Understanding JCAHO's latest PI revisions

Hospitals must balance clinical, financial issues

By Judy Homa-Lowry, RN, MS, CPHQ

Director of Quality Improvement

The Delta Group

Greenville, SC

In health care today, case managers continually struggle with the demand to coordinate and deliver high-quality health care services in the most cost-effective manner. As the amount of available resources continues to shrink, the challenge to provide high-quality patient care services requires constant evaluation and innovative ideas. To ensure that patient care is not being compromised in this cost-conscious environment, the demand for health care data and information continues to escalate.

This reduction in cost and increased demand for quality has motivated many organizations to become more quantitative in their health care monitoring and reporting. This is a difficult issue for two reasons:

· Many of the issues considered critical in health care delivery are either qualitative or difficult to monitor.

· The availability of comprehensive information to provide insight into the delivery of health care services is limited.

As case managers become more involved with measuring and monitoring health care outcomes, they realize that this process not only provides insight into the effectiveness of the delivery of patient care, but is in fact essential to the economic survival of the organization. Key considerations for case managers are competition, ability to attract contracts, public perception, ongoing licensure, and accreditation. Unless there is a balance between clinical evaluation and financial constraints, there is a tendency for organizations to react to the information at the risk of reducing patient care services.

To guard against this tendency, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has strengthened its performance standards to mandate more extensive measurement of clinical as well as operational issues. Patient safety and improvement are the major motivators of the JCAHO standards. However, the standards have been criticized for not providing adequate information about the outcomes of patient care services. Therefore, the Joint Commission has changed its performance standards to provide further guidance in methods and requirements for effective performance improvement activities.

If one word could describe the changes in the new and proposed performance improvement standards, it would be measurement. The Joint Commission has just approved its new standards for performance improvement, which will become effective on Jan. 1, 1999. In addition, the Baltimore-based Health Care Financing Administration (HCFA) is proposing a stronger relationship between its standards and the Joint Commission's. The proposed changes, which were discussed in the Federal Register (62:244; Dec. 19, 1997), make the HCFA standards more consistent with the revised Joint Commission standards for performance improvement. If the HCFA standards are approved, much of the confusion and inconsistency that arises from maintaining two separate sets of requirements for performance improvement (PI) will be significantly reduced.

The revised JCAHO PI chapter still contains five standards:

1. The first change in the standards is contained in PI.I. The Leadership Role in Improving Performance has also been added to the PI chapter. This is the first PI standard; however, it will be scored in the Leadership Chapter. This reinforces the importance of leadership in PI. Case managers should be considered leaders, and therefore, should be included in the leadership responsibilities for PI.

The major change in the second PI standard is the addition of the following: "incorporates available information from other organizations about occurrence of sentinel events in order to reduce the risk of similar sentinel events and incorporates the results of performance improvement activities." This replaces the statement "establishes baseline performance expectations to guide measurement and assessment activities." This statement is now contained in PI.3. This language encourages organizations to have a mechanism in place to monitor sentinel events and to evaluate prospectively whether their organization is at risk for the same events. It also reinforces the need for organizations to use the outcomes of their improvement activities in improving clinical and operational activities.

Case managers must be involved in the organization's sentinel event policy. The policy should not only define sentinel events, but also must discuss how the organization will evaluate the systems and processes that contributed to the event by conducting a root-cause analysis. Because case managers are directly involved in the care of patients as well as in patient care services, they have the knowledge about existing processes. Their insight, as well as suggestions for improving the processes that may have contributed to the sentinel event, are important components of an organization's sentinel event policy.

Aggregate data reveal trends

Organizational data on patient care outcomes should be shared with case managers. This is a good barometer for case managers to evaluate whether or not the care/interventions recommended for the care and services for patient populations should be reviewed and revised. Case managers often rely on single-case outcomes instead of aggregate data. However, aggregate data provide insight for the case manager to determine if trends or patterns exist in the delivery of patient care services and outcomes. Data can help focus case management efforts that are intended to improve patient care outcomes.

Outcomes also should be reported organizationally as well as by product and/or service line. This will help to determine if the outcome is a breakdown of an organization system or process or if the breakdown is contained within a product/service line.

2. PI standard 2.1 states that "performance expectations are established for new and modified processes," while PI.2.2 says "the performance of these new and modified processes is measured." The intent statements have been modified to include specific requirements. Examples of requirements in the intent statements include:

· measures identify events that were intended to be measured;

· the use of numerators and denominators;

· description of the population to be studied;

· defined data elements;

· measures that can detect performance changes;

· the measure allows comparison over time;

· data intended for collection are available;

· results are reported in a way that is useful for the organization and other interested stakeholders.

Case managers must have access to information which provides an evaluation of the effectiveness of patient, care services, and outcomes. Typically, goals are established for performance. Providing information about new and modified performance expectations and outcomes to case managers assists in their evaluation of patient care and what can be done to continuously improve patient care. An example of this would be designing a critical pathway and then analyzing the variances for improvement.

This standard also helps guide organizations when they are in the process of changing the way they do things. If organizations carefully determine the purpose for a new process and then use appropriate tools and methods to measure the process, a good evaluation of the effectiveness of the process can be made. This approach also will be helpful in pointing out areas for improvement.

3. PI standard PI.3 has changed slightly. The revised standards state that data are collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain changes. The intent statement changes require areas to be identified for more focused data collection and sustaining improvement. This is a change from identifying areas for improvement and determining whether changes in a process have met objectives. These changes should further encourage leaders to identify and prioritize issues for more focused data collection.

This standard also can be applied to the ongoing measurement and monitoring of clinical pathways. As case managers, variances are identified and analyzed. Revisions are made to the pathway when appropriate to reduce variation and improve patient outcomes.

PI.3.1 has been changed to simply state that the organization collects data to monitor its performance. The current list of required data elements includes:

· performance measures related to accreditation and other requirements;

· risk management;

· quality control;

· staff opinions and needs, if used;

· behavior management procedures;

· outcomes of processes or services;

· autopsy results when performed;

· performance measures from acceptable databases;

· customer demographics and diagnosis;

· financial data;

· infection control surveillance and reporting;

· research data;

· performance data discussed throughout the manual.

As a reminder, you must collect data on needs, expectations, and satisfaction of individuals and organizations served.

Case managers should have access to the results of this information. If this information, pointed at improvement opportunities, is not shared with appropriate individuals, it can have a negative impact on the organization. Case managers who have direct input with patient care activities and the people who provide these services need the information to guide the need for revisions in existing processes.

It would be helpful if organizations collected these required measures and developed an internal report card. If all of these measures were reported in a single document and trended over time, it would help in evaluating trends and patterns in performance. In addition, the measures should be reported by department and/or service line as well as organizationally. As mentioned, this will help to determine whether or not the issue is isolated to one area of the organization or if it is prevalent throughout the organization.

PI.3.1.1 has been modified to state that the organization collects data to monitor the performance of processes that involve risks or may result in sentinel events. These include medication use, operative and other procedures that place patients at risk, use of blood and blood components, restraint use, seclusion when part of care or services are provided, and care or service provided to high-risk populations.

Case managers have the opportunity to suggest that required JCAHO measurement activities be incorporated into clinical pathways. Instead, many organizations measure patient care activities through the pathway process and again through the performance improvement process. This duplicates effort and wastes resources.

Organizations need to determine if their existing processes are in compliance. Flowcharting may be necessary. If their processes are not in compliance, they need to make the necessary adjustments. Many organizations develop a new process to be in compliance with the JCAHO without any consideration for the existing processes. This approach creates confusion and can be extremely costly for the organization.

PI.3.1.2 states that the organization collects data to monitor performance of areas targeted for further study. This will help the organization focus on priorities that will potentially lead to improvement in performance.

PI.3.1.3 states that the organization collects data to monitor improvements in performance. This will assist the organization in evaluating the effectiveness of the improvement and its value to the organization.

Most case managers are already collecting information about patient care performance. Are the case managers in your organization sharing it and integrating it into the performance improvement process?

4. PI standard PI.4 discusses data that are systematically aggregated and analyzed on an ongoing basis. PI.4.1 states that appropriate statistical techniques are used to analyze and display data. PI.4.2 states that the organization compares its performance over time with other sources of information. This further encourages the use of statistical and nonstatistical tools in the PI process.

Case managers need to become data analyzers. Many resources are spent by organizations collecting data and information. Unfortunately, much of the information is never analyzed so it can be used to improve performance. Case managers need to be more involved in data analysis so that improvements in patient care can be made as result of this analysis.

The most striking changes in the standards occur in standard PI.4.3. Undesirable patterns and trends in performance and sentinel events are intensively analyzed. These standards reinforce the need for an effective root-cause analysis. Organizations should have policies and procedures in place for handling sentinel events.

As mentioned, case managers need to be aware of their organizations' sentinel event policies and procedures. When a sentinel event occurs, it would probably be a rare event that would not include a case manager in the analysis. They need to be educated in the process and be an active participant if a root-cause analysis is necessary to evaluate a JCAHO-defined sentinel event.

PI.4.4 requires the organization to identify changes that will lead to improved performance and reduce the risk of sentinel events. This standard reinforces the need to use the results of data analysis to improve performance.

Many times the case managers are the most familiar with the systems and processes on patient care units. They are also responsible for much of the patient care planning efforts. Therefore, if systems and processes need changes to be improved, the case manager should be involved.

5. PI standard PI.5 is the final standard in this section. It requires that improved performance is achieved and sustained. This will be evaluated by the documented improvements and sustained performance in priority areas.

This can accomplished by ongoing efforts in pathways. Many times data from pathways provide information about outcomes over time. These should be continuously monitored for sustained and consistent care. Variances should be analyzed for improvement opportunities as well as for ongoing quality performance outcomes.

If you are a Joint Commission-accredited organization, review the proposed standards and begin to think through how you as a case manager can have input into your current program to ensure compliance with the proposed changes. This is not only the responsibility of the quality department or regulatory compliance group, but of the individuals that have direct impact on the improvement of patient care processes and outcomes - case managers.