A problem with JCR software sets off alarm bells at organizations
A problem with JCR software sets off alarm bells at organizations
JCR CEO says organizations’ compliance shouldn’t be affected
What would you think if your computer screen indicated that no measures of success were required for any Joint Commission standards? Would you be relieved or skeptical? That’s the dilemma many quality professionals faced recently, due to a mistake in software used to help organizations complete periodic performance reviews (PPRs).
As quality managers at University of California-Irvine Medical Center in Orange worked alongside a consultant to complete their PPR, both using what they thought was the same version of Joint Commission Resources’ (JCR) Accreditation Manager Plus (AMP), they noticed something strange: One version was missing all the "M"s, which signify that measures of success are required for that standard if the organization is out of compliance.
"The consultant had her own updated version on her laptop," recalls Mary M. Owen, RN, MPA, director of outcomes case management. "We thought they were the same release, but her version was different from our version — all the Ms were erased. We didn’t know whether to be happy or concerned. It was certainly significant, particularly since JCAHO had not notified us of the glitch until we contacted them. I don’t know how long they had known about it."
JCAHO provided the organization with a list of the Ms that actually were required. "It was fortunate that we had someone to compare copies with or we would have not necessarily questioned it right away," says Owen, adding that the organization was due to complete its PPR in August.
The problem involved the second update of JCR’s 2005 AMP CD-ROM toolkit, which was released in late May 2005. More than 1,000 hospitals use the software to assess and maintain compliance with JCAHO standards. JCR is an affiliate of JCAHO and provides services to health care organizations independently, including consulting, educational programs, and publications to assist patient safety and quality improvement efforts as well as meeting JCAHO standards.
Each of JCAHO’s standards includes elements of performance, the actual requirements against which organizations are surveyed and compliance is scored. Some, but not all, elements of performance require a "measure of success" (MOS) when they are noncompliant, which means a hospital later must document that it is maintaining sustained compliance four months after the acceptance of its Evidence of Standards Compliance or its Plan of Action.
In the late May software update, many of the MOS-required elements of performance did not include a check box to let an organization know which element of performance required an MOS when scored as noncompliant.
According to Karen H. Timmons, CEO of JCR, the mistake was discovered by one of JCR’s own technicians, and a notice was posted immediately on its web site as a software patch was being developed and tested. When opening the file after downloading the patch, the check boxes will appear where an MOS is necessary.
The Update 2 version was mailed out at the very end of May 2005, Timmons notes. "So the timing was such that it was only out there for a few days when we noticed it," she says. No organization will lose data entered into the updated software since late May, according to Timmons.
Separately and unrelated, in May 2005 JCR had notified its AMP customers that there was a temporary moratorium on uploading PPR data to the JCAHO’s secure extranet during the month of June, due to the new standards that were becoming effective July 1.
"A lot of customers probably weren’t working on the software because they were waiting for the new standards. The window of time was small, and we were very fortunate," says Timmons. "So there were no uploads of PPR data that would have been impacted. The issue was corrected before there was a need to send any information to the JCAHO."
As soon as a patch was developed, customers were notified by e-mail and letter, followed by another letter, which clarified that no data were lost as a result. (The Accreditation Manager Plus product homepage can be accessed on the JCR web site at www.jcrinc.com/amp. The corrective software patch can be found at www.jcrinc.com/amp05-u2.)
The main question at hand: Could an organization’s compliance be affected in any way, shape, or form as a result of the error? "I don’t think so," Timmons says. "Because there is a notice on the JCAHO extranet that if organizations are uploading from the AMP, they need to make sure they are using the current version of the patch, and there is a bounce-back if they haven’t done the correction. That’s what we’ve done to ensure there will be no impact on scoring once the upload occurs," she adds.
According to Jeff Cleary, a spokesman for Corte Madera, CA-based Xpediate Consulting, computer specialists who closely monitor JCR software for their clients discovered the error on their own. "We called JCAHO and asked if they had removed the measures of success from the standards, and they said they hadn’t, so we realized this was obviously going to be a pretty big problem." Xpediate, which sells JRepository Software, a competing web-based tool to automate continuous survey readiness, advised its clients to contact JCAHO directly. "Two of our clients had a survey coming up in July and didn’t know what to do — they couldn’t use the AMP because it was incomplete," he says.
According to a JCAHO spokesperson, the software issue in JCR’s AMP relates to the program’s PPR component and bears no relation to the JCAHO’s on-site accreditation surveys, nor did it affect the JCAHO’s web-based PPR application in any way.
Timmons adds that although the graphical display was missing the Ms, the areas of the text where the organization would have to submit the measures of success still were visible. "So I think customers would have realized — it wouldn’t have gone on too long without being noticed," she says. "The important thing is that no one is losing any data."
Cleary insists that the fact that measures of success were required would not have been apparent to the average quality professional. "It wasn’t obvious at all. We have several engineers who work full time on this, and they didn’t find it. That’s the reason we called JCAHO," he says. He adds that several hospital clients still are worried about the possibility of losing quality data, but "don’t want to appear critical of JCR."
Many organizations privately say that JCR wasn’t as upfront as it should have been about the problem, which was potentially very serious, says Frederick P. Meyerhoefer, MD, a Canton, OH-based consultant specializing in JCAHO and regulatory compliance. "They have the perception that JCR didn’t take the flaw seriously and was not as forthcoming as they should have been to maintain credibility," he says, adding that no one was willing to publicly criticize JCR’s handling of the problem. "That just emphasizes how guarded some hospitals feel that they must be in dealing with JCAHO."
Putting the recent problem aside, some organizations find JCR’s AMP difficult to use and choose instead to purchase products from other vendors.
"Our clients were having a hard time working with it. We tried it and also found it very difficult, so we developed a product in an Excel format," says Judy B. Courtemanche, president and CEO of Courtemanche & Associates, a consulting firm based in Charlotte, NC, specializing in regulatory compliance and outcome management.
The product, called SOAR (Score Ongoing Accreditation Readiness) to Success, allows organizations to assess and track compliance with every standard and EP and currently is used by approximately 200 hospitals.
Although quality professionals at Presbyterian Healthcare in Charlotte, NC, have used AMP in the past, they no longer find it useful, says Paula Swain, MSN, CPHQ, director of clinical and regulatory review. "Because it was not web-based, we found it useless," she explains. "A smaller facility might find it OK to enter in and use as JCAHO designed it, because only one person handles the information. We have multiple people engaged in our review and action planning process and need a more flexible, communicative process."
The AMP site license does allow multiple users to access and enter data simultaneously, according to the JCAHO spokesperson. Although not web-based, the site license allows it to be installed on a corporate network for multiple users to access.
With ongoing requirements for self-assessment and hundreds of EPs to determine compliance with, tracking all this manually is almost impossible, Courtemanche notes. "JCAHO changes their requirements often, and in order to stay on top of those changes, organizations need something to guide them," she adds. "It is almost imperative at this point."
[For more information, contact:
- Judy Courtemanche, Courtemanche & Associates, P.O. Box 17127, Charlotte, NC 28227. Phone: (704) 814-0685. Web: www.courtemanche-assocs.com.
- Mary M. Owen, RN, MPA, Director, Outcomes Case Management, University of California, Irvine Medical Center. Phone: (714) 456-8964. E-mail: [email protected].]
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