1. Accreditation Standards George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004 Used with Permission

2. Standards – the foundation  All standards extensively reviewed and modified  An external task force assisted JCAHO  Standards were rewritten and formatted to provide a paradigm that organizations can use to provide safe, high quality healthcare appropriate evaluation criteria – disclosure of elements of performance

3. Standards – the changes  25-60% decrease in the number of standards in the functions  Leaner more clear standards  Appropriate evaluation criteria – disclosure of the elements of performance

4. Improved 2004 Standards  Standards are more precise and concise statements of performance expectations  A rationale offers additional text describing the standard’s purpose and background  Elements of performance (EP’s) are statements of objective performance expectations scored via simple, objective criteria.  EP’s are the same in the manual, in Periodic Performance Review and in the surveyor’s laptop  Scoring is based on an aggregation of compliance with all EP’s

5. Elements of Performance (EPs)  Clearly defined statements of performance expectations  Only part of the standard that is scorable  EP’s replace the narrative “intent” statements  List of scorable requirements identical to list used by surveyors to score standards  No hidden information

6. JCAHO Standards Patient Focused  Patient Rights  Patient Care Assessment Treatment Continuum Education  Medication Use  Surveillance, Prevention and Control of Infection Organization Focused  Improving Organization Performance  Leadership Governance Management  Environment of Care  Management of Information  Management of Human Resources

7. JCAHO Standards (continued) Others  Medical Staff  Nursing

8. Example of a Leadership Standard  Standard LD.4.30 The leaders ensure that an integrated patient safety program is implemented throughout the organization.  Rationale for LD.4.30 The leaders should work to foster a safe environment throughout the organization by integrating safety priorities into all relevant organization processes ….

9. Examples of Elements of Performance for LD.4.30 (3 of 8 EP ’ s) The patient safety program includes: (1) one or more qualified individuals or an interdisciplinary group assigned to manage the organization-wide safety program; (2) definition of the scope of the program ’ s oversight, typically ranging from no harm frequently occurring "slips" to sentinel events with serious adverse outcomes; (3) integration into and participation of all components of the organization into the organization-wide program;

10. Application for Accreditation

11. Extranet Application for Accreditation Represents the first JCAHO e-business venture Available on a secure, password- protected web space Improves the quality and consistency of data Allows for efficiency in analysis of information provided by the HCO

12. Benefits of the Improved Application for Accreditation  Key areas are pre-populated  HCO cannot submit unless all required fields are complete  Account Rep can view on line to assist HCO with timely, accurate submission  Surveyor can view via laptop technology  Information contributes to the Priority Focus Process

13. 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 Visions—New 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.