Avoid pitfalls with corrective action plans: Quality experts share strategies

You won’t receive accreditation until 100% compliance is demonstrated

Imagine the moment when surveyors leave after your next Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey — or when you just have submitted your organization’s periodic performance review (PPR). You may be tempted to breathe a sigh of relief — but if noncompliant areas are identified, your work has just begun.

You will have problems with JCAHO if corrective action plans are not successful in bringing the organization into compliance in required time frames, warns Catherine M. Fay, RN, director of performance improvement at Paradise Valley Hospital in National City, CA. "When you receive your official report, you will have 90 days to become compliant with the standards. You have to be 100% compliant when you submit your Evidence of Standards Compliance (ESC) at the 90-day submission date."

Requirements for Improvement (RFIs) are received at the time of your survey, just as Type I Recommendations were previously, Fay says. Through June 2005, organizations will have 90 days to submit an ESC, because they will not have the benefit of completing a PPR and identifying standards that are not compliant prior to the on-site survey.

After June 2005, organizations will have 45 days to submit an ESC to the Joint Commission because the PPR will be available to them. If your hospital doesn’t receive any RFIs after your survey, you will receive your accredited status right away, but otherwise, this is not determined by the JCAHO until your organization submits the ESC, she explains. "At the end of the survey, you know what requirements for improvement to expect, which enables you to start working on compliance before you receive the official results."

The most difficult part of the new process was to develop and implement the action plans to be 100% compliant within 90 days of receiving the hospital’s official accreditation report, Fay says.

As in the past, you’ll need to develop and implement an action plan, but the new survey process requires demonstration of compliance within 90 days and identification of how ongoing compliance will be measured over the next four months, Fay explains. "There is no longer a six-month progress report," she says. "Action plans have to be implemented so to be 100% compliant."

Here are key points to address in your organization’s ESC, Fay explains:

  • State what actions actually have been taken, as opposed to planned actions, to become 100% compliant.
  • Use short, concise sentences.
  • Address each specific element of performance (EP) noted in the RFI.

For example, IM.6.20 lists information that should be found in the medical record, but one or more of the EPs could be identified in your RFI.

  • Identify how compliance will be measured for each standard.

For example, "The health information management staff will collect and maintain data on the completeness of the history and physical."

  • Include the sample size, to show that you are reviewing an appropriate sample to determine the measure of success (MOS).

Recommended sample sizes can be found on the JCAHO web site (www.jcaho.org). Click on "Accredited Organizations," "Hospitals," "Survey Process," "Guidelines for Submission of Evidence of Standards Compliance."

  • Identify an MOS.

When you submit your ESC, you have to be 100% compliant, but when you report your MOS, the lowest acceptable score is 90%, Fay notes. "When you submit your ESC, you include what your measure of success goal will be for the four months of monitoring," she explains. "Less than 90% does not demonstrate compliance with the standard."

Submit the ESC before the deadline, so if all of the required information isn’t included, you have the time and opportunity to make corrections, Fay advises.

The hospital will not receive accreditation unless the ESC is accepted by JCAHO. "If the ESC does not meet the requirements for compliance, you automatically receive provisional accreditation," she adds. "This reinforces the need to submit earlier than your deadline date."

You are notified by e-mail when your ESC is accepted, and your MOS for each standard is placed on the Internet with a space to enter results and the date you are required to report your actual MOS, if needed. "While all RFIs require an ESC, not all require measures of success," Fay explains. "This can be found in the JCAHO Comprehensive Accreditation Manual for Hospitals."

Monitoring of the ESC is required for four months, and the MOS that is reported for each standard is the average of the four months of monitoring results, she says.

The responsibility for developing and implementing actions to demonstrate compliance has to fall to those with the greatest responsibility for the standards addressed in the RFI, Fay adds. "You have to keep on top of the actions you have implemented to maintain compliance. We used newsletters, bulletin boards, and reminders at meetings to keep focus on our need to be compliant."

After a recent JCAHO survey at United Regional Health Care System in Wichita Falls, TX, the organization received several RFIs, and a corrective action plan was submitted for each, says Darlene Adams, RN, MSN, the organization’s patient care safety/quality management officer.

"Right after the surveyors left, we set up teams to address each issue," she says. Multidisciplinary teams should include administration, management, direct care staff, and quality managers — both those involved with the process changes and those whom the change affects, including physicians, she recommends. "I spoke with my liaison and several other support staff persons from JCAHO to get instructions for these action plans," Adams points out. "I had also attended a workshop on the new survey process that had a section on the corrective action plans."

The JCAHO liaison gave helpful tips and direction to ensure the action plan was complete, she adds. "There was much emphasis on concise information and no extra submission of policies, procedures, data, or other papers."

The liaison instructed Adams to outline the process of correction, implementation, education (including who attended and gave inservices), and how compliance would be demonstrated. "We had to show how our assessment forms were changed, the planning and input from staff for this change, the education of staff on this change, when it was implemented, and what data are being collected to show sustained compliance for the next four months," says Adams.

In addition, you need to show leadership support and physician involvement if indicated, and she suggests writing action plans in a report format. "When we changed our forms to reflect the time-out requirement, we did not send in the actual forms. The JCAHO does not want policies, forms, or papers. They want everything input into the on-line secured access JAYCO’ extranet site."

To sustain corrective actions, quarterly monitoring will be done until 95% compliance is achieved for two quarters, and then spot checks will be done biannually, Adams explains.

Sample ESCs submitted to JCAHO

One of the organization’s RFIs involved the initial assessment, pain assessment, and reassessment, which was being completed inconsistently, she says. Here are the steps that were taken, which were submitted to JCAHO:

  • The safety opportunity session, a subcommittee of the quality council, developed a proposal for the RFI pending the final JCAHO report. The quality council approved specific plans and made assignments to address each RFI.
  • The medical/surgical nursing director led a team to improve initial assessment documentation. The group developed a plan to help staff improve. Each week, a specific section of the patient assessment was presented to staff on each unit. A "Topic of the Week" inservice reviewed all major areas of the assessment record, including pain, Braden Scale/skin assessment, medication/allergies, functional screening, and referrals. At the end of the five-week cycle, an inservice to review all five areas was held on both shifts, and staff were given an opportunity to ask questions and resolve any misunderstandings. A synopsis of the topics was published in the hospital newsletter.
  • The ambulatory nursing director led a team to develop a plan for improving pain assessment and reassessment. This inservice was presented at the clinical manager’s meeting, and the topic was revisited with a poster presentation at the units.
  • A videotape — Documentation: Sharpening Your Skills (Nashville, TN-based Envision Inc.) — was purchased and incorporated into skills fairs, including a post-test, and now is part of the nursing orientation process. Directors for the medical/surgical, ambulatory, emergency department, critical care, pharmacy, and respiratory divisions presented this information at unit meetings. Clinical managers presented a review of initial assessment requirements during staff meetings.
  • The initial assessment tool was revised to emphasize specific areas related to skin assessment, pain assessment, and fall risk.
  • Staff from nursing, respiratory, and radiology were educated with formal training sessions on improving documentation of the initial assessment, including initial assessment and reassessment for pain. These training sessions have occurred in skills fairs, inservices, and unit poster presentations.
  • A section on documentation was added to employee performance evaluation tools. Orientation was revised to include more emphasis on documentation of initial assessment, pain assessment, and reassessment.
  • Managers reviewed open medical records for compliance to the standard from September 2004 to January 2005. The audit tool has been edited to include the items related to assessment standards. Fifty reviews will be completed each month and submitted to quality management, which will tally results and report compliance to the quality council. Each staff nurse also has several reviews by peers to determine compliance to these standards, and this information is used in the evaluation process to further re-enforce continuous compliance.
  • Directors are conducting tracer activities monthly to assess compliance and validate employee understanding and knowledge. Compliance will be at 90% for the next four months.

To address another RFI involving the requirement for intravenous (IV) admixtures to be made only in pharmacy unless urgent/emergent or a stability concern, the following was submitted to JCAHO:

  • The RFI was presented at medical staff department meetings by the vice president of clinical services and the director of quality to facilitate the change in ordering practice related to medications being added to the present hanging IV.
  • The quality council approved recommendations to address this RFI, and the medication management committee, a multidisciplinary clinical group, recommended a special team to develop a new policy with restrictions for IV admixtures. This special team included representation from nursing, parental nutrition, oncology nursing, pharmacy, critical care, cardiac catheterization lab, quality management, patient safety, and administration.
  • The new policy was brought by the director of pharmacy for review and approval by the pharmacy and therapeutics committee, and the team met again to finalize the implementation.

Here is a summary of the new policy:

1. Pharmacy will provide commercially available sterile IV admixtures or sterile IV systems when available. IV admixtures that are not commercially available will be mixed by the pharmacy in an appropriate laminar flow hood. Exceptions to the policy are nonstable medications and urgent and emergent medication such as Pitocin, Levophed, epinephrine, and Neo-Synephrine.

2. IV flow sheets and documentation tools have had prompts added to remind staff not to add any medications to hanging IVs.

3. Staff in nursing and pharmacy were educated about this new policy by their managers.

4. Pharmacy has purged the automated drug-dispensing machines of nonurgent medications used as admixtures. Automated drug- dispensing machine reports will be monitored by the pharmacy for compliance to this process.

[For more on corrective action plans, contact:

Darlene Adams, RN, MSN, Patient Care Safety/Quality Management Officer, United Regional Health Care System, 1600 10th St., Wichita Falls, TX 76301. Phone: (940) 764-3062. E-mail: dadams@urhcs.org.

Catherine M. Fay, RN, Director of Performance Improvement, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4263. Fax: (619) 470-4162. E-mail: FayCM@ah.org.]