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Organization of the 2006 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”

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Organization of the 2006 Accreditation Manual

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  1. 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) Healthcare Engineering Consultants

  2. 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 Healthcare Engineering Consultants

  3. 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 ! Healthcare Engineering Consultants

  4. 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 “non- compliant”  No grid score calculation Rationale is not scored Healthcare Engineering Consultants

  5. Joint Commission Scoring for EP’s  Category A: usually used forpolicies 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 Healthcare Engineering Consultants

  6. 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) Healthcare Engineering Consultants

  7. 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 Healthcare Engineering Consultants

  8. 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”!) Healthcare Engineering Consultants

  9. 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! Healthcare Engineering Consultants

  10. 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” Healthcare Engineering Consultants

  11. 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 Healthcare Engineering Consultants

  12. 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 Healthcare Engineering Consultants

  13. 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 Healthcare Engineering Consultants

  14. Recent Scoring Results*  Full accreditation: 97.1%  Conditional Accreditation: 2.2%  Preliminary Non-Accreditation: 0.7%  Average Non-Compliant Standards: 3.66 *319 surveys Healthcare Engineering Consultants

  15. 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 Healthcare Engineering Consultants

  16. 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 Healthcare Engineering Consultants

  17. 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 Healthcare Engineering Consultants

  18. JCAHO Expected Changes for 2006  Continued revisions to scoring for A’s, B’s and C’s  Revised patient safety goals  Hospital rules forLife Safety Specialists may be changed  Focus on SOC competency  Expected changes in USP 797  Evolving relationship with OSHA Healthcare Engineering Consultants

  19. 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 Healthcare Engineering Consultants

  20. 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 Healthcare Engineering Consultants

  21. 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 Healthcare Engineering Consultants

  22. 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 Healthcare Engineering Consultants

  23. 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 Healthcare Engineering Consultants

  24. Top “EC” Focus Areas for 2006  Patient Safety  Infection Control  Emergency Management (Katrina impact)  Life Safety (engineering surveyors)  Risk Assessment Healthcare Engineering Consultants

  25. 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 Healthcare Engineering Consultants

  26. 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 Healthcare Engineering Consultants

  27. 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 Healthcare Engineering Consultants

  28. 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 Healthcare Engineering Consultants

  29. 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 Healthcare Engineering Consultants

  30. 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 next triennial survey Healthcare Engineering Consultants

  31. 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 Healthcare Engineering Consultants

  32. 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 Healthcare Engineering Consultants

  33. 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 Healthcare Engineering Consultants

  34. 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 Healthcare Engineering Consultants

  35. 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 Healthcare Engineering Consultants

  36. 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 Healthcare Engineering Consultants

  37. 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 Healthcare Engineering Consultants

  38. 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.) Healthcare Engineering Consultants

  39. 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 Healthcare Engineering Consultants

  40. 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 Healthcare Engineering Consultants

  41. 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! Healthcare Engineering Consultants

  42. 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! Healthcare Engineering Consultants

  43. 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! Healthcare Engineering Consultants

  44. The Expectation Triad Regulatory Compliance Performance Improvement Risk Assessment Healthcare Engineering Consultants

  45. The Expectation Triad Regulatory Compliance: “Ensuring that all of the required standards are being met” Healthcare Engineering Consultants

  46. The Expectation Triad Performance Improvement: “Attempting to measure and improve performance on an ongoing basis in the Environment of Care” Healthcare Engineering Consultants

  47. The Expectation Triad Risk Assessment: “Prioritization and management of resources through an assessment of probability and impact” Healthcare Engineering Consultants

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