# Presentation: 114549

## Transitions & Changes in JCAHO:“How to Stay Current”

## Joint Commission’sShared Visions – New Pathways

*Sharpening the focus of the accreditation process on care systems critical to the safety and quality of care.*

## Why?

- Continuous performance improvement indicated opportunities exist to improve value accreditation

## Value Enhancements

- Increased relevance of standards and survey process to most important patient care and safety issues
- Better focus of on site evaluation on delivery of services related to these patient care and safety issues
- Provide rigorous, fair evaluation
- Increase consistency of surveyors
- Improve education benefit of accreditation
- Control or lower accreditation – related costs
- Improve customer service and satisfaction

## Shared Visions – New Pathways Will Not:

- Lengthen the survey process
- Increase organizational fees

## Achieving the Vision

- Certain JCAHO standards eliminated or modified
- Accreditation relies on onsite survey processes and Periodic Performance Review

## Strategies

- Complete review of standards
- Electronic request for survey
- Periodic Performance Review at mid-point of the THREE-YEAR accreditation cycle
- Priority Focus Process to standardize the evaluation of pre-survey data
- New onsite survey agenda
- New accreditation decision and reporting system

## Review of Standards

- Clear
- Streamlined
- Redundancy removed
- Critical standards remained

## Reformatting of Standards

- Introduction
- Standards
- Rationale
- Elements of Performance

## Corrective Action Plan

- Entered into the Periodic Performance Review
- Submitted to the Joint Commission

## Critical Focus Areas

- Assessment and Care/Services
- Communication
- Credentialed and Privileged Practitioners
- Equipment Use
- Infection Control
- Information Management
- Medication Management

## Critical Focus Areas (Continued)

- Organizational Structure
- Orientation & Training
- Rights & Ethics
- Physical Environment
- Quality Improvement Expertise & Activity
- Patient Safety
- Staffing

## Onsite Survey Goals

- Incorporate periodic Performance Review
- Incorporate Priority Focus Process
- Use Tracer Methodology
- Provide more time for education
- Offer organizations systems analysis

## Survey Agenda Items

- Opening conference
- Leadership Interview
- Validation of Periodic Performance Review
- Systems tracers
- Tracer visits
- HR/Credentialing review
- Environment of Care review

## Accreditation Decision

- Elimination of “accredited with requirements for improvement”
- No published scores

## Accreditation Decisions

- Accredited
- Conditional accreditation
- Preliminary denial of accreditation

## Key Terms and Abbreviations

- Periodic Performance Review (PPR)
- Plan of Correction
- Measures of success (MOS)
- Priority Focus Process (PFP)
- Priority Focus Area (PFA)
- Clinical/service group (CSG)
- Tracer methodology
- Elements of performance (EPs)
- Evidence of Standards Compliance (ESC)

## Accreditation Participation Requirements(APR’s)

## 2004 APR New Requirements

- Organizations cannot use surveyors as consultants for accreditation-related consulting
- Consulting includes:
-     • Help in meeting the standards
-     • Completing the Periodic Performance
-        Review
-     • Improving problematic areas identified in the
-        PPR
-     • Conducting mock surveys
-     • Consulting to address Priority Focus Process
-        information

## 2004 APR New Requirements

- Fulfill Periodic Performance Review
-     requirements at midpoint in organization’s
-     accreditation cycle
- Organizations can choose one of the following:
-     • Full PPR
-     • Option one
-     • Option two
-     • Option three (in development)

## 2004 APR New Requirements

- National Patient Safety Goals
- NPSGs no longer grouped under one APR
- Each one now scored at a separate APR or   standard

## Complex Organizations

- Defined as those organizations accredited under more than one JCAHO accreditation manual
- Integrated and more streamlined accreditation processes
- More customized, focused, efficient, and educational
- Replaces “tailored survey” terminology

## New On-site Survey Process for Complex Organizations

-  Integrated, generalist surveyors survey common standards that apply to multiple programs (i.e. hospital, home care, long term care) once across entire complex organization
- Program-specific surveyors survey specialty standards requiring evaluation at individual program level

## Changes to the 2004 CAMH

## Changes in the CAMH

- Reformatted Standards and Rationales
-     • See _***crosswalks.***_
- An organization is either “compliant” or “not compliant” with a _***standard***_ .

## 2004 Standards

**Elements of Performance (EPs):**
- Specific statements of expectations
- The *only *part of standard that is “scorable”
- Replaces narrative “intent” statements
- No hidden information

## Periodic Performance Review(PPR)

- A Tool and A Process

## PPR Components

- Review of all standards and identification of areas for improvement
- Plan of Correction (POC)
- Measure of Success (MOS)
- Phone conference with Standards Interpretation Group (SIG)

## Extranet Application for Accreditation

- Joint Commission’s first venture into e-business environment
- Available on a secure, password-protected web space
- Improves quality and consistency of data
- Allows for efficiency in analysis of information provided by HCO

## Periodic Performance Review

- Electronic format with extranet access
-     •   Password-protected site
- Accreditation Participation Requirement
- Between 15th and 18th month point in accreditation cycle
- 3 months to complete
- HCOs choose own approach to assessment

## Plan of Correction (POC)

- Based on standards review
- POC for each non-compliant standard
- 	• Describe action plan for EPs marked:
-        - Partial compliance
- 	    - Not compliant
- 	• Develop measure of success (MOS)

## Measure of Success (MOS)

- Definition:
- 	• Numerical or other quantitative measure
-       usually related to audit that validates
-       when action was effective & sustained
- All EPs may not require a MOS

**M**

## Consultation With SIG

- Standards Interpretation Group at JCAHO
- Phone conference
- Review of POC or standards related issued
- Compliance education
- Activities dependent on PPR option chosen

## PPR Options

- Full PPR
- Option One
- Option Two
- Option Three (In Development)

## Full PPR

- Includes:
- 	• Self-assessment of all applicable standards
-     • Development of POCs and MOS (as
-       needed
-     • Submission of PPR data to JCAHO
- Involves:
-    • Telephone interaction between HCO and JCAHO (review and approval of POAs and MOSs)

## Key Characteristics of Full PPR and Options

- All accredited HCO’s develop Plans of Correction and Measures of Success (as appropriated) at mid-point of accreditation cycle
- All accredited HCO’s share MOS information with surveyors at time of full survey
- All accredited HCO’s demonstrate a 12-month track record of standards compliance at time of full survey
- Any area of non-compliance discovered at time of full survey will be scored

## PPR Option One

- HCOs will
- Attest that they have been advised by legal counsel not to participate in full PPR
- Self-assess compliance with standards
- Develop POAs and MOSs
- Submit standards related issued for discussion with JCAHO staff during interactive phone call
- 	- Submission is optional
-  	- No inference relative to compliance will be made

## PPR Option One (Cont’d)

- HCOs will _**not**_:
- Submit PPR data to JCAHO
- Use extranet tool to score compliance (Only view and print standards and EPs)

## PRP Option Two

- HCOs will attest that they have been advised by legal counsel not to participate in full PPR
- On-site survey (mid-cycle)
- Survey length approximately one-third of usual survey
- Surveyor uses priority focused information
- Fee charged to cover costs of survey

## PPR Option Two (Cont’d):

- If standards not compliant, surveyor writes “requirements for improvement” and enters this into PPR tool
- HCOs access info thru extranet and submit POAs and MOSs for surveyor identified areas of non-compliance
-     • PPR tool has screen for stds related issued (no deficiencies revealed) or HCO may opt out
- Required conference call with JCAHO staff scheduled (Optional only if no deficiencies from surveyor, though encouraged)

## PPR Option Three:Operational Process in Development

- Organizations will affirm that after careful consideration with legal counsel, they have decided not to participate in full PPR
- On-site survey will take place of self-assessment activity
- Organizations will be charged fee to cover costs of on-site survey
- Survey length will be approximately one third of usual triennial survey

## PPR Option Three: (cont.)

- Organizations will be able to submit standards related issued for discussion with JCAHO staff during interactive, scheduled phone call, but no inference relative to compliance will be made

## Benefits ofPeriodic Performance Review

- Employs same tool used by surveyors
- Expands intra-cycle interaction with JCAHO
- Supports continuous operational improvement
- Assists HCO’s in quest for 100% compliance, 100% of the time

## Priority Focus Process(PFP)

## Priority Focus Process Tool

- Automated tool to support PFP
- Uses logic to bring consistency to review of pre-survey data
- Converts data about HCO into information
- Shapes survey process

## Rules Driven Priority Focus Process

**E-App**

**Previous**
**On-site**
**Survey Data**

**QMS,ORYX OTHER PM DATA**

**External Data (Medpar, Oasis MDS, and Proficiency Testing**

**APS**
**Rules**
**Priority **
**Focus**
**Rules**

**Complement**

**Standards**

**Length**

**Fee**

**PFP Output: Priority Issues, Relevant Standards, Survey Activity**

**Surveyor**
**Feedback**
**Loop**

**= Today**
**= 2005 PFP**

**APS =Application Processing System**

## Priority Focus Areas

- Key Areas
- Positive clinical outcomes are more likely when systems work well
- HCO areas most relevant to patient safety and quality of care

## Priority Focus Areas

- Assessment and Care/    Services
- Communication
- Credentialed and Privileged Practitioners
- Equipment Use
- Infection Control
- Information Management
- Medication Management

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

## Clinical Service Groups

- Key Populations
- What has been done to address future issues:
- 	• Revised definitions in PFP tool
- 	• Plan to collect additional information in
-       e-app for 2005

## Tips for Success

- Use tool to identify opportunities to improve
- Ensure organization-wide assessment
- Determine communication processes
- • Written
- • Verbal
- Evaluate performance using standards (Elements of Performance)

## Survey Activities

## Link Between PPR   and On-Site Survey

- Triennial survey
- • Surveyors will review Measures of Success (MOS) from the PPR
- • Surveyor will ask for data related to each MOS
- Track record requirements remain

## Systems Analysis

- Set of components that work together toward common goal
- Evaluation of how and how well systems function
- Addresses interrelationships of elements
- Translates standards compliance issues into potential vulnerabilities

## On-site Survey Process

- Use of pre-survey, focused information
- Tracer methodology allows on-site survey process to be customized to
- • Settings
- • Services
- • Populations specific to HCO

## Tracer Methodology

- Process surveyors use during on-site survey
- Follow patients through organization’s processes and services experienced by patient
- Surveyed across programs
- Multi-level participation

## Tracer Methodology-A Systems Approach to Evaluation

- Tracer methodology follows experience of care for a number of patients through HCO’s entire health care process
- As cases are examined, surveyor may identify performance issues in one or more steps of process – or in interfaces between processes

## Objectives of Tracer Activity

- Follow course of care and services provided to patient/client/resident
- Assess relationships among disciplines and important functions

## Tracer Activity

- Comprises 50 – 60% of on-site survey time
- Will be approximately 90 minutes in length (but can be up to 3 hours)
- Starts in setting/unit where tracer patient/client/resident is located
- May include sequential following of course of care – but no mandated order for visits to other care areas

## Tracer Selection Criteria

- Identified Clinical Service Groups from PFP
- Patient/Client/Resident who received complex services (often those close to discharge)

## Tracer Selection Criteria(cont’d)

- Patient/Client/Resident who cross different programs (such as hospital and long term care)
-  Patient/Client/Resident who relate to _**systems**_ tracers
- • Infection Control
- • Medication Management

## Tracer Visits Include

- Evaluation of top 4-5 priority focus areas identified in PFP
- Observations of care areas and EOC issues
- Review of medical record with staff

## Selecting Tracer Patients

- Example of additional criteria for hospitals
- • Complex Situations
- – ICU
- – ED
- – Anesthesia Services
- – Labor and Delivery
- – 23 hour admit

## Tracer Activity Examples

- Observation of direct care
- Observation of medication process
- Observation of care planning process
- Individual or family interview
- Review of additional medical records
- Staff level interaction
- Review of policies and procedures

## Example of Hospital Tracer

- If Pediatrics is one of top CSG’s
- If Medication Management is one of top PFA’s
- Surveyor will select pediatric patient from active patient list, follow care provided to that patient and focus on medication management, for example,
- •Dispensing, administering, monitoring
- •Training of staff responsible for processes

## System Tracers

- Data Use
- Medication Management
- Environment of Care
- Infection Control
- More on system tracers later in program

## Tracer Logistical issued.....

- Issues:
- • Two surveyors arriving at same unit at same time•
- • One unite being “over-visited”
- What has been done to address issues:
- Tools for planning tracer activity
- “Team-building” education for surveyors
- Additional surveyor meeting added to agenda
- Peer Coaches in 2004 surveys

## Scoring

## Determining an Organization’sDecision....

- Accreditation decisions are based on total count of compliant standards

## EP Scoring

- EP’s are scored on a 3 point scale
- • Satisfactory compliance (2)
- • Partial compliance (1)
- • Insufficient compliance (0)
- Track record (history)considered
- Bulleted EP’s have some scoring nuances

## How Standards Compliance is Determined

- If any one EP under a standard is insufficiently compliant (0), entire standard is not compliant
- If EP’s are scored in a combination of 1s and 2s, standard is in compliance if 65% or more of EP’s are scored 2
- If less than 65% of EP’s are scored 2, standard is not compliant

## How EP’s Are Scored

- EP’s have been assigned to one of three scoring categories
- Each scoring category has guidelines

## Categories for EP’s

- The scoring guidelines will divide EP’s into different categories
- Category A (EP’s scored yes or no)
- Category B (EP’s address situations in which literal intent is met, but there is need to evaluate quality or comprehensiveness of effort)
- Category C (EP’s that address frequency)

## How Is Each Category Scored

**“****A”** EP’s scored only 0 or 2 (yes or no)
- Unless there was a track record issue leading to a score of 1 (partial compliance)
- For example, if you answer yes to the EP; however, it was only in place for 6 – 11 months
- Score 1
- • Usually EP’s related to law and regulation

## How Is Each Category Scored

**Category B:**
- Structural or process requirement
- Yes or No but quality, adequacy or comprehensiveness impact score

## How Is Each Category Scored

- Category B: (cont’d)
- • Depends on design of process using new LD.4
- Mission, vision, values, goals, objectives, plans
- Needs of individuals served
- Clinically sound, accepted practices
- Available information regarding risks, SE, NPSG
- Use of relevant PI information
- All components of EP

## How Is Each Category Scored

**Category B: (cont’d.)**
- • Scoring
- All principles = Score 2
- Only some principles = Score 1
- No principles considered = Score 0

## How Is Each Category Scored

- Category** C:**
- • Frequency of observations, occurrences
- Score 2 (satisfactory compliance) if no or one observance
- Score 1 (partial compliance) if two observances
- Score 0 (insufficient compliance) if three or more observances

## Track Record Impacts EP Scoring

- 12 months (4 months for initials) needed for a score of Satisfactory Compliance (2)
- 6 – 11 months (2-3 months for initials) needed for a score of Partial Compliance (1)
- Less than 6 months (< 2 months for initials) is a score of Insufficient Compliance (0)

## Standard Level Scoring

- EP’s aggregate to determine standards compliance
- Standards are
- • Compliant
- • Not compliant

## Determining Standard Level Compliance

- EP scores “roll up” to standard level
- If any EP is scored insufficient Compliance (0), standard is **Not Compliant**
- 35% rule: A standard is **Not Compliant** if more than 35% of the EP’s are scored Partial Compliance (1)

## Not Applicable EP’s

- EP’s that are scored _Not Applicable _are removed from calculation
- Important: Identify EP’s that are Not Applicable

## EP Roll Up to Standard Level

- If a standard has only one EP and the EP is scored Partial compliance (1), that standard is **Not Compliant **(Applies to all other programs)

## Follow-up

- 45 days after survey (90 days for 2004):
- Submit “evidence of standards compliance” (ESC) report for each finding
- Submit an indicator or “measure of success” for each finding to assess sustained compliance over time.
- Four months after an approved ESC:
- • Submit data on each indicator or measure of success over past 4 months

## Remember, a Measure of Success (MOS) is....

- A numerical or other quantitative measure usually related to an audit that validates that an action was effective and sustained
- Submitted via the extranet
- Submitted on electronic form with space limited to a brief indication of the numerical measure-often just a numerator and denominator with definitions of each

## Evidence of StandardsCompliance (ESC)

- Clarifying ESC:
- If Organization believes it was in compliance with the standards at time of survey
- Evidence to submit will be specified
- No “measures of success”
- Corrective ECS:
- • What you’ve done to correct finding
- • Measures of success (if applicable)

## If No ESC SubmissionWithin 90 Days?

- During the 90 days, the HCO maintains its current accreditation status
- After 90 days, if no ESC submitted or ESC fails, the HCO will move into “Provisional Accreditation” status
- • This status is disclosable
- Once ESC and indicators are accepted, HCO will then be in “Accredited” status

## What about revisions?

**No longer need for revisions**
**During 90 days* after on-site survey, HCO can send information to JCAHO to demonstrate what they have done to come into compliance (corrective evidence), OR to demonstrate that they were in compliance at the time of survey (clarifying evidence)**
**During this time period, the HCO maintains its current accreditation status**
- 	**Note: HCO’s surveyed after July 1, 2005 have 45 days for ESC submission; this timeframe is subject to revision by Accreditation Committee after review and analysis of actual submission data.**

## Final Accreditation Decision

- Made after the JCAHO received and approves the HCO’s evidence of standards compliance (ESC) and identified measure of success
- If an acceptable ESC is received, then the HCO will receive an “Accredited” decision

## Accreditation Decisions

**Elimination of the category of Accredited with Requirements for Improvement**
**New decision rules for Conditional Accreditation and Preliminary Denial of Accreditation (PDA) based on total number of recommendations**
**• *****2 or more, but less than 3 standard deviations from mean for conditional***
**• *****3 or more standard deviations from mean for PDA***
**Elimination of the disclosure of scores to HCO or public**

## Quality Reports

- Will replace Performance Reports
- Will include new information relative to quality and safety
- • Performance on National Patient Safety Goals
- • Performance on National Quality Goals (future)
- ORYX core measures
- Special recognitions/achievements (e.g., Codman Award)
*These are the measures that will distinguish organizations-not scores!*

## For More Information

- See the January 2004 issue of the “Joint Commission Perspectives.”

## Hospital Standards

## RI.2.10Patients’ Rights

- Respect each patient’s cultural, psychosocial, spiritual, and personal values, beliefs and preferences
- Support patient’s right to personal dignity
- Accommodate pastoral and other spiritual services

## PC.2.20Assessment

- Data & Information defined in writing
- For patients receiving end-of-life care assessment must include the patient’s spiritual variables, values, beliefs and preferences

## PC.3.120Treatment for Addictions

- Obtaining & interpreting information:
- Substance abuse
- Dependence
- Other addictive behaviors
- Spiritual Orientation
- “Spiritual Orientation refers to the individual’s attitudes and outlook about the non-physical aspects of life—the “spirit.”  It is often reflected in belonging to a church, following a religion, or holding specific religious beliefs.”
- Develop treatment plan

## PC.3.130Treatment for Emotional orBehavioral Disorders

- Additional assessments:
- Vocational or educational
- Legal
- Community resources
- Evaluations performed

## PC.6.10Education

- Specific to patient’s needs
- Patients given information to:
- • Make decisions
- • Take responsibility
- Patients & family educated
- • Improve outcomes

## PC.7.10Nutritional Care

- Process for preparing and/or distributing food & nutrition products

## PC.8.70End of Life Care

- Comfort & dignity optimized
- Patient right to physical & psychological comfort
- Psychosocial & spiritual needs
- Patient
- Family

## Long Term Care Standards

## RI.2.10Patients’ Rights

- Respect each patient’s cultural, psychosocial, spiritual, and personal values, beliefs and preferences
- Support patient’s right to personal dignity
- Accommodate pastoral and other spiritual services

## RI.2.220Patients’ Rights

- Respect each patient’s cultural, psychosocial, spiritual, and personal values, beliefs and preferences
- Support patient’s right to personal dignity

## RI.2.240Patients’ Rights

- Respect each patient’s decision to participate or refuse to participate in spiritual groups.

## PC.2.20Assessment

- Data & Information defined in writing
- Information gathered includes spiritual status and spiritual orientation.
- “Spiritual Orientation refers to the individual’s attitudes and outlook about the non-physical aspects of life—the “spirit.”  It is often reflected in belonging to a church, following a religion, or holding specific religious beliefs.”

## PC.5.60Providing Care

- Consistency with scope of care
- Internal & external resources
- Coordination between providers & setting
- Spiritual Services

## PC.6.10Education

- Specific to patient’s needs
- Patients given information to:
- • Make decisions
- • Take responsibility
- Patients & family educated
- • Improve outcomes

## PC.7.10Nutritional Care

- Process for preparing and/or distributing food & nutrition products

## PC.8.70End of Life Care

- Comfort & dignity optimized
- Patient right to physical & psychological comfort
- Psychosocial & spiritual needs
- Patient
- Family

## Behavioral Health Care

## RI.2.10Patients’ Rights

- Respect each patient’s cultural, psychosocial, spiritual, and personal values, beliefs and preferences
- Support patient’s right to personal dignity
- Accommodate pastoral and other spiritual services

## RI.3.100Patients’ Rights

- Children’s Rights Are Respected.
- Allow to develop their own spirituality.

## PC.2.60Assessment

- The assessment includes the client’s religion and spiritual orientation.
- “Spiritual Orientation refers to the individual’s attitudes and outlook about the non-physical aspects of life—the “spirit.”  It is often reflected in belonging to a church, following a religion, or holding specific religious beliefs.”

## PC.3.100Assessment

- The assessment includes the client’s religion and spiritual orientation.
- “Spiritual Orientation refers to the individual’s attitudes and outlook about the non-physical aspects of life—the “spirit.”  It is often reflected in belonging to a church, following a religion, or holding specific religious beliefs.”

## PC.3.140Foster Care - Assessment

- The assessment and case plan include the child’s religion and spiritual orientation.
- “Spiritual Orientation refers to the individual’s attitudes and outlook about the non-physical aspects of life—the “spirit.”  It is often reflected in belonging to a church, following a religion, or holding specific religious beliefs.”

## PC.6.10Education

- Specific to patient’s needs
- Patients given information to:
- • Make decisions
- • Take responsibility
- Patients & family educated
- • Improve outcomes

## PC.7.10Nutritional Care

- Process for preparing and/or distributing food & nutrition products

## Ambulatory Care

## RI.2.10Patients’ Rights

- Respect each patient’s cultural, psychosocial, spiritual, and personal values, beliefs and preferences
- Support patient’s right to personal dignity
- Not Present - *Accommodate pastoral and other spiritual services*

## PC.6.10Education

- Specific to patient’s needs
- Patients given information to:
- • Make decisions
- • Take responsibility
- Patients & family educated
- • Improve outcomes

## PC.7.10Nutritional Care

- Process for preparing and/or distributing food & nutrition products