10 steps to acing your first JCAHO survey
10 steps to acing your first JCAHO survey
Get everyone on board PI train
An agency's first survey is never easy. But enough smart, well-organized preparation can make it a successful experience.
Lourdes Home Health Services of Collingswood, NJ, is proof of that statement. The agency received a 99% on its first survey by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
The high score was not a fluke. The agency had systematically strived to improve quality at every level for a year before the actual survey.
"Our philosophy at Lady of Lourdes was total quality management, and we brought that into home health care," says Ann O'Malley, RN, BSN, director of performance improvement for the hospital-affiliated agency, which serves one county in southern New Jersey with 84,000 visits a year.
Lourdes Home Health laid the groundwork for its success by looking at the Joint Commission's 10-step performance improvement process, and designing its program to match.
The 10 steps helped the agency organize its performance improvement program, and no areas were left unexamined. Here's how it worked:
1. Assigning responsibility organizationwide.
The performance improvement group, consisting of 11 people representing all disciplines, helped assign responsibility to everyone on staff.
"We assigned responsibilities to all personnel," O'Malley says. "It worked out really well because everyone, including office staff and clinical staff, is responsible for performance improvement."
The group wrote down each person's responsibilities, based on what their jobs were and how these could be improved.
The administrator's responsibility, for example, is to ensure an annual review and the revision of all policies and procedures by the board of trustees.
The clinical staff's responsibilities are to identify opportunities for improvement in patient care and to participate in performance improvement activities, such as data collection and making recommendations for actions, O'Malley says. "They also sit in on PI group meetings."
Clerical employees are required to do the same as the clinical staff, and they're expected to report any problems to their direct supervisors.
2. Identifying the scope of care.
The agency developed a 20-page performance improvement plan and PI calendar, with the help of a Joint Commission consultant. The PI plan identifies the agency's scope of care, including the following items:
· that the agency is Medicare-certified;
· the services the agency provides;
· the type of population the agency serves;
· the major diagnoses;
· the primary clinical activities the agency conducts, such as skilled assessment, evaluation, and client education.
Under the category of services, the plan specified each service the agency provides, including nutritional counseling, home health aide services, cardiac services, and services to pediatric and adult patients, O'Malley says.
Also, the plan includes the 12 function monitors or indicators that relate to the Joint Commission's accreditation manual for home care. At the back are the performance improvement calendar and all performance improvement tools. "That way the Joint Commission can take a quick look at what tools we're using," O'Malley says.
3. Identifying important aspects of care.
Lourdes Home Health looks specifically at the high-risk, high-volume, and problem-prone areas. Volume refers to the amount of patients with a certain diagnosis, and the risk level refers to the potential for infection or complications.
"We thought infection control was a very high-risk category, and so was risk management," O'Malley says. "We just decided those were the areas we really wanted to concentrate on."
The agency also has focused on the areas of infusion therapy, maternal-child health, client education, and timely physician orders.
These important aspects of care are reported on a monthly basis at the PI group meetings.
4. Developing indicators.
The PI group addressed this task by looking at its strategic plan to see which areas of care were going to be the chief focus during the upcoming year. These areas, which included wound care, would require regular monitoring.
After doing a record review, the group saw that Lourdes Home Health had a surge of wound care cases. "So we said, `Let's take a look at what nurses were documenting for wound care and see what we can do to improve outcomes,'" O'Malley says.
Also, the group checked these identified areas against Joint Commission standards to determine whether the agency currently was following correct procedures.
Matching indicators to chapters
The team, which spent six months writing the indicators, created at least one indicator to correspond with each chapter in the Joint Commission's manual.
"We put our indicators right under the chapter heading, and that helped [the staff] a lot," O'Malley says.
The indicator under the chapter on Rights and Ethics, for example, includes the following:
· Low volume, high risk.
· Indicator: There is evidence of documentation in the record that the patient or designated decision maker is involved in decisions to withhold resuscitation.
· Outcome indicators: Do-not-resuscitate measures are discussed on the initial visit, and as needed with the patient, family, decision-maker, and procurement of the order from the physician.
· Dimension of care: respect and caring for patients' needs, expectations, and individual differences.
· Source: patient record, progress notes.
· Sample method: is all current DNR clinical records.
· Sample size: all records in sample method.
· Evaluation trigger: a threshold less than 95%.
"Say we have eight or nine DNRs for that month. Then I review all DNR charts, or the supervisor does it for me," O'Malley explains. "We look to make sure documentation is there and that they've talked with the patient, family, or decision maker."
Nurses are required to discuss this issue with every patient and document whether the patient desires a DNR or advance directive.
5. Determining thresholds.
The team decided that a quality agency would not have less than 90% on any indicator. And for high-priority indicators, the threshold should not be less than 95%, O'Malley says.
"We looked at the Joint Commission standards to see which was their heavy focus, and those were given a 95%," she adds.
Physician orders being returned in a timely fashion, for instance, is a high priority for the Joint Commission, and it's a Medicare standard. So that indicator received a threshold of 95%.
Also, the team examined whether an indicator was high-risk or low-risk, high-volume or low-volume. The team concentrated on the high-risk areas, such as infection control. Anything with a high risk received a 93% to 95% threshold requirement.
6. Collecting and organizing data.
O'Malley analyzes and graphs the data. For instance, an indicator under assessment is that documentation by the nurse reflects a concise assessment of the wound and clients receiving wound care. And the outcomes indicator for that is the wounds will be described completely: color, drainage, odor, measurement and depth, and evidence of healing or infection on a weekly basis.
O'Malley or a supervisor does a clinical record review, collecting all that information. Then O'Malley calculates and presents the statistical results to the PI group.
She found, for example, that nurses were doing accurate wound measurements only 75% of the time. They were measuring wounds in different ways, such as some using centimeters and others using inches.
Since that 75% performance was below the 90% threshold, the PI group recommended improving that outcome through an action plan. The action plan said the agency should show the staff the performance results of 75%, and then hold inservices for nurses on how to consistently measure and document wounds using centimeters, O'Malley says.
The analyzed data are routinely presented to all employees at monthly staff meetings. Then the data are presented quarterly to the agency's Professional Advisory Committee, which consists of the administrator, O'Malley, therapy representatives, executives, and others.
The Professional Advisory Committee meets four times a year and reviews for approval all recommendations of the PI group.
The agency has worked at keeping its data collection clean by making sure employees adhere to the specified sample sizes and sample methods for each indicator.
"We made our indicators very specific so you know exactly what you're looking for when you do a review," O'Malley says. "It's collected quarterly unless we see that there's an improvement that needs to be made, and then sometimes we review it on a monthly basis until we get to the threshold we want."
7. Evaluating care when thresholds are reached.
Each month the team reviews the care provided. When an indicator has reached its thresholds, that area is monitored on a less frequent basis.
If a specific area has results that are poorer than desired, the team develops an action plan. The plan is written on a performance improvement reporting form that the agency developed. (See Lourdes' performance improvement reporting form, p. 68.)
The form includes categories for listing the indicator, the results or analysis, conclusions, recommendations, actions planned, and evaluation of effectiveness of actions.
8. Taking action to improve care.
The team uses the Joint Commission's FADE formula in taking action. This is as follows:
Focus: Choose a problem; look at a problem, and describe it.
Analyze: Learn about a problem by collecting data and analyzing it.
Develop: Develop a solution and a plan, which is an action plan.
Execute: Implement the plan and monitor results, adjusting them as needed.
The team followed this process in improving its wound care documentation, for example. After discovering that the number of wound care patients had surged due to early hospital discharges of such patients, the team decided to examine its outcomes and look for ways to improve them.
The team acted by holding an inservice for nurses on wound care and by requiring them to write a concise description of any wound care they provide on a weekly basis. Previously the documentation was inconsistent, and sometimes nurses may have forgotten to document when they provided wound care.
Also, the PI team learned that it could receive help with the inservice and with developing a new wound care form from one of its equipment suppliers. Hill-Rom Home Care in Charleston, SC, a bed company, has offered free wound care consultation to its customers, O'Malley says.
9. Assessing the effectiveness of actions taken.
"The PI group evaluates the effectiveness of actions taken, and they recommend any further actions as necessary," O'Malley says.
An example is how the agency handled a problem with the timeliness of recertifications. Only about 56% of the recertifications were arriving back within two weeks, which was unacceptable. So the agency formed a task force that went through the entire PI process and finally assessed the effectiveness of its actions.
"One of the nurses on the task force sent out a little questionnaire about what is good and bad about recerts, and that helped us because we received input from all the nurses," O'Malley says.
10. Communicating findings.
The PI team communicates its findings and progress through a staff bulletin board, monthly staff meetings, and team meetings for nurses and other employees.
The bulletin board is located next to the copier. It includes bar graphs showing outcomes. For instance, a graph might show that 90% of aides follow the plan of care. Each month the board will feature different indicators.
"We review any staff improvement at the monthly staff meetings so everybody can keep involved in the philosophy of performance improvement," she says.
And finally, the agency has a form that gives employees a chance to write down their suggestions for improvement.
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