1. Shared Visions – New Pathways George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004 Understanding the Accreditation Process

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 public’s 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 organization’s 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 organization’s 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 organization’s entire health care system. The recipient of care–a patient, resident or client–is 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 Visions—New 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.