Complex organization survey process begins 2004
Before long, the Joint Commission on Accreditation of Healthcare Organizations will change the way surveyors judge your worthiness for accreditation. Some of the changes will make the accreditation process easier, but they also bring their own additional risks.
Questions remain about how the new survey process will work, but two facets of the revised process were announced earlier than the rest, and some observers say they merit a good dose of caution. The first involves the introduction of a new complex organization survey process that will replace the Joint Commission’s current process for conducting tailored surveys. Tailored surveys are conducted at organizations that provide services covered by standards in more than one of the Joint Commission’s nine accreditation programs.
Introduced in 1982, the tailored survey has become "substantially fragmented and inefficient, resulting in duplicative surveys of certain organizationwide functions, such as leadership," the Joint Commission now says. The new complex organization survey process is meant to remedy that problem, and it will begin in 2004. It includes these factors:
- survey profile that includes information about the applicant organization’s specific settings and services;
- customized sets of standards matched to the organization’s survey profile;
- surveyors who have skills and expertise most appropriate to the organization to be surveyed;
- use of interrelated evaluation techniques such as self-assessment to assess standards compliance;
- concurrent evaluation of the various organization components.
While the survey process will change, complex organizations will continue to receive a comprehensive accreditation decision that reflects the performance of the entire organization. Performance information at both the organization and component levels will continue to be publicly disclosed.
Those changes will be welcomed by many large providers, but beware of the hidden risks, says Susan Mellott, PhD, RN, CPHQ, FNAHQ, a consultant in Houston. The change for "complex organizations" really applies to just about any hospital or health care system that has more than one patient care unit, she says. That could be a hospital with a long-term care facility, an ambulatory surgery center, or a home care service, for instance.
"It means the entire organization and all of its components will be surveyed at the same time with a group of surveyors who will be there all at once to speak with the hospital leadership and to see all the information at the same time," she says. "They’re trying to get the whole group of services provided by the hospital to go through the process at once. That should cut down on the duplication and the extra effort by the surveyors."
The new system will offer benefits to accredited providers, she says. For starters, you will have fewer surveys to prepare for and less disruption from repeated visits by Joint Commission surveyors. A single, comprehensive survey also will reduce much of the confusion that hospitals can be left with when different health services are surveyed separately. Too often, Mellott says, hospitals are left with inconsistent and sometimes contradictory survey results when the surveyors work independently.
Most providers will welcome that change, but it may come with an increased risk, she adds. With the entire hospital system under scrutiny at once, there will be more pressure than ever to have everything in order at the same time. There will be no opportunity to focus all your preparation efforts on one area facing an upcoming survey and then move on to the next. Everything will have to be ready at once, and that actually is one goal of the Joint Commission’s change, Mellott says. Many of the process improvements at the Joint Commission are intended to encourage providers to be survey-ready all the time, rather than just when the surveyors are due.
"I’ve talked to hospital leaders who are worried about what’s going to be included in this new process that was never included before. I don’t think we know yet," she says. "And they’re worried that the survey team will spend more time at the hospital and have more time to find problems. With the focus on integrating the survey process for different service areas, I’m sure they will look more closely at whether you have all those areas integrated well into your operations."
That leads to Mellott’s recommendation about how to prepare for the 2004 survey changes: If you have associated health care services such as long-term care, make sure they are clearly and effectively integrated into the hospital’s overall quality program. And make sure you will be able to show that integration to the surveyors.
In addition to that major change, another more immediate change addresses the concerns of long-term care providers. Effective Jan. 1, 2003, the Joint Commission is offering hospital-based and freestanding long-term care services two new accreditation alternatives that are intended to be responsive to concerns about the costly duplication of federal Medicare surveys. These new options include the exclusion of long-term care services from the organization’s tailored survey or selecting a new accreditation option that is substantially based on Medicare/Medicaid certification at a lower cost. The new alternatives are in addition to the current long-term care accreditation program offered by the Joint Commission.
These are the new alternatives:
• No review of long-term care services. For hospitals and other complex organizations that provide long-term care services, this alternative allows for the exclusion of these services from the organization’s tailored accreditation survey as long as they are able to provide evidence of Medicare/Medicaid certification of these services at the time of survey. The organization’s accreditation certificate will explicitly exclude the organization’s long-term care services from the JCAHO accreditation award.
• Medicare/Medicaid-based accreditation. Accreditation will be based substantially on the most recent Medicare/Medicaid certification survey. These surveys cover approximately 70% of the Joint Commission’s long-term care standards. The Joint Commission’s accreditation survey will address areas of deficiency identified through the Medicare/Medicaid certification survey, as well as selected Joint Commission standards not addressed by the Medicare/ Medicaid certification survey. For complex organizations, the accreditation survey findings will be incorporated into the accreditation decision for the organization. For freestanding long-term care organizations, the accreditation survey findings will constitute the sole basis of the decision. In both organizations, the accreditation certificate will indicate that accreditation is substantially based on the organization’s most recent Medicare/Medicaid certification evaluation of its long-term care services.
So why continue the Long-Term Care Accreditation Program at all? According to a statement from the Joint Commission, the program is being retained "to support the more than 2,200 long-term care organizations currently accredited under this program as well as for new long-term care organizations desiring this comprehensive evaluation." The accrediting body says it developed the new alternatives to decrease the survey burden on long-term care organizations that already receive an annual, unannounced Medicare/Medicaid certification survey. In the future, the Joint Commission says it will be examining whether health care organizations accredited in any of its other accreditation programs undergo a similar annual Medicare/ Medicaid survey.
"Long-term care groups were dropping out of the Joint Commission’s accreditation program faster than any other group, so I think these changes are being offered to try to keep them, to get them back in the fold," Mellott says. "The Joint Commission is giving them more options to make it more attractive and keep them from leaving."
Two initiatives being tested
The Joint Commission also reports that it is in its third year of working on accreditation process improvement (API) initiatives to make the accreditation process more consistent, relevant, and focused on important issues specific to each health care organization.
During 2002, two critical initiatives — the priority focus process and organizational self-assessment — are being pilot tested and the technological infrastructure to support them is being built. The priority focus process will use pre-survey data to identify critical processes to be addressed, appropriate agenda activities, and relevant standards.
Findings from pilot testing will be integrated into a new on-site survey process.
The model for this new process, now being pilot tested, includes:
- time for surveyors to review pre-survey data from the priority focus tool output and the organization’s corrective actions identified in their self-assessment;
- more time for evaluation at the sites of care guided by use of a systems analysis approach that the Joint Commission calls the tracer methodology and for educational activity on key issues, such as emergency management and patient safety;
- physician involvement in survey process, particularly as part of tracer methodology;
- time for surveyor team interaction in order to create a dynamic, flexible survey that meets the needs of the specific organization being surveyed.
Pilot testing has been completed in eight hospitals with positive results, including support for increased surveyor time spent "out on the floor" using the tracer methodology and positive feedback about the elimination of many of the interviews and much of the document review time from the current survey agenda — indications that the survey team is better able to link findings at the patient level to systems issues using tracer methodology.
Refinement of the new survey model, additional pilot testing, and intensive surveyor training are planned during 2003.
[For more information, contact:
- Susan Mellott, 5322 W. Bellfort, Suite 208, Houston, TX 77035. Telephone: (713) 726-9919.]