The JCAHO Accreditation Process: An Overview

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The JCAHO Accreditation
Process An Overview

2
Joint Commission On The Accreditation Of
Healthcare Organizations

• The Joint Commission Accredits More Than 17,000
  Health Care Organizations In The United States
  And Many Other Countries.

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Accredited Organizations Include

• Hospitals
• Healthcare Networks
• Long Term Care Facilities
• Ambulatory Care Facilities
• Home Care Organizations
• Clinical Laboratories
• Behavioral Healthcare Facilities
• Office-Based Surgery Practices

4
Why Get Surveyed?

• Enhances Community Confidence
• Provides A Report Card For The Public
• Offers An Objective Evaluation Of Performance
• Stimulates Quality Improvement Efforts
• Aids In Professional Staff Recruitment
• Provides A Staff Education Tool
• May Be Used To Meet Certain Medicare
  Certification Requirements
• DOD Requirement

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The JCAHO Goal

• Send Specially Trained Surveyors To Evaluate
  Each Health Care Organizations Compliance And
  Identify Strengths And Weaknesses. The
  Surveyors Goal Is Not Merely To Find Problems,
  But Also To Provide Education And Consultation So
  Health Care Organizations Can Improve.

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Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

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Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

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Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

9
Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

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Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

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Survey Types

• Triennial
• Focused
• Conditional Follow-up
• Unannounced For Cause
• Unscheduled
• Random Unannounced

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Worried About Unannounced Surveys?

• JCAHO No Longer Always Gives Advance Warning
• Inspectors Are Conducting Very Thorough Surveys
• No More Cramming To Comply
• The JCAHO Is Basing Unannounced Surveys On Your
  Last Survey Aimed Directly At Any Weaknesses

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Best Motto Stay Prepared

• Its Important To Always Be Ready For A JCAHO
  Inspection
• Always Maintain Management Plans, And Local
  Policies And Procedures
• Always Complete Annual Evaluations Specifically
  Identifying Problem Areas
• Never Let Compliance Slide

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Keep All Staff Informed

• Education Is A Big Piece Of The Puzzle
• Inform Staff Members About Maintaining Competency
• Discuss How Your Facility Would Respond To An
  Unannounced Survey
• Make Staff Accountable and Simplify Operations
  Where Possible

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This Is The Key

• Be Organized And Surveyors Are Less Likely To Dig
  Deep
• Always Have Key Information Handy
• Demonstrate Improvement - Surveyors Will Want To
  See Whether Your Facility Has Corrected Areas Of
  Deficiency Previously Cited

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Document Review Session Tips

• Review Applicable Standards Supporting
  Documentation
• Organize Your Material According To The Chapters
  In The CAMH Tabbing Them With Standard Number Is
  Helpful
• Only Include Required Documents, e.g., SOC, ILSM
  Policy Documentation, The 7 Management Plans,
  Safety Officers Responsibilities

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Building Tour Tips

• Prior To The Survey, Spot Check LSC Compliance
  Update PFI If Necessary
• Keep The Tour Group Small Essential Staff Only
• Have A Ladder, Flashlight, and Keys to Locked
  Areas Available
• Know That The Physician Nurse Evaluate The
  Environment Of Care

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Functional Interview Tips

• Assemble The Necessary Documents In A Central
  Location
• Invite All Staff With Environment Of Care
  Responsibilities

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Scoring- Scale

• 1 - Substantial
• 2 - Significant
• 3 - Partial
• 4 - Minimal
• 5 - Noncompliance

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Scoring - EC Grid Elements

• Design (EC 1)
• Implementation (EC 2)
• Measuring Outcomes Of Implementation (EC 3)
• Other Environmental Considerations (EC 4)

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Scoring - Example

• EC.2.9
• Are EPP Drills Conducted Regularly As
• Described In The Intent?
• Score 1 Yes
• Score 3 One Exercise Is Missing Or There Is
  Less
• Than 4 Months Or More Than 8 Months Between
• Exercises
• Score 5 No

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Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For
• Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

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Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

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Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

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Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For
• Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

26
Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

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Accreditation Decisions

• Accreditation With Full Standards Compliance
• Accreditation With Requirements For Improvement
• Provisional Accreditation
• Conditional Accreditation
• Preliminary Denial Of Accreditation
• Accreditation Denied

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Shared Visions New Pathways

• In Fall 2002, The JCAHO Announced Significant
  Changes To The Accreditation Process For Health
  Care. The New Initiative Will Progressively
  Sharpen The Focus Of The Accreditation Process On
  Operational Systems Critical To The Safety And
  Quality Of Patient Care.

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Shared Visions

• Represents A Vision That JCAHO Has With Health
  Care Organizations--As Well As With Health Care
  Oversight Bodies And The Public--To Bridge What
  Has Been Called A Gap Or Chasm Between The
  Current State Of Health Care And The Potential
  For Safer, Higher Quality Care.

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New Pathways

• Represents A New Set Of Approaches Or
  Pathways Through The Accreditation Process That
  Will Support Fulfillment Of The Shared Visions.

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New Pathways Will Include

• Substantial Consolidation Of The Standards To
  Reduce The Paperwork And Documentation Burden Of
  The Survey Process And Increase Its Focus On
  Patient Safety And Health Care Quality.

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New Pathways (Cont)

• A Required Mid-Cycle, Self-Assessment During
  Which The Health Care Organization Evaluates Its
  Own Compliance With Applicable Standards And
  Develops A Plan Of Correction.

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New Pathways (Cont)

• Pre-Survey Review Of Organization-Specific
  Information, Such As, Previous Recommendations,
  Demographic Data On Types And Volumes of
  Services, Complaints, And Sentinel Event
  Information.

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New Pathways (Cont)

• On-Site Evaluation Of Standards Compliance In
  Relation To The Care Experience Of Actual
  Patients.

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New Pathways (Cont)

• Revision Of Individual Organization
  Performance Reports To Provide Performance
  Information Not Portrayed in the Current Reports.

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New Pathways (Cont)

• Active Engagement Of Physicians And Other
  Direct Caregivers In The New Accreditation
  Process.

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Shared Visions--New Pathways

• Will Shift The Focus From Survey Preparation
  To Continuous Improvement Of Operational Systems
  That Directly Impact The Quality And Safety Of
  Patient Care.

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Shared Visions--New Pathways

• The JCAHO Has Initiated A Number Of Other
  Enhancements As Part Of The Future Accreditation
  Process, Including An Electronic Request For
  Survey, Formal Certification For Surveyors, And
  A Consolidated Database Of Standards For All Of
  JCAHOs Accreditation Programs.

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Shared Vision--New Pathways

• Facilitating Communication
• Streamlining Standards
• Self-Assessment
• On-Site Survey Process
• Priority Focus Process
• Decision And Performance Reports
• New Approach To Complex Organizations
• Surveyor Development

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JCAHO NOW

• October To December 2003Organizations Will Be
  Given 3 Months To Complete Their Self-Assessment
  And, If Indicated, Corrective Action Plan(s).
• January 2004 (At The 18 Month Point In The
  Accreditation Cycle For Organizations Due For
  Their Regular Triennial Survey In July 2005)
  Organizations Submit The Self-Assessment And
  Corrective Action plan(s) To JCAHO Via The
  Extranet.

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JCAHO NOW (Cont)

• January To February 2004--Within One Month, JCAHO
  Conducts A Phone Interview With Each Organization
  To Review The Corrective Action Plan(s).
• January To March 2005--Each Organization
  Completes The Electronic Request For Survey And
  The Onsite Survey Is Scheduled.

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JCAHO NOW (Cont)

• During The Exit Interview Of The Onsite Survey,
  JCAHO Will Provide A Final Accreditation Report.
• Within The Next 30 Days The Organization Will
  Develop Its Report Of Evidence Of Compliance.
• Within 30 Days of Receipt Of This Report, The
  JCAHO Will Notify The Organization Of The
  Acceptability Of The Report.

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Summary

• Know Applicable Standards
• JCAHO Updates - EC News/Website
• Refresher Training
• Network With Other Medical Facilities
• Resolve Previous JCAHO Recommendations Findings
• Conduct Mock Surveys - Include Weekend And
  Evening Shift Workers
• Always Remain Prepared!