New JCAHO process designed for focus

Surveys to focus more on actual care delivery

The Joint Commission on Accreditation of Healthcare Organizations says its health care accreditation process for 2004 will sharpen the national focus on care systems that are critical to the safety and quality of patient care.

The improved process is called "Shared Visions — New Pathways." "Shared Visions" refers to the common vision of health care organizations, purchasers of care, health care consumers, and the Joint Commission and how the accreditation process can sharpen that focus, says the Joint Commission. "New Pathways" references a new set of approaches or "pathways" to the accreditation process that will support fulfillment of the shared visions.

"’Shared Visions — New Pathways’ shifts the focus from survey preparation to focusing on operations and internal systems that directly impact the quality and safety of care," says Dennis S. O’Leary, MD, Joint Commission president.

"The net effect of these changes is to substantially increase the relevancy of the accreditation process to health care organizations and to direct even greater attention to improving patient safety and health care quality," he told reporters in a teleconference.

According to the Joint Commission, the new pathways include:

  • A required mid-cycle self-assessment during which the health care organization will evaluate its own compliance with the applicable standards and develop a plan of correction for identified areas of non-compliance. Validation of corrections and other randomly selected self-assessment findings will occur during the on-site survey at the end of the triennial period.

Because the self-assessment process will occur at the approximate midpoint of the accreditation cycle, O’Leary told reporters, it should make the accreditation process itself more continuous, reduce the ramp-up efforts many organizations undertake before their next surveys, and promote continuous organization compliance with the standards.

  • Pre-survey review of organization-specific information, such as ORYX core measure data, sentinel event information, and MedPar data, through an automated process to identify critical processes relevant to patient safety and health care quality for evaluation during the on-site survey.

For example, if an organization’s data indicate that it serves a large geriatric population with a high volume of medical admissions, it would most likely have a high number of prescribed and dispensed medications. Therefore, medication use issues would be critical for that organization.

  • Substantial consolidation of the standards to reduce the paperwork and documentation burden of the survey process and increase its focus on patient safety and health care quality.
  • On-site evaluation of standards compliance in relation to the care experience of actual patients.
  • Revision of individual organization performance reports to provide performance information not portrayed in the current reports.
  • Active engagement of physicians in the new accreditation process.

Russell Massaro, MD, executive vice president of the Joint Commission’s accreditation operations, told reporters that organizations are going to find that the new accreditation process focuses more on the actual delivery of clinical care and that the Joint Commission is going to provide a more continuous picture of an organization’s performance, particularly through the periodic gathering and monitoring of ORYX data.

An administrator of a hospital that pilot-tested the new process agreed.

"It gave the surveyors an actual, more realistic assessment of our day-to-day hospital operations," said Charles Young, administrator of Shriners Hospital in Spokane, WA, at the teleconference. The new procedures simplified the accreditation process, he said, and were a "natural outgrowth" of the organization’s own self-assessment efforts.

For more information about the new accreditation process, see the 16-page edition of Perspectives, the Joint Commission’s official newsletter, at the Joint Commission Resources web site: