Are you ready? Cap changes could threaten your next accreditation

Changes reflect Joint Commission move to harder line

You had a Joint Commission survey three years ago. It all seemed to go very well, and although you know there are some changes in standard capping afoot, you don’t think your survey early in 1997 will cause you much of a problem. Think again.

There are 107 Joint Commission on Accreditation of Healthcare Organizations standards that had their caps altered as of Jan. 1. Although they are spread throughout the various standards, about half are in three chapters: improving organization performance, leadership, and management of information. (See list, pp. 3-4.) Forty-two standards are seeing the caps change from 2 to 3 — meaning the standards will have an impact for the first time — and another 31 are going from 3 to 4.

The Joint Commission scoring system can be likened to an A to F letter grade system, explains Judy Homa-Lowry, RN, MSBA, CPHQ, a quality consultant based in Detroit. A score of 1 is akin to an "A," while a 5 is a failure for that particular standard. If that standard is considered a vital one — and the Joint Commission manual mentions those key areas — a 5 can lead to non-accreditation, she says.

"My sense is that this is going to up the stakes considerably," warns Regina Walczak, MPH, a health care consultant at RMW Associates in Simi Valley, CA. "A third of these standards are going to bear weight for the first time; even one 3 can lead to a type-one recommendation."

Michelle Pelling, RN, MBA, a consultant with the Propell Group in Portland, OR, agrees that the next round of surveys will be vastly different than the last. "Before, you didn’t have to comply with any of the 2’s," she explains. "You could do nothing and it wouldn’t affect your accreditation."

Part of the reason for the Joint Commission coming down harder, says Pelling, is a spate of serious mistakes that have cost patients lives and limbs. The public is clamoring for more accountability.

Walczak says that in her 10 years of working with and for the Joint Commission, she has noted cycles. "For a while, you see a real collaborative effort between the Joint Commission and hospitals. Then, you get a few well-publicized mistakes, like we have had recently, and the Joint Commission starts coming down a lot harder. I think that’s where we are now. I think we are going to see a lot less accreditations with commendations because of this. It’s like we’ve been in a bear market and the bull market is around the corner."

Concentrate on the 2’s

Walczak and Pelling recommend that those facing a survey look closely at the 42 standards that are changing from a cap 2 to a cap 3. "You have to understand that if before, you could get away with very little in a particular standard, that won’t work anymore," Pelling says. For example, previously, a required "information management plan" was scored at a 2, regardless of what it contained. "Now you have to have a plan in place which outlines your system, how your information is maintained, your inventory of information. The expectations are much higher."

While standards moving from 2 to 3 are important, Walczak says hospitals should not forget about those going from a 3 to a 4. "There are some times where getting a 4 can be a real ding. It can lead to a type-one recommendation," she says.

Eleven of the standards moving from 3 to 4 are in the leadership chapter, Walczak says, which is notoriously underprepared by hospitals. "It’s a very deceptive chapter. It’s a place where a lot of standards end up that don’t seem to fit anywhere else. A lot of it is overlooked."

"The leadership section has to embrace the entire corporate culture of the hospital," says Homa-Lowry. "You have to have an organization that allows for communication and teaming. Those standards can be the hardest to comply with for some," she says.

Walczak says communication is the "theme" of the changes. "The Joint Commission seems to want more communication between departments." For example, in the leadership section, one standard moving from a 2 to a 3 asks the hospital to ensure that its budgetary review process considers the appropriateness of the hospital’s plan for providing care (standard LD.1.5.2). This would require the finance staff to confer with the medical and nursing staff to make sure the budget and operating plan do not impinge on patient care.

More changes ahead?

Rick Croteau, MD, vice president of accreditation services at the Joint Commission’s office in Oakbrook Terrace, IL, says hospitals have had three years to get ready for the changes. "We don’t remove the caps until we see that there is improvement," he says. "Really, this isn’t all that unusual an event. Maybe there are more changes than in other years, but these are not new requirements."

Pelling says if your facility hasn’t been working toward these changes, you are facing a shock. "I don’t know if there will be more conditional accreditations," she says. "But I would bet there will be more type-one recommendations. This shouldn’t be a big deal because the Joint Commission has been providing education and guidance for three years. But in reality, people spend a lot more time worrying about other changes in the health care industry — mergers, reorganizations, and staff changes. In reality, not much has been done, and the surveys are seen as secondary to what the hospitals are experiencing in other aspects of their existence."

Distractions could bring trouble

Walczak says only a few hospitals integrate standards into their philosophies. "I agree there is more firefighting than true planning. I think people are very complacent, and I think they are going to find their hospitals at risk," she says.

What remains to be seen is whether the caps on these standards will change again next year. Walczak says the Joint Commission may wait to see "where the big hits occur" after the first round of surveys takes place. "Usually, standards don’t change until everyone has had a survey with them — about every three years. But because these are capping changes, we may see it differently."