Shared Visions

1
Shared Visions New Pathways
Understanding the Accreditation Process

• George Mason University
• College of Nursing and Health Science
• Regulatory Requirements for Health Systems
• Summer 2004

2
Shared Visions

• Health care organizations share a dedication to
  providing safe, high-quality care.
• JCAHO shares this vision and supports quality
  and safety efforts through the accreditation
  process.

3
New Pathways
New pathways introduces a new set of approaches
or pathways to the accreditation process that
will support the shared visions of JCAHO and
health care organizations.
4
Reasons for Change

• Part of JCAHOs own continuum of process
  improvement
• Supports the mission of JCAHO to continuously
  improve the safety and quality of care provided
  to the public

5
Enhancing the Accreditation Process

• JCAHO gathered information and opinions about
  the accreditation process from health care
  organizations, purchasers, consumers, and other
  accreditation stakeholders.
• The culmination of all the input led to the
  dramatic redesign and improvement of the
  accreditation process that took effect in January
  2004.

6
A Change in Emphasis

• The new paradigm shifts the emphasis from
  survey preparation to systems improvement
• Move focus away from the exam to the score
• Concentrate on using the standards to achieve
  and maintain excellent operational systems

7
The New Accreditation Process

• Focuses the evaluation more on the quality and
  safety of care.
• Shifts the accreditation-related focus from
  survey preparation and scores to continuous
  operational improvement in support of safe,
  high-quality care.
• Customizes the survey to an individual health
  care organization.
• Makes the accreditation process more continuous.

8
The New Accreditation Process (continued)

• Relies on new technologies to facilitate the
  continuous flow of information between health
  care organizations and JCAHO.
• Increases the publics confidence that health
  care organizations continuously comply with
  standards that emphasize patient safety and
  health care quality.
• Improves consistency of surveyors.
• Enhances relevancy of standards.

9
Components

• Complete Review of Standards
• Enhanced use of Extranet
• Organizational Periodic Performance Review
• Priority Focus Process
• Tracer Methodology
• New on-site Survey Agenda
• Enhanced Surveyor Development
• New Accreditation Decision and Reporting
  Approach
• Complex Organization

10
Complete Review of Standards
Streamline standards and reduce documentation
burden to focus more on critical patient care
issues.
11
Relevancy and Consistency

• An external task force, comprised of
  representatives from accredited organizations,
  state hospital associations and JCAHO advisory
  groups, assisted JCAHO in an extensive review of
  all standards.
• Substantial consolidation of the standards to
  reduce paperwork and documentation burden of the
  survey process and increase focus on safety and
  health care quality.

12
Periodic Performance Review (PPR)
The Periodic Performance Review supports an
organizations continuous standards compliance.
13
Continuous Accreditation

• Periodic Performance Review facilitates a more
  continuous accreditation process.
• A required mid-cycle Periodic Performance
  Review during which the health care organization
  will evaluate its own compliance with all
  applicable standards.

14
Continuous Accreditation (continued)

• When identifying areas of non-compliance,
  health care organizations develop a corrective
  action plan and a measure of success.
• Telephone call between JCAHO and the health
  care organization to review and approve
  corrective action.
• Accreditation status not impacted if corrective
  action plan is approved.
• At the triennial survey, validation of the
  corrective action and review of findings of
  Periodic Performance Review.

15
Priority Focus Process (PFP)
The Priority Focus Process incorporates
organization- specific data and identifies areas
for focus during a site survey.
16
Focus on Critical Issues

• The customized accreditation process
  concentrates on issues relating to safety and
  quality.
• These issues are unique to the health care
  organization being surveyed.

17
PFP Data Sources

• Pre-survey Data
• JCAHO (ORYX core measure data, complaint data,
  past recommendations, sentinel event data)
• Health care organization (Periodic Performance
  Review, Application for Accreditation)
• Publicly available data (MedPar)
• Enables Prioritization of On-Site Data
• Potential processes to address
• Appropriate on-site survey activities
• Relevant Standards

18
Tracer Methodology

• The Tracer Methodology uses actual patients
  being treated in the health care organization.
• These individuals are traced the
  organizations entire health care process.

19
Elements of the Tracer Methodology

• A systems approach to evaluation.
• The Priority Focus Process guides an individual
  through critical focus areas within the
  organizations entire health care system.
• The recipient of carea patient, resident or
  clientis referred to as a tracer.
• Tracers are randomly selected and followed by a
  surveyor through the organization in the sequence
  they receive care.
• The surveyor examines the components of a
  system (i.e. care within each department), and
  how those components work together (i.e. the
  hand off between departments/areas).

20
Issue Identification in the Tracer Methodology

• As actual cases are examined, the surveyor
  looks for performance issues or trends in one or
  more steps of the process or in the interfaces
  between processes.
• The surveyor will then work with the
  organization to address performance, rules and
  trends and provide onsite education and guidance
  on how to improve.
• If problems are identified, the surveyor may
  issue a recommendation. The organization then has
  90 days to submit evidence of compliance (45 days
  after July 1, 2005). A final decision will be
  given after the response has been reviewed and
  approved.

21
The Value of Systems Tracers

• Provide a forum for discussion of important
  topics related to the safety and quality of care,
  treatment and services at the systems level
• Relate to organization findings and structure
• Allow exchange of information on key topics
• - Medication management
• - Use of data
• - Infection control

22
Survey Agenda

• The survey agenda emphasizes
• systems analysis
• education

23
Goals of Survey Agenda

• Incorporate Priority Focus Process and Periodic
  Performance Review
• Focus on direct care through the tracer
  methodology
• Provide more time for education on
  high-priority issues
• Engage physicians in the accreditation process
• Provide an organization systems analysis

24
On-Site Survey Agenda

• Opening and closing conference
• Leadership conference
• Validation of corrective action plan
  implementation from Performance Review
• Priority Focus Process - guided visits to care
  areas using the tracer methodology
• In-depth evaluation and education regarding
  high- priority safety and quality of care issues
• Environment of Care review and conference

25
Benefits of On-Site Survey Process

• Provides process-driven approach, initiated by
  the Priority Focus Process
• Ensures customized on-site survey
• Promotes review of continuum of services and
  programs
• Includes multi-level participation
• Focuses on actual delivery of care and services

26
Enhanced Surveyor Development

• Enhanced surveyor development implies better
  trained surveyors who are skilled in systems
  analysis.
• The common skill set facilitates an improved
  and consistent survey process.

27
Surveyor Development

• Certification exam administered to all
  surveyors in January 2002
• Distance learning methodologies developed and
  implemented
• Virtual classrooms
• Surveyor mentors/supervisors assigned to direct
  field observation every month
• Feedback reports created to profile surveyor
  performance against the mean
• Renown graduate program delivers instructional
  and distance learning curricula related to
  organizational systems analysis

28
Accreditation Decision and Performance Reporting

• Shift from survey preparation to systems
  improvement
• New Quality Report format
• Provide outcomes data and safety information
• 90-day timeframe to submit evidence of
  compliance when recommendations are given at
  survey (45 days after July 1, 2005)
• Posted to extranet site 48 -72 hours after
  survey
• Simplified aggregation process

29
Enhancements

• JCAHO has initiated a number of enhancements to
  the accreditation process
• Electronic Application for Accreditation
• Formal certification for surveyors
• Consolidated database of standards
• Integrated survey process for complex
  organizations
• Elimination of Accreditation with Commendation
• Random unannounced surveys no notice given to
  organization

30
Complex Organizations

• Complex organizations (i.e. those that are
  surveyed under more than one accreditation
  program manual) participate in a customized,
  integrated, and streamlined JCAHO accreditation
  survey
• All patient services areas are evaluated
  concurrently, rather than surveying each health
  care delivery entity individually
• Generalist surveyors survey and only score
  standards that apply to multiple programs across
  the complex organization

31
Sources
Blomme, Jane (2002) ppt. Shared Visions New
Pathways Sharpening the focus of the
accreditation process on care systems critical to
the safety and quality of care. Joint Commission
on Accreditation of Health Care Organizations.
Used with permission. Massaro, Russ (May 2003)
ppt. Executive Briefings, JCAHO Shared
VisionsNew Pathways 2004 Accreditation Process,
Joint Commission on Accreditation of Health Care
Organizations. Used with permission. SMART Staff
Maintaining Accreditation Readiness Together
(2003) ppt. Shared Visions New Pathways Update
on the Survey of the Future. Inova Health System.