Transcript Organization of the 2005 Accreditation Manual

Organization of the 2006 Accreditation Manual
Section 1 - Patient Focused Functions
 Ethics, Rights and Responsibilities (RI)
 Provision of Care, Treatment and Services (PC) - was “TX”
 Medication Management (MM) - was “TX”
 Surveillance, Prevention and Control of Infection (IC) - revised
Section 2 - Organization-Focused Functions
 Improving Organization Performance (PI)
 Leadership (LD) - (includes previous governing body)
 Management of the Environment of Care (EC)
 Management of Human Resources (HR)
 Management of Information (IM)
Section 3 - Clinical Functions
Medical Staff (MS)
Nursing (NR)
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JCAHO Survey Process for 2006
Typical Surveys Still Include:
 Two to five days “on-site”
 Two, three or more surveyors (usually nurses
and physicians - includes a “Life Safety Specialist”
if >200 beds
 Review of documents (survey planning meeting)
 Life safety-focused facility tour
 Three-part “EC” interview
 Questions to staff based on tracer methodology
 Summary conference to present tentative findings
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Random Unannounced JCAHO Surveys
Reasons for Survey:
 Scheduled survey
 Random selection (5%)
 Sentinel event review
 Adverse media coverage of specific issue
 Complaint from the public
All surveys will be unannounced starting in
January, 2006, except for new applicants !
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Joint Commission Scoring Guidelines
 Continuation into 2006:
 “EP’s” scored 0, 1 or 2
0 = insufficient compliance
1 = partial compliance
2 = satisfactory compliance
 Scoring categories have been introduced for
each
EP: A, B or C
 Standards are scored “compliant” or “noncompliant”
 No grid score calculation
 Rationale
is not scored
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Joint Commission Scoring for EP’s
 Category A: usually used for policies and
procedures
or the presence or absence of a requirement
 Scored either “0” or “2”
 A “2” may become a “1” or “0” if the track record
is insufficient
 Category B: used for process requirements
 If requirement exists, then process design and
track record is scored
 Category C: instances of non-compliance
 Score “2”: 1 or no instances of non-compliance
 Score “1”: 2 instances of non-compliance
 Score “0”:
3 or more
instances
of non-compliance
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Joint Commission Scoring for EP’s
 If A, B or C categories are initially scored as a “2”,
then the track record is assessed as follows (and may
affect the score):
Score 2: at least 12 months (initial survey: 4 months)
Score 1: 6 to 11 months (initial survey: 2 to 3 months)
Score 0: < 6 months (initial survey: < 2 months)
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Joint Commission Scoring for EP’s
 When percentages are appropriate, the following
guidelines are used:
Score 2: 90% to 100%
Score 1: 80% to 89%
Score 0: less than 80%
 Note: Sample sizes are based on total population
size
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Joint Commission Scoring for EP’s
 If any “EC” is scored “0”, the standard is
not compliant
 If 65% of the EP’s are scored “2”, then
the
standard is considered “compliant”,
unless any other EP is scored “0” (up to
35% of the EP’s may be scored a “1”!)
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Special Scoring for SOC Deficiencies
“X” is considered a minor deficiency
(example: 1 smoke barrier penetration
found) – Score 1
“Y” is considered a midrange deficiency
(example: 2 smoke barrier penetrations
found) – Score 2
“Z” is considered a major deficiency
(example: each floor does not have at least
two approved exits) – Score 4
Note: Use the scoring grid and key to determine the X,
Y and Z scores; 1-5 total score is partial compliance; 6
or greater is non-compliance, or a “Z” score!
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Joint Commission Scoring Decisions
Accreditation Decisions
 Accredited
 Provisional Accreditation
 Conditional Accreditation
10 or more non-compliant standards (HAP)
 Preliminary Denial of Accreditation
13 or more non-compliant standards (HAP)
 Denial of Accreditation
 Preliminary Accreditation
Accreditation “Watch”
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JCAHO Accreditation Decisions
 Accredited - in compliance with all standards
 Provisional - fails to meet all of the “Evidence of
Standards Compliance” (ESC) within 45 days
 Conditional - ESC not accepted for second time
 Within 6 months of survey, success in meeting
ongoing compliance submitted to JCAHO failure to meet results in provisional
accreditation
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Joint Commission Scoring
 Measures of success (M)
 when EP’s are judged to be out of compliance, a
quantitative measure must be adopted to determine
when the action taken to correct the deficiency is
effective
 It is not expected that accredited facilities would
routinely verify “EP” compliance using
measures of success
 Data is submitted to JCAHO four months after
acceptance of the ESC
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JCAHO “EC”-Related Scoring Rules
 Preliminary Denial of Accreditation (PDA)
PDA01 - Immediate threat to health or safety
PDA03 - Falsification of documentation
PDA06 - Non-compliant standards count 3
standard deviations above the mean (13 RFI’s)
 Conditional Accreditation (CON)
CON01 - Non-compliant standards count 2 standard
deviations above the mean (10 RFI’s)
CON03 - Failure to clear repeat non-compliant
standards
CON04 - Delayed PFI or no ILSM’s when required
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Recent Scoring Results*
 Full accreditation: 97.1%
 Conditional Accreditation: 2.2%
 Preliminary Non-Accreditation: 0.7%
 Average Non-Compliant Standards: 3.66
*319 surveys
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Joint Commission Quality Report
 Description of accreditation
 Summary of quality information
Special quality awards (Codman?)
Accreditation decision, date and services
Key to measurement (, +, , -)
 - achieved best possible results
+ - above performance of most organizations
 - performance similar to most organizations
- - performance below most organizations
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Joint Commission Quality Report
 Measurements applied to:
National patient safety goals
National quality improvement goals
 Hospitals may submit up to two
pages of “report commentary” to
post with the report on the JCAHO
internet site
 Quality reports first released on
JCAHO.org on July 15, 2004
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Joint Commission Changes for 2005
 Revised interpretations for scoring
(A’s, B’s and C’s assigned)
 Changes to scoring categories
 Some MOS measures eliminated
 Adoption of “life support” definition
 Revised patient safety goals
 Life safety training for “EC” surveyors
 Inclusion of engineering surveyors
 Note: Knee-jerk reaction to events
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JCAHO Expected Changes for 2006
 Continued revisions to scoring for
A’s, B’s and C’s
 Revised patient safety goals
 Hospital rules for Life Safety Specialists
may be changed
 Focus on SOC competency
 Expected changes in USP 797
 Evolving relationship with OSHA
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JCAHO Changes for 2005 and 2006
Revision to EC.5.20.6: (7/1/05) Those
completing the SOC must be “competent”
(building knowledge, LSC knowledge and
life safety experience)
LSS Citations: (7/15/05) Only life safety
deficiencies listed in the LSA will be issued –
others will be consultative
Electronic BBI and PFI: 8/15/05) Will be
accessible via hospital extranet portal
voluntarily; will require annual SOC update
electronically on 1/1/07
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JCAHO Changes for 2005 and 2006
Revision to LSS: (1/1/06) Due to
unannounced surveys, the LSS will
participate on the 2nd survey day; number of
days present may be based on hospital
square footage; threshold for LSS may be
reduced from 200 beds
USP 797:
1/05 – interim measures in place
7/05 – renovation plan completed
1/06 – bacterial monitoring in place
1/08 – required renovations completed
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JCAHO Changes for 2005 and 2006
2006 AIA Document:
 Approval voted June, 2005
 May be adopted by JCAHO in 2006
 Available for purchase in 1st quarter of 2006
 Multiple changes for single rooms, expanded
ICRA, space revisions, HVAC changes, patient
safety language, surge capacity information in
Appendix
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JCAHO Changes for 2006
PPR Completion (1/1/06)
 Must be completed every year on
anniversary date of last on-site survey
 All PPR’s due in 2006
 Due date reset after unannounced
survey
Patient Safety Goals (1/1/06)
 Remove IV free flow issue
 Implement fall prevention program with
effectiveness evaluation
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JCAHO Changes for 2006
Wireless Frequency Change (1/1/06)
 460-470 MHz freeze ends
 No more extensions will be issued!
 1 million new licenses for the band have been
issued and users can go “on air” on 1/1/06
Emergency “tests” vs. “drills” (1/1/06)
 Possible change to EC.4.20
 Tests based on HVA results
 Measurable (numerical) performance
 Identify and implement improvements
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Top “EC” Focus Areas for 2006
 Patient Safety
 Infection Control
 Emergency Management
(Katrina impact)
 Life Safety (engineering
surveyors)
 Risk Assessment
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Patient Safety Goals for 2006
 Ambulatory Care
Keep goal #11: Reduce OR fire risk
 Hospital
Eliminate goal #5: Infusion pump “free
flow” (score under EC.6)
Clinical alarms (score under EC.6)
Keep goal #9: Reduce risk of patient
falls
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Self-Assessment Document (PPR)
 Extranet site, password protected
 Complete annually beginning in 2006
 Due on anniversary of last on-site survey
 Covers all applicable standards
 Unannounced surveys will still exist
 Scheduled surveys due in or after July,
2005 should have completed the PPR
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Periodic Performance Review Options
Full PPR:
 Uses automated PPR tool to assess
EP compliance
 Create plan of action (POA) and adopts
MOS for non-compliant EP’s
 Submits PPR results to JCAHO and
conducts call with SIG within 30 days
 SIG approves POA and surveyors
review MOS at triennial survey
Advantage: Will not be cited for PPR deficiencies
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Periodic Performance Review Options
Option 1:
 Organization chooses, for legal
reasons, to not participate in Full PPR
 Assessment is completed, POA is
developed, MOS are adopted and
JCAHO is notified of PPR completion
 Completed PPR is not sent to JCAHO!
 Surveyors review MOS (but not POA)
at
triennial survey
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Periodic Performance Review Options
Option 2:
 Organization chooses, for legal reasons, to not
participate in Full PPR
 On-site survey scheduled at midpoint of
triennial accreditation cycle
 On-site survey is one day, all standards
subject to review, fee is charged
 POA is developed and MOS are adopted based
on findings; submitted to JCAHO within 30 days
 Surveyors review MOS (but not POA) at
triennial survey
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Periodic Performance Review Options
Option 3:
 Organization chooses, for legal reasons, to not
participate in Full PPR, intends midpoint review
 On-site survey scheduled at midpoint of
triennial accreditation cycle
 On-site survey is one day, all standards
subject to review, fee is charged
 Oral summary of findings provided at end of
survey; results not reported to the JCAHO
 Surveyors will not review PPR survey findings
at
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next triennial
survey
Organizational Function Overview
 Human Resources (HR)
Staff training, competency and performance
 Leadership (LD)
Compliance, resources, patient safety
 Performance Improvement (PI)
Data collection, aggregation, analysis , action
 Information Management (IM)
Data collection, aggregation, security
 Infection Control (IC)
Measurement and reduction of infections
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The Four Survey Points of Vulnerability
 The Survey Planning Session
 The “EC” Interview Session
Involves all seven EC areas
Documents and staff must be available
Consists of three phases
 LSC Building Tour
 “EC” Tracers
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The Survey Planning Session for “EC”
Documents likely to be reviewed include:
 The seven required management plans
 Safety committee minutes from the last 12
months
 Annual effectiveness evaluations from
each “EC” area
 Statement of Condition documents
 May request safety officer job description, signed
appointment letter and intervention authority
statement
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The LSC Building Tour
 The visits will include
Hazardous areas
At least two fire separations
Two exit stairwells
Laundry/ trash chutes
Fire alarm panel/ fire pump
Validation of the SOC
 The list above only applies to the nurse,
administrative or physician surveyor
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The LSC Building Tour
 Life Safety Specialist (LSS) survey
responsibilities include:
EC.5.20: SOC and Life Safety Code
EC.5.40: Fire system tests , building features
EC.5.50: Interim life safety measures
EC.7.40: Emergency power systems
EC.7.50: Medical gas and vacuum systems
 The LSS survey will be scheduled for a
single day, on the first survey day in
2005, second survey day in 2006
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The “EC” Interview Session
 Discussion Phase (30%)
Meet with key staff who manage “EC”
Review risk cycle: Plan, Teach, Implement,
Monitor, Respond and Improve
Evaluate “loop closure”
Assess regulatory compliance
Find areas of vulnerability
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The “EC” Interview Session
 Observation Phase (60%)
Tracer methodology based on results of
discussion phase
Assessment of identified risks
“Cradle-to-Grave” review of selected risk
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The “EC” Interview Session
 Conclusion Phase (10%)
Summary of observed vulnerabilities
Staff participants include:
Safety officer and security director
Facility manager
Medical equipment manager
Emergency management coordinator
Safety committee chair
Organizational leadership
Others as desired (IC, patient safety, etc.)
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Tracer Methodology
 Focus on real issues, actual patients
 Uses PFP to identify patients of interest
 Will follow patients through treatment
 Will review patient records, interview staff
and evaluate policies and procedures
 2-3 hours per tracer, 11-12 total patient
record reviews
 May include “EC” topics
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Likely “EC Tracer Topics
 Medical waste stream
 Chemical spills
 Infant and child security
 Safety in behavioral health
 Medical equipment training
 Utility alarm and failure response
 Emergency decontamination
 Fire safety training (OR focus)
 Interim life safety and PCRA
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Ten Survey Strategies to Remember
1. Be confident - you are the expert concerning your
organization - not the survey team!
2. Anticipating the survey is more stressful than the
actual survey - don’t panic!
3. You will pass the survey by meeting regulatory
requirements, but you will excel by demonstrating
performance improvement
4. Preparation for the survey includes documentation,
but also requires organization - effectively
communicating what you know to the survey team is
extremely important!
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Ten Survey Strategies to Remember
5. Be ready to show the surveyors completed risk
assessments, “RCA’s” and “FMEA’s”. Be prepared to
discuss the “EC Risk Cycle”
6. First impressions are extremely important; after a few
hours, the survey team will attempt to validate what
they think they know about you and your program
7. “Closing the loop” on identified problems can be
more important than the problem itself!
8. If what you have done can’t be measured or
documented, it doesn’t exist!
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Ten Survey Strategies to Remember
9. Prepare for the survey by organizing the required
survey planning documents, practicing the “EC”
interview and pre-planning the building tour
10. If you disagree with a surveyor, tactfully uncover
their perspective, and:
Relax!
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The Expectation Triad
Regulatory Compliance
Performance Improvement
Risk Assessment
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The Expectation Triad
Regulatory Compliance:
“Ensuring that all of the required
standards are being met”
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The Expectation Triad
Performance Improvement:
“Attempting to measure and
improve performance on an
ongoing basis in the
Environment of Care”
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The Expectation Triad
Risk Assessment:
“Prioritization and management
of resources through an
assessment of probability
and impact”
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