Joint Commission rep answers your questions

Richard W. Scalenghe, RMT, associate director of the department of standards for the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations was on hand at the First Annual Hospital Case Management Conference to answer questions regarding how the survey process affects case management.

Here are some of the questions and answers covered at the conference:

Q: Will a case manager's job description, defining job responsibilities, suffice for measuring competency?

A: If the job description is too broad, it will not suffice; however, if it lists specific functions, it may provide enough information. The standards do not dictate a particular credential for case managers, but we will be asking how you have defined the qualifications for competency and how you, as directors of case management, determine the adequacy of the members of your staff. There must be communication based upon identified patient needs as opposed to, "Administration just gave up, and we just do the best that we can."

For example, a surveyor may ask you to describe the mechanisms by which the leaders assess the organization's staffing patterns to fulfill its mission, or what mechanism is used to identify the learning needs of staff to foster competence.

Q: How can we ensure that critical pathways are meeting Joint Commission standards, and what specifically will surveyors be looking for in them?

A: When designing critical pathways, think about the patient benefits and how that is incorporated into your entire process. Keep in mind that the surveyor will want to investigate any new design process. For example, a surveyor may ask, "Have you designed any new programs?" or "What are you doing now that is different from the way you were doing it one year ago?" If you say that you have developed a new critical pathway, that's a new process, and the surveyor will want to review it.

In fact, a critical pathway may enable you to address and meet many of the Joint Commission's standards. For example, patient assessments are addressed in section 1: Patient-Related Functions. Specifically, areas such as initial screening/assessment, discharge planning, and diagnostic testing are reviewed.

Surveyors may ask at what point the initial screening process is conducted; what type of screening criteria are in place to address changes in patients' conditions requiring further assessment; or what process is used to ensure a patient's status is periodically reviewed so that care decisions remain appropriate.

Q: How will the Joint Commission view group practices that have been purchased by the hospital or health care organization?

A: If the practice is considered part of the continuum, it is viewed as an ambulatory setting and will be part of the survey process. Otherwise, it would not be included in the survey process. Regardless, most likely every site will not be visited during a survey.