Are your plans in order?

By Patrice Spath, ART

Brown-Spath & Associates

Forest Grove, OR

In the mid-1990s, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, removed many of the prescriptive requirements from its standards. The standards currently outline general functions and activities that must be performed. Hospitals are expected to define how those requirements will be met within their organization.

For example, hospitals must perform functions related to risk management. The hospital’s leaders must determine the scope of their risk management activities, definitions for report -able incidents, and how the function will be performed. The increased flexibility in the standards makes it easier for hospitals to meet their unique internal needs while still maintaining compliance with standards. However, this increased flexibility means hospitals must prepare numerous written plans or statements to meet the intent of the standards.

At the time of the survey, Joint Commission representatives compare what the plan describes vs. what the hospital is doing. That’s why it’s important to get your plans in order before your survey. Below are four of the written plans specifically required or implied by the Joint Commis sion’s standards, a brief description of what the plan should include, and how they are evaluated by surveyors. All of these plans should be formally approved by the hospital’s medical executive committee and the board of directors. In next month’s column, the remaining plans will be discussed.

Strategic plan (LD.1, LD1.1): The responsibility for strategic planning lies with the hospital’s senior leadership team. The team should develop a business plan that describes the organization’s mission, vision, values, and strategic operational and programmatic objectives. The plan also should detail the mechanism for developing the annual operating budget and long-term capital expenditure strategy. Surveyors will interview the chief executive officer, chief operating officer, and leaders of the medical and nursing staffs to determine how strategic planning and resource allocation is carried out in the organization and how these plans are communicated to physicians and staff.

Recruitment, retention, staff development, continuing education (LD.1.9, HR.1-HR.5): The organization must have in place programs to promote recruitment, retention, and development of physicians and staff members. The description of these programs can be included as a section in the organization’s overall strategic plan or developed as a separate plan.

Code of organizational ethics (RI.1 - RI.4.4): While not technically a plan, a written code of ethics must be developed by the organization. This may be in the form of a policy or general operational procedure issued by the hospital’s governing board. The code of organizational ethics should describe how patients, employees, physicians, and visitors are to be treated with dignity, respect, and courtesy. It should address issues such as conflict resolution, recognition of potential conflicts of interest, billing practices, marketing practices, patients’ rights to perform or refuse to perform tasks, confidentiality, and relationships with other health care providers and payers. The role of the hospital’s Ethics Committee should be described. All other policies and procedures relevant to ethical conduct, such as policies on sexual harassment, advance directives, transfers, payer contracts, and so on, can be referenced in the ethics statement but do not need to be attached as appendices. The code of organizational ethics will be reviewed by surveyors during leadership conferences.

Plan for the provision of patient care (LD.1.3): The organization’s plan for provision of patient care should include the following components:

• definition of patient care, distinguishing between those departments that provide direct patient care and patient support services delivered by individuals who may not have direct contact with patients;

• definition of the organization’s continuum of care — a list of inpatient and outpatient departments that provide patient care according to the organization’s definition of patient care;

• description of the community’s role in the design of patient care services;

• the scope of services provided within the organization, to include:

— what services are provided and how patients are assigned to these services, for example, standards, practice guidelines, appropriateness, clinical necessity, and level of care;

— criteria for admission and discharge from specialty patient care units;

— methods used to assess and meet patients’ needs;

— location(s) of each service;

— when (hours/days) services are provided;

— types of patients, ages of patients served, and scope and complexity of patients’ needs;

— who provides patient care (type/mix of staff members);

— how staffing is determined and how necessary staff is made available;

• functions performed within the organization and who performs them, what they do, and with whom they do them — a description of how each important function is delivered collaboratively through the coordinated efforts of each discipline;

• mechanism to support collaboration, coordination, and integration of patient care delivery — for example, monthly management meetings, staff meetings, interdisciplinary team rounds, and so on;

• performance improvement mechanism — how departments participate to improve patient care services in the organization;

• mechanism for annual review and update of the plan.

There must be evidence of uniform performance of patient care processes throughout the organization to ensure that patients with equivalent health care needs receive the same standard of care throughout the hospital.

Departments need individualized care plans

Each department should have a written patient care plan for its scope of responsibilities. The plan should include the same components as the organizationwide plan, but individualized for the department. These departmental plans can be included as appendices to the org anizationwide plan; however, surveyors will expect managers and staff to have an understanding of their role in the overall provision of patient care services.

A model that organizations can use in developing their plan for the provision of patient care as required in the leadership standards is outlined below.

1. Develop the department and service "building blocks" for the plan. Each department and service should describe in writing the scope and goals of their services (LD.1.7). (The outline shown in the chart on p. 129 can be used for this purpose.) The outline differentiates between patient care and support service departments.

2. Each department and service should describe in writing how it performs each of the patient-focused functions found in the Joint Commission’s Comprehensive Accreditation Manual for Hospitals. This task is best accomplished through the creation of a standard matrix to be completed by each department and service.

3. Once each department and service has completed the tasks in steps one and two, the organization can use these "building blocks" to create an overall plan that describes how the organization performs each of the patient-focused functions, what departments and services are involved, and what each group contributes to the provision of patient care. The matrix approach also allows the organization to identify areas where there is needless duplication of effort.

(Editor’s note: Next month’s Quality-Cost Connection column will describe the remaining plans required by the Joint Commission’s standards.)