Is your practice ready for a JCAHO survey?

Network accreditation can put you in the spotlight

If your practice is part of a health care network seeking accreditation from the Joint Com mis sion on Accreditation of Healthcare Organiza tions (JCAHO), your office may be selected for a site review as part of the accreditation survey process.

JCAHO, based in Oakbrook Terrace, IL, includes a sample of practitioner sites in its survey activities to determine if the network is meeting the standards for communicating with and providing oversight to its components.

JCAHO’s Network Accreditation Program, begun in 1994, offers accreditation to health care networks, including integrated delivery networks, health plans, and preferred provider organizations. JCAHO standards state that networks must have a process for selecting and continuously evaluating the performance of its contractors. The networks must evaluate the clinical records and office practices of practitioners being appointed and reappointed to the network.

All sites with which the network contracts are held to the same performance and quality standards applied to the network.

"We’re not looking at the actual decisions being made about clinical care or what the practice is doing with a particular patient," says Gina Val Zimmerman, executive director of network accreditation surveys for JCAHO. "We are looking for issues around the communication and linkage of the practice site and the network or health plan."

Joint Commission surveyors pick up to eight physician office sites during a network survey, says Zimmerman. Networks are notified of what physician office sites will be surveyed at least six weeks prior to the survey. It is up to the network to notify the practice sites involved in the survey.

Performance issues that will be addressed by the surveyors include:

• level of integration of health care treatments and services throughout the network;

• availability and accessibility of care and services;

• communication between the network and practitioner sites;

• involvement of the practitioner site in network performance improvement activities.

Survey includes interviews, observation

At most physician offices, the surveyors will be looking at four months’ worth of records. This is because most of the networks seeking accreditation are doing so for the first time since the network accreditation program was established in 1994. When the JCAHO does its second survey, three years down the road, surveyors will look at a year’s worth of data, Zimmerman says.

The survey process includes interviews with staff, observation of how the physician practice operates, and an examination of medical records.

"Surveyors generally spend most of their time with the office staff. At some point during their visit, they want to have an opportunity to talk with the practitioners, even if it’s just for a few minutes," Zimmerman says.

Surveyors are likely to ask the physicians about their experiences with the health plan or network, she adds.

"We’re not looking at clinical care, but at issues relating to communication, documentation, and what the patient experience is," Zimmerman says.

When the Joint Commission chooses physician offices to review during a network accreditation survey, your office is more likely to be selected if:

• you had a lot of patient volume related to the health plan or integrated delivery network in the 12 months prior to the survey;

• your office is among the sites that have been reviewed by the network during the previous 12 months.

"We won’t go to a site with no activity for that particular network, nor would we select a site that hasn’t been reviewed by the network," says Zimmerman.

The number and type of physician office sites chosen for review as part of the accreditation survey process is based on the number of sites in the network or health plan and the types of practitioners in the network.

For instance, if the network includes between one and 200 physician office sites, the surveyors would visit up to four practice sites. If the network has more than 500 physician office sites, the surveyors would choose eight for a site visit.

"We based our selection on a representative sample of the types of practitioners in the network. For instance, if the network has primary care and specialty care sites, we look at both types of sites," Zimmerman says.