Priority Focus Process

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Priority Focus Process

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

Used with Permission
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Overview of the Priority Focus Process

• PFP provides the process and infrastructure for
  the purpose of
• Converting pre-onsite survey data into
  information
• Focusing on-site survey activities
• Increasing consistency in the accreditation
  process
• Customizing the accreditation process

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Changing Data Into Information

• PFP uses automation to gather pre-survey data
  from multiple sources
• Joint Commission data (QMS, ORYX Core Measure)
• Data supplied by the HCO (E-app,Periodic
  Performance Review )
• Publicly available data (MedPar)
• PFP then applies rules to identify
• Potential processes and clinical service groups
  to address
• Relevant standards
• Appropriate on-site survey activities

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Future Rules Driven Priority Focus Process . . .
Complement
Standards
APS Rules
E-App
Length
Previous On-site Survey Data
Fee
QMS, ORYX Data
PriorityFocus Rules
PFP Output Priority Issues, Relevant Standards,
Survey Activity
Medpar Data, Periodic Performance Review Data
APS Application Processing System
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PFP Information

• Includes the top 4-5 critical focus areas
  specific to the organization
• Includes the clinical service groups most
  relevant to the organization
• Organizations have access to their PFP
  information (on the Extranet) at the 15-month
  point with Periodic Performance Review and 1-2
  weeks prior to survey

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Priority Focus Process Outputs Critical Focus
Areas

• PFP displays an organizations priority Critical
  Focus Areas (CFAs)
• Critical Focus Areas are processes, systems or
  structures in a health care organization that
  significantly impact safety and/or quality care
• Surveyors use the priority CFAs to
• Review supporting data
• Plan on-site survey activity
• Plan tracer focus areas and potential relevant
  standards

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Critical Focus Areas include

• Assessment and Care
• Communication
• Competency and Credentialing
• Equipment Use
• Infection Control
• Information Management
• Medication Use

• Organization Structure
• Orientation and Training
• Rights and Ethics
• Physical Environment
• Quality Improvement Expertise and Activity
• Patient Safety
• Staffing

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EXAMPLE Top Critical Focus Areas for ABC
Medical Center, January 2004
Critical Focus Areas Critical Focus Areas are
defined as processes, systems or structures in a
healthcare organization shown to be necessary to
patient safety and quality care. Your
organizations prioritized Critical Focus Areas
(and definitions for those areas) are

• Care and Assessment
• Determination of what kind of care is required to
  meet a patient's initial needs as well as his or
  her needs as they change in response to care.
  Also, includes re-assessment and discharge
  planning needs.
• Communication
• A process in which information is exchanged
  between individuals and departments.
  Communication includes an organization's policies
  and procedures - as a mechanism to communicate
  with staff.
• Staffing
• Providing the correct number, skill mix, and
  trained (competency) resources to meet the needs
  of patients. Staffing includes employees who are
  the direct and indirect caregivers at the health
  care organization.
• Patient Safety
• Limiting the risk an intervention (e.g., use of a
  drug or a procedure) and the care environment
  have for a patient.

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Priority Focus Process Outputs Clinical
Service Groups

• PFP display an organizations priority Clinical
  Service Groups (CSGs)
• Clinical Service Groups are groups of patients in
  distinct, clinical populations for which data are
  collected
• Surveyors use the priority CSGs to
• Identify clinical service groups for focus
• Use organizations active patient list and
  identified clinical service groups to select
  tracer patients

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EXAMPLE Top Clinical Service Groups for ABC
Medical Center, January 2004
Clinical Service Groups Clinical Service Groups
are categories of patients/clients into distinct
groups for use in the Priority Focus Process.
Your organizations prioritized Clinical Service
Groups are

• Cardiology
• General Surgery
• Orthopedic
• Rehab

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Priority Focus Process Outputs On-Site Survey
Activities

• Information from the prioritized Critical Focus
  Areas and Clinical Service Groups are used to
  help guide the focus of on-site survey activities
  such as
• Leadership Conference
• Systems Tracer Data Use
• Systems Tracer Infection Control
• Systems Tracer Medication Management
• Patient/client/resident tracers

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Priority Focus Process Goals . . .

• The goal of the Priority Focus Process (PFP)
• Modify the on-site survey process by providing
  consistent focus on issues most relevant to
  patient safety and quality of care specific to
  the HCO
• Provide the process and infrastructure to
• Convert pre-survey data into information that
  focuses on-site survey activities (consistency)
• Position the Joint Commission to customize the
  accreditation process (specificity)

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Priority Focus ProcessContent Development

• In order to develop the PFP, JCAHO did research
  and conducted focus groups to identify data that
  are associated with priority issues these
  issues were defined as critical focus areas
• JCAHO developed categories for sorting services
  these are called clinical service groups
• JCAHO then identified a process to obtain these
  data from multiple sources, and to use automation
  to sort the data
• These data are then used in the PFP

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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. Massaro, Russ (May 2003) ppt.
Executive Briefings, JCAHO Shared VisionsNew
Pathways 2004 Accreditation Process, Joint
Commission on Accreditation of Health Care
Organizations. SMART Staff Maintaining
Accreditation Readiness Together (2003) ppt.
Shared Visions New Pathways Update on the
Survey of the Future. Inova Health System.