JCAHO unveils changes to accreditation process

Self-assessment, continued role of ORYX

In what its president calls "the next step in the evolution of accreditation," the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, announced significant changes to its accreditation process.

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

The New Pathways include:

  • A required midcycle 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 noncompliance.
  • Validation of corrections and other randomly selected self-assessment findings, which occur during the on-site survey at the end of the triennial period.
  • 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.
  • 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.

The process has several new and revised elements, including:

  • Self-assessment: A process through which organizations assess and attest to their own compliance with JCAHO standards using an assessment tool on JCAHO’s secure extranet site and plan the organization’s corrective actions to compliance issues.
  • Priority focus process (PFP): A process that consistently uses pre-survey information about health care organizations to focus the accreditation survey on areas, which are significant to that organization’s patient safety and quality processes.
  • Priority focus tool (PFT): An automated tool that supports the priority focus process through the use of algorithms, sets, or rules to convert data about health care organizations into information that shapes the survey process.
  • Critical focus areas: Areas of an organization’s systems, structures, and processes that are most relevant to that organization’s patient safety and quality of care and most at risk for negative outcomes should these systems or processes fail.

The ORYX initiative, and its latest evolution of core measures implemented for hospitals in July 2002, is another integral element of JCAHO’s redesign initiative.

Experiencing self-assessment

While the new pathways were just announced, a number of organizations were able to test components over the past several years. For example, Shriners Hospitals for Children in Spokane, WA, piloted the self-assessment tool in December 2001.

"It was really very positive for us," says Tom Moerschel, director of performance improvement. "We learned a lot about ourselves as an organization, and I think it helped the [pilot-test] surveyor understand how other organizations out in the field will look at the self-assessment."

Moerschel says the quality team gave each question serious consideration, sparing their organization nothing.

"We found we scored ourselves much harder than the surveyors would," he says.

Tift Regional Medical Center in Tifton, GA, was another test site. "I can certainly see a lot of value to the self-assessment," says Angie King, quality management director.

"I think it will cut down a lot of unnecessary time because it allows you to say either it is or it isn’t here [standards compliance]. And if you’re not up to speed, you can show the surveyors during the triennial how you’ve corrected any issues," she says.

Changes no surprise

The changes came as no surprise to Linda Kosnick, RN, of Overlook Hospital in Summit, NJ.

"We all knew the Joint Commission would have to have some way to incorporate value added, based on feedback from organizations like the Leapfrog Group," she says.

Kosnick contends the steps that JCAHO is taking make sense in the current health care environment.

"I see where they’re trying to go [with self-assessment] and appreciate what they’re trying to do, because I think our system should be safe every day," she says.

"If anything, the Joint Commission is pushing us toward regulatory readiness, 24/7, 365 days a year. Perhaps it’s the push we need to think every day about what we’re supposed to do."

Giving consumers safer health system

In the long term, Kosnick says, the biggest push will come from organizations such as the Washington, DC-based Leapfrog Group, which she feels the Joint Commission is emulating. Of course, it’s the change itself, rather than the change agent that matters most.

"Consumers are simply asking for a safer system, and we should be able to supply that without someone regulating us," she asserts. "But I think we’re getting there."

Need More Information?

For more information about "Shared Visions — New Pathways," contact:

  • Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Web site: www.jcaho.org.