1. The Accreditation Survey On-Site Agenda George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004 Used with Permission

2. Why a data-driven accreditation process?  Consistency – evaluates data the same way for all organizations  Greater focus - Turns pre-survey data into information to target on-site survey activity  Prepared surveyors - Reduces surveyor inconsistency and bias and adds to the educative nature of the on-site survey  Identifies tracers – leads surveyors to best clinical choices for tracer selection

3. Goals of the On-Site Survey Process Incorporate the use of the Priority Focus Process and Periodic Performance Review Incorporate the use of the tracer methodology to focus on direct care Allow more time for education on high-priority issues Better engage physicians and other direct care providers Provide an organization systems analysis

4. Fine-tuning the on-site survey process  The on-site survey agenda is more in sync with the HCO’s normal operational systems  Fewer formal interviews – more attention to actual individuals receiving care  Use of pre-survey, focused information and the tracer methodology allows the on-site survey process to be customized to the settings, services and populations specific to the HCO

5. Elements of the On-Site Survey Agenda  Opening and closing conferences  Leadership conference  Validation of corrective action plan implementation from the Periodic Performance Review  PFP-guided visits to patient care areas using the tracer methodology  In-depth evaluation and education regarding high priority safety and quality of care issues – systems tracers  Environment of Care review and conference

6. EXAMPLE: On-Site Survey Agenda No formal document review session Visits to patient care settings and functional areas guided by tracer methodology Leadership Conference Medical Staff Conference Environment of Care (EOC) Conference and EOC rounds guided by Priority Focus Process and some aspect of tracers Leadership Exit / Closing Conference

7. Previous Survey Process2004 Survey Process Opening conference Document review sessionNo formal document review session Leadership interviewLeadership conference(s) Validation of the organization’s implementation of its corrective action plan created as part of Periodic Performance Review Prescheduled Visits to patient care settings Visits to patient care settings and functional areas, guided by randomly chosen open records (tracer methodology) Building tour EOC review guided by PFP and integrated for some aspects with tracers Environment of care interviewEnvironment of care conference Functional interviews Systems tracer sessions on topics that are a high priority

8. A Systems Approach to Evaluation  The approach, or tracer methodology, traces a number of patients through the organization’s entire health care process  As cases are examined, the surveyor may identify performance issues in one or more steps of the process – or in the interfaces between processes

9. Map of Tracer – Example on a Cardiac Stent Patient Date: __5/19/02__________ Medical Record Number:_123456____ Hospital: _General Hospital, AZ___ Surveyor:__John Doe________ Clinical Service Group:__Cardiology__________ Rationale for Tracer Selection: _PFP identified 2 points for this CSG______________ Page 1 of 2 Site (START) ParticipantsActivity Site (END) Site # 2 Participants Standards Interface Site # 1 Participants Standards Interface Survey Methods - Interviews - Medical Record Entries Survey Methods - Interviews - Assessment Forms Survey Methods - Staff interviews - Patient interviews - Medical Records - Review of educational materials Start & End at same site to recap & validate findings with several other records Cardiac Care Unit Charge Nurse Attending MD Review open medical record to map-out tracer Emergency Dept. Cath Lab Cardiac Care Unit Nurse supervisor Advance directives Assessment PI initiatives, ORYX Med Use Leadership EC issues Verbal orders Informed consent Assessment PI initiative Med Use EC issues Staff nurse Attending MD Participants Staff nurse Patient educator Case manager Cardiac Rehab RN Attending MD Standards Interface Education Rights Continuum Pain management Medication use Assessment EC issues

10. Systems Tracers, interactive and scheduled… 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 educational information on key topics including Medication management Use of data (includes review of ORYX and staffing effectiveness as appropriate) Infection control

11. Complex Organizations  Defined as those organizations accredited under more than one JCAHO accreditation manual  Complex organizations have integrated, and therefore more streamlined accreditation processes  Changes make the accreditation process more customized, focused, efficient, and educational  The revised format provides a health system with a “system analysis”  Replaces the “tailored survey” terminology

12. 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 the entire complex organization  Program-specific surveyors survey specialty standards requiring evaluation at an individual program level

13. Benefits of the New On- Site Survey Process  Provides a process driven approach, initiated by the Priority Focus Process  Ensures a customized on-site survey specific to the health care organization  Promotes review of the continuum of services and programs  Includes multi-level participation  Focuses on execution – actual delivery of care and services

14. Key Success Factor The key success factor for the on-site survey process is the professional JCAHO surveyor.

15. Surveyor Development  All surveyors must successfully pass a certification examination  Annual conferences and distance learning events are structured to build standards and accreditation process expertise  Contracted with Kellogg School of Management to deliver didactic and distance learning curricula related to Organizational Systems Analysis in 2003 and 2004

16. 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.