Prepare for more surprise visits from thorough but fair’ Joint Commission
JCAHO reorganizes around new accreditation unit
Reeling from intense criticism that they are too soft on providers, officials of the nation’s most powerful hospital accreditation body — the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) — say they expect to make substantive changes in their approach to scrutinizing the nation’s acute-care providers.
However, clinicians, including those in critical care, should not expect any lessening of the meticulous, demanding approach accreditation officials have taken in the past. Like other inpatient departments, ICUs will continue to receive the same degree of intense scrutiny regarding routine nursing care, physician services, clinical safety, and documentation standards as in the past.
In fact, if supporters of reform have their way, nursing administrators should anticipate a raft of new measures, beginning with surprise hospital visits and greater involvement by the Health Care Financing Administration (HCFA) in the accreditation process.
In exchange what providers can expect, the Joint Commission recently stated, is a greater degree of "fairness and more consistency" during site reviews, better-trained professional surveyors, and questions that focus on similar key areas of patient care across different hospitals and departments.
"We expect to remain vigorous and thorough but fair," says Joe Cappiello, RN, MA, the Joint Commission’s vice president of accreditation services, based at the group’s headquarters in Oakbrook Terrace, IL. "We’re making internal changes that will result in more consistency nationwide. Our goal is to put out a uniform message that we are here to work with you [the hospital]."
Cappiello attempts to paint a friendly, conciliatory picture of the new, emerging JCAHO. But if the image of the old JCAHO was that of a tough, demanding regulator, it may have not been tough enough to satisfy the federal government and may have gotten the organization in trouble.
In July, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) issued an exhaustive two-year study of the private, nonprofit accreditation body and its regulatory style.
In its report, the OIG found "significant weaknesses" and "major deficiencies" in the way the Joint Commission has handled the hospital oversight process in recent years.
The agency assailed what it termed a "collegial," rather than regulatory method of oversight and recommended more frequent, unannounced hospital visits. It also called for more accountability and disclosure of data on hospital surveys.
Details of the report did surprise many ICU professionals, including some nurse managers, who could hardly believe the government’s claim.
"Collegial? I don’t know a single nurse who has ever perceived a Joint Commission visit as anything but threatening. They just put everyone in an upheaval," says Susan Goran, RN, MSN, a 12-year ICU manager, now a staff development specialist at Maine Medical Center in Portland.
Other nurses voiced similar views as they told of site surveys involving often arrogant, overly demanding reviewers and questions that had little to do with good patient care and often bordered on the ridiculous.
Goran recently recalled one reviewer who asked about the location of the unit’s defibrillator equipment. When told there was one located within feet of each ICU patient’s room, the reviewer insisted on being told the exact number of feet separating each defibrillator from each patient’s bed. "I think their intentions are good, but their methods are often highly subjective, and therefore inconsistent."
Surveys will have different emphasis
"I don’t think the survey process is going to get tougher, but certainly different. It’s very clear that they’re changing," says Roberta Fruth, RN, PhD, vice president of nursing at Catholic Health Partners, a three-hospital system in Chicago.
In September, Fruth, a critical care nurse, underwent an accreditation renewal at her hospital, and says she noticed differences in past and present surveys.
For one, she believes the emphasis now to be more on clinical processes rather than structural standards. They’re still quite demanding regarding physical plant and safety issues.
But "they’re paying more attention to things like patient outcomes, acuity, nursing care plans, and proper documentation," she says.
The objective, Fruth adds, seems to lie in determining whether you are following your own policies and procedures. "They seem to be asking not how good are your standards but how well are you following them."
Fortunately, for the ICU the expectations are more clear-cut than for other units, she notes.
"Because of the nature of critical care, you usually know what they’ll look at. It’s pretty constant: your charting, the time intervals between monitoring, the effectiveness of the ventilator weaning. Things like that," Fruth says. (For suggestions on how to prepare for the next Joint Commission visit, see article on p. 123.)
In the meantime, HCFA has drawn up its own hospital oversight plan that incorporates many of the OIG’s recommendations, including the call for more frequent, unscheduled hospital visits. The federal agency also agreed to:
• require state agencies to get more involved in surveys of non-accredited hospitals;
• increase its oversight of the accreditation process;
• balance collegial and regulatory styles to oversight;
• more clearly define priorities during surveys involving basic health and safety issues, including medication errors and surgery mix-ups.
Furthermore, HCFA, which administers the Medicare and Medicaid programs, intends to incorporate its new, purportedly tougher accreditation standards in upcoming revisions to its Conditions of Participation regulations. The regulations cover eligibility to participate in Medicare/Medicaid programs.
Cappiello acknowledges the scathing assessment and agreed that there indeed has been in many cases a cooperative, if not exactly collegial, relationship between site surveyors and providers.
That’s because "the Commission doesn’t see itself as a regulatory body, but more as a consultant or a systems analyst," he says. "The goal is and has been to work with hospitals to assess systems and to get them to work better."
JCAHO working to end subjectivity
The organization, Cappiello says, is working to eliminate the subjectivity and antagonism reportedly used by individual reviewers against hospital personnel during site visits. In late September, JCAHO announced a reorganization into three operating units: Evaluation and Accreditation; Consolidation and Education; and Research. Several open management jobs were eliminated, resulting in a "modest" reduction in the work force.
JCAHO is also attempting to achieve more consistency on what reviewers will actually be looking at in making assessments and providing guidelines on the extent to which they will question providers on particulars.
As a whole, Cappiello indicates that surveyors will be more closely supervised during visits and held more accountable than in the past.
The OIG report did not surprise the Joint Commission. In fact, that JCAHO had been working with HHS for months prior to the public release of the report. Internal reforms have since been drafted in conjunction with HHS and HCFA to blunt future criticism, Capiello says
Since many of the reforms have been adopted, hospital scores have not changed significantly, Cappiello adds, without citing specifics. And they aren’t likely to alter much under the reforms, an indication that providers will not fare more poorly under the changes.
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