commodity to a value-added product, Cappiello says. "We will ask the organizations we accredit to constantly look at their systems and processes and have continuous quality improvement, to improve on what they do best."

Additionally, in a recent decision that affects all accreditation programs beginning in 2006, the JCAHO board of commissioners has approved the initiation of fully unannounced surveys beginning in 2006, he says. That move likely will affect some aspects of the Shared Visions, New Pathways process, Cappiello adds, and those details currently are being worked out.

In the years since the initial Medicare legislation was signed in 1964 and being accredited by the Joint Commission was deemed to satisfy a hospital’s Conditions of Participation in the program, he points out, there has been "a lot of misdirected effort to come into compliance."

"Many [providers] have decided they just need to do whatever it takes to be accredited so they are entitled to reimbursement under Medicare," Cappiello says. "It’s not unusual for hospitals to ramp up the year before a survey, make sure their policies are nice and neat, and direct resources away from process improvement and direct care. A lot of that is nothing more than a stage play."

Shared Visions, New Pathways is designed to put the focus back where it belongs, he says, on helping health care organizations "identify objectively the means and methods to improve care and give [them] an objective assessment of what their vulnerabilities in providing safe, quality care might be."

Under the new model, access services may find itself a more integral part of the survey process, he notes, due in large part to the "tracer methodology" that will be employed. Simply put, Cappiello says, "there is a realization that every patient who is admitted to the hospital comes into contact with every standard of the Joint Commission."

By following the natural course of patient care, which generally begins in admitting or the emergency department, the surveyor can get a very good view of how the health care delivery system is aligned to meet a specific patient’s needs at a specific time, he adds.

Here are some components of the new accreditation model:

• An 18-month mark event

"Think of the date of the last survey and the three-year interval before the next one," Cappiello says. "About 15 months after that first survey, we will send out electronically a self-assessment tool called the Periodic Performance Review [PPR]. [Providers] will be asked to go through each of the standards and honestly assess themselves and tell us where they have failed to achieve full compliance with the standards.

"The idea is that if [hospitals] do a rigorous and thorough self-assessment and outline for the Joint Commission — what they plan to do to come into compliance and how they will measure the fact that they are now in compliance — there will be no penalty for that admission, and it won’t change their accreditation status."

Hospitals will have until the 18th month to complete and submit that self-assessment, Cappiello adds.

• Phone call with Standards Interpretation Group

Before submission, he says, hospitals will schedule a telephone call with the JCAHO’s Standard Interpretations Group to go over such questions as, "Have I scored this correctly?" or "What about this special situation?"

"[JCAHO] will go through and answer the questions so [the hospital] can fill that out as accurately and honestly as possible," Cappiello says. "We expect when we arrive 18 months later that they have done what they expected to do. We will spend 40 minutes to an hour looking at corrective action plans and make sure they’ve done what they said they would do."

If surveyors find that such action hasn’t been taken and that the hospital is not in compliance with the standards, he adds, it will be scored in much the same way as with the current process.

• Priority focus process

The JCAHO’s on-site survey process will be changed under the new model, Cappiello says. "We are going to have some tools that will potentially identify some critical issues for that medical center. There is a list of 14 critical focus areas, including communication, patient safety, and other things."

Such data as the organization’s last survey result, any complaints made about them to JCAHO, and any sentinel events, such as a patient suicide or a wrong-site surgery, will be put into an algorithm, he explains. "We have designed a way for that to give us some information to better focus our survey activities."

"This priority focus process [PFP] may say that the cardiology unit, at a particular hospital for example, should be one of the spots to focus our activity because of high volume, a sentinel event, or something else," Cappiello says.

• Tracer methodology

Continuing the above example, surveyors are directed to the cardiology unit by PFP as part of something called tracer methodology, he says. "[The surveyor] would pick a chart out of the rack and review that chart on site to understand the entry point of the patient into the health care system, take some notes, and then trace the movement of the patient through the hospital."

Learning, for example, that a patient who speaks only Spanish was in Day 4 of a stay on the unit, had been driven to the hospital by her son, and was admitted through the emergency department after complaining of chest pain, a surveyor might ask the following questions of the registrar who admitted her.

"How did you ask whether the patient had advance directives? What are the procedures for dealing with patients who have a language problem? How did you get the consent to do the cardiology procedure? How did the transfer to radiology take place? How did the information about her move from this unit to that unit?"

By looking at the tracer, Cappiello says, surveyors can see compliance with the standards as care delivered, rather than saying, for example, "I want to see your policy on dealing with patients who don’t speak English."

"It’s inductive rather than deductive," he adds. For the average hospital survey, which is three surveyors for three days at a community-sized hospital, according to Cappiello, about 12 tracers will be done.

This following of charts through the health care delivery system, he explains, means there will be "a much higher engagement of access services staff than we have ever had before. We will talk about what they are responsible for and how to ensure they are doing the things they need to do. It’s a conversation, not an inquisition, and there is no pat, right answer."

In the past, Cappiello notes, JCAHO would develop a series of probe questions to gain insight on how hospitals complied with its standards. "By the time we ask them at about the third hospital, they are all over the Internet," he says wryly. "Then it’s about [hospitals] constructing the right answer, putting information on the back of ID badges and saying, If the Joint Commission asks this question, this is the answer.’"

"Think about the wasted effort in doing that," Cappiello adds, "when they could be spending time in more meaningful activities."

Although, during the survey, hospitals are required to demonstrate only that they’ve been in compliance for the past year, he points out, "We require hospitals to be in compliance with our standards every day of the year, every year."

Still being discussed, Cappiello notes, is how surveys will be scheduled so that they truly are unannounced, in accordance with the recent decision by the JCAHO board.

"In order to test this system," he adds, "we have accepted and will continue to accept on a voluntary basis, offers from organizations that wish to have their accreditation surveys unannounced in 2004 and 2005. We will probably do around 100 unannounced surveys [in 2004]."

It’s likely that there will be some sort of yearly update of the PPR so that essentially it is current all the time," Cappiello explains. "Sometime the year a hospital is due, we’ll show up. In practical terms, it could be a year before or a year after it’s due. There will be no five-day notice. Literally, we will just arrive that morning."

Meanwhile, he says, the underlying purpose of Shared Visions, New Pathways remains.

"We really wanted to make [the accreditation process] something of value and to move the field toward continuous compliance," Cappiello notes, "not just for the burst of time when the Joint Commission is there, but all the time."