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Part I: Discussion of the Joint Commission on Accreditation of Healthcare Organizations'Agenda for Change
AORN JOURNAL
JULY 1993, VOL 5X, NO I
Clinical Issues Part I: Discussion of the Joint Commission on Accreditation of Healthcare Organizations’ Agenda for Change
This is the first part of a two-part “Clinical Issues” focusing on the Joint Commission OIY Accreditation of Healthcare Organizations’ Agenda for Change. Part I1 will appear in the August issue of the Journal.
Q
uestion: I have heard about the Agenda for Change of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for some time. Can you explain what it is?
A
nswer: The Agenda f o r Change is a set of initiatives designed to create an updated, sophisticated accreditation process to evaluate organizational performance and foster continuous improvement in the performance of important governance, managerial, clinical, and support functions in health care organizations.’ These initiatives will enable JCAHO to evaluate an organization’s actual performance, as opposed to an organization’s ability to perform. The Agenda f o r Change was created in 198’7 and will continue until 1996, when, according to current guidelines, the change process will be completed. The major goals of the Agenda f a r Change are to reformulate JCAHO standards to emphasize the effective performance of importantoorganizational functions, redesign the accreditation survey and decision-making process, develop reliable and valid indicators (ie, performance measures), and develop a related interactive reference data base.
uestion: What are “important organizational functions”?
Q A
nswer: Important functions in a health care organization are processes or activities that most affect the quality of care and services delivered, thereby influencing patient outcomes.* These functions involve governance, management, clinical, and support activities. Some important functions affect patients directly, while others support the care provided. Patient outcomes can be defined in relation to a variety of quality aspects that include accessibility, appropriateness, effectiveness, efficiency, efficacy, timeliness, safety, continuity, and acceptability of care. Varying combinations of these quality aspects determine a patient’s health status, satisfaction with care, and perception of value received. uestion: 1 understand JCAHO is making major changes in the 94lAMH Accreditation Manual f o r Hospitals and that it will be substantially different from the 1993 manual. What will these changes be?
Q
A
nswer: Because it is the intent of JCAHO to evaluate actual performance as opposed to a facility’s ability to perform, all standards in the 1993 manual are being recast into a functional format. The JCAHO began reducing structural standards requirements with the 1992 manual, and this will continue through 1995 when all standards will have changed. Certain structural requirements relating tQ 127
JULY 1993, VOL 5 8 , NO 1
AORN JOURNAL
Changes to the 1994 Joint Commission on Accreditation of Heathcare Organizations Manual Part A-Care
of the patient
1. Rights of patients 2. Assessment and evaluation of patients 3. Entry into setting or service 4. Nutritional care 5. Treatment of patients 6 . Operative and other invasive procedures 7. Education of patients and family 8. Continuity of care
Part B- Organizational functions 1. Leadership 2. Management of information 3. Management of human resources 4. Management of the environment of care 5. Surveillance, prevention, and control of infection 6. Improvement of organizational performance Part C-Structures with important functions 1. Governing body 2. Management and administration 3. Medical staff 4. Nursing major organizational functions of hospitals, however, will be retained. The intent is to have the 1994 manual more patient focused. The 1994 manual will be organized into three sections: “Care of the Patient,” “Organizational Functions,” and “Structures with Important Functions.” (See “Changes to the 1994 Joint Commission on Accreditation of Healthcare Organizations Manual.”) According to the current JCAHO plan for the 1994 manual, the present “Surgery and Anesthesia” chapter will be incorporated into several chapters (eg, “Operative and Other Invasive Procedures,” “Nursing”) throughout 128
the manual. To be in compliance with JCAHO standards, perioperative nurses and managers must be familiar with the entire manual. The JCAHO views perioperative nursing as patientfocused and as a part of nursing. Perioperative nursing is subject to the same patient-focused standards that apply to all areas of nursing.
Q
uestion: I have heard the JCAHO site visit and survey process will be different. Is this part of the Agenda f o r Change, and how will the process differ?
A
nswer: The JCAHO is proposing a new survey and accreditation model for 1994 and b e y ~ n d Some .~ of the proposed changes already have begun. In the proposed model, selected JCAHO staff members become “account representatives” to an assigned number of organizations that desire accreditation. Each of these account representatives will have a group of surveyors with whom to work. In the proposed model, account representatives gather presurvey information, including information related to standards compliance from facilities to be surveyed. This permits presurvey review and analysis of some portions of a facility’s documentation. These currently are reviewed during the site visit. Account representatives prepare reports for the survey team before the site visit. These reports provide descriptive information about the facility (eg, its ownership, mission, populations served, services provided, volume). The report also identifies potential problem areas such as recent senior leadership changes andlor high staff turnover rates. The report directs surveyors’ attention to potential standards compliance issues. The creation of such a report is intended to allow on-site survey time to be more productive for surveyors and more educational for facilities being surveyed. The on-site survey is closely related to the information gathered in the presurvey analysis. Presurvey information is confirmed, and new data is gathered. When the new model takes effect, surveyors will spend less time reviewing documentation and more time interviewing
AORN JOURNAL
staff. The on-site survey will focus on functions important to the quality of patient care services. Many of the new model functions cross departmental lines and are multidisciplinary in nature. As a result, surveys will be less departmentally focused. It is JCAHO’s intent that all surveyors will interact across all discipline^.^ Physician surveyors will no longer interact only with physicians. Nurse surveyors will no longer interact only with nurses. With the new model, the survey process also is expected to be more interactive (eg, surveyors interviewing staff to determine performance issues). Staff members will be expected to articulate the mission and goals of the organization and to describe how standards are complied with in their practice, how the quality improvement plan is implemented, and how they interrelate with other disciplines in the facility. Finally, the new model will allow surveyors to provide the facility with an accurate preliminary report of its findings regarding standards compliance and a final written report consistent with the preliminary on-site report. This written report identifies the organization’s strengths and weaknesses and helps set priorities for improvement^.^
Q
uestion: What are the different types of accreditation that can be awarded to a facility, and what happens when JCAHO makes a recommendation?
A
nswer: Accreditation can be granted as simple accreditation, accreditation with commendation, or conditional accreditation. When granting accreditation, the JCAHO may give either type I or type 11 recommendations. Many accredited hospitals receive some type of recommendation. Type I1 recommendations are less serious than type I and require correction of the deficit by the next survey/accreditation visit. A type I deficit must be corrected within a specified period of time (ie, usually six months), and the facility must submit to a focused survey that addresses the recommendation or submit a 130
JULY 1993, VOL 58, NO 1
progress report to JCAHO. If, after the specified period of time, the type I deficit has not been corrected, a conditional accreditation is given. Conditional accreditation provides an additional four-month period in which to correct the deficit. After the four-month period, another focused survey is conducted. Failure to pass this focused survey results in a recommendation to deny accreditation.(jIf a facility had its original survey and received a type I recommendation during one calendar year and must submit to a focused survey that occurs during the following calendar year, the focused survey will be based on the standards that were in effect at the time of the initial survey. DOROTHY FOGG,RN, MA PERIOPERATIVE NURSING SPECIALIST CENTER FOR NURSING PRACTICE Notes 1. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” Perspectives 12 (JanuaryFebruary 1992) 1,5. 2. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” Perspectives 12 (March/April 1992) 5. 3. Joint Commission o n Accreditation of Healthcare Organizations, “Agenda for change: New accreditation process model for 1994 and beyond,” Agendu f o r Change Overview Accreditation Process Improvement (December 1992). 4. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change Q & A: The survey process and surveyors,” Perspectives 12 (NovemberDecember 1992) 13,14. 5 . Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” 1, 5. 6. Joint Commission on Accreditation of Healthcare Organizations, “Failed second generation deficiencies to result in conditional accreditation,” Perspectives 11 (November/December 1991) 12.
JULY 1993, VOL 5X, NO I
Clinical Issues Part I: Discussion of the Joint Commission on Accreditation of Healthcare Organizations’ Agenda for Change
This is the first part of a two-part “Clinical Issues” focusing on the Joint Commission OIY Accreditation of Healthcare Organizations’ Agenda for Change. Part I1 will appear in the August issue of the Journal.
Q
uestion: I have heard about the Agenda for Change of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for some time. Can you explain what it is?
A
nswer: The Agenda f o r Change is a set of initiatives designed to create an updated, sophisticated accreditation process to evaluate organizational performance and foster continuous improvement in the performance of important governance, managerial, clinical, and support functions in health care organizations.’ These initiatives will enable JCAHO to evaluate an organization’s actual performance, as opposed to an organization’s ability to perform. The Agenda f o r Change was created in 198’7 and will continue until 1996, when, according to current guidelines, the change process will be completed. The major goals of the Agenda f a r Change are to reformulate JCAHO standards to emphasize the effective performance of importantoorganizational functions, redesign the accreditation survey and decision-making process, develop reliable and valid indicators (ie, performance measures), and develop a related interactive reference data base.
uestion: What are “important organizational functions”?
Q A
nswer: Important functions in a health care organization are processes or activities that most affect the quality of care and services delivered, thereby influencing patient outcomes.* These functions involve governance, management, clinical, and support activities. Some important functions affect patients directly, while others support the care provided. Patient outcomes can be defined in relation to a variety of quality aspects that include accessibility, appropriateness, effectiveness, efficiency, efficacy, timeliness, safety, continuity, and acceptability of care. Varying combinations of these quality aspects determine a patient’s health status, satisfaction with care, and perception of value received. uestion: 1 understand JCAHO is making major changes in the 94lAMH Accreditation Manual f o r Hospitals and that it will be substantially different from the 1993 manual. What will these changes be?
Q
A
nswer: Because it is the intent of JCAHO to evaluate actual performance as opposed to a facility’s ability to perform, all standards in the 1993 manual are being recast into a functional format. The JCAHO began reducing structural standards requirements with the 1992 manual, and this will continue through 1995 when all standards will have changed. Certain structural requirements relating tQ 127
JULY 1993, VOL 5 8 , NO 1
AORN JOURNAL
Changes to the 1994 Joint Commission on Accreditation of Heathcare Organizations Manual Part A-Care
of the patient
1. Rights of patients 2. Assessment and evaluation of patients 3. Entry into setting or service 4. Nutritional care 5. Treatment of patients 6 . Operative and other invasive procedures 7. Education of patients and family 8. Continuity of care
Part B- Organizational functions 1. Leadership 2. Management of information 3. Management of human resources 4. Management of the environment of care 5. Surveillance, prevention, and control of infection 6. Improvement of organizational performance Part C-Structures with important functions 1. Governing body 2. Management and administration 3. Medical staff 4. Nursing major organizational functions of hospitals, however, will be retained. The intent is to have the 1994 manual more patient focused. The 1994 manual will be organized into three sections: “Care of the Patient,” “Organizational Functions,” and “Structures with Important Functions.” (See “Changes to the 1994 Joint Commission on Accreditation of Healthcare Organizations Manual.”) According to the current JCAHO plan for the 1994 manual, the present “Surgery and Anesthesia” chapter will be incorporated into several chapters (eg, “Operative and Other Invasive Procedures,” “Nursing”) throughout 128
the manual. To be in compliance with JCAHO standards, perioperative nurses and managers must be familiar with the entire manual. The JCAHO views perioperative nursing as patientfocused and as a part of nursing. Perioperative nursing is subject to the same patient-focused standards that apply to all areas of nursing.
Q
uestion: I have heard the JCAHO site visit and survey process will be different. Is this part of the Agenda f o r Change, and how will the process differ?
A
nswer: The JCAHO is proposing a new survey and accreditation model for 1994 and b e y ~ n d Some .~ of the proposed changes already have begun. In the proposed model, selected JCAHO staff members become “account representatives” to an assigned number of organizations that desire accreditation. Each of these account representatives will have a group of surveyors with whom to work. In the proposed model, account representatives gather presurvey information, including information related to standards compliance from facilities to be surveyed. This permits presurvey review and analysis of some portions of a facility’s documentation. These currently are reviewed during the site visit. Account representatives prepare reports for the survey team before the site visit. These reports provide descriptive information about the facility (eg, its ownership, mission, populations served, services provided, volume). The report also identifies potential problem areas such as recent senior leadership changes andlor high staff turnover rates. The report directs surveyors’ attention to potential standards compliance issues. The creation of such a report is intended to allow on-site survey time to be more productive for surveyors and more educational for facilities being surveyed. The on-site survey is closely related to the information gathered in the presurvey analysis. Presurvey information is confirmed, and new data is gathered. When the new model takes effect, surveyors will spend less time reviewing documentation and more time interviewing
AORN JOURNAL
staff. The on-site survey will focus on functions important to the quality of patient care services. Many of the new model functions cross departmental lines and are multidisciplinary in nature. As a result, surveys will be less departmentally focused. It is JCAHO’s intent that all surveyors will interact across all discipline^.^ Physician surveyors will no longer interact only with physicians. Nurse surveyors will no longer interact only with nurses. With the new model, the survey process also is expected to be more interactive (eg, surveyors interviewing staff to determine performance issues). Staff members will be expected to articulate the mission and goals of the organization and to describe how standards are complied with in their practice, how the quality improvement plan is implemented, and how they interrelate with other disciplines in the facility. Finally, the new model will allow surveyors to provide the facility with an accurate preliminary report of its findings regarding standards compliance and a final written report consistent with the preliminary on-site report. This written report identifies the organization’s strengths and weaknesses and helps set priorities for improvement^.^
Q
uestion: What are the different types of accreditation that can be awarded to a facility, and what happens when JCAHO makes a recommendation?
A
nswer: Accreditation can be granted as simple accreditation, accreditation with commendation, or conditional accreditation. When granting accreditation, the JCAHO may give either type I or type 11 recommendations. Many accredited hospitals receive some type of recommendation. Type I1 recommendations are less serious than type I and require correction of the deficit by the next survey/accreditation visit. A type I deficit must be corrected within a specified period of time (ie, usually six months), and the facility must submit to a focused survey that addresses the recommendation or submit a 130
JULY 1993, VOL 58, NO 1
progress report to JCAHO. If, after the specified period of time, the type I deficit has not been corrected, a conditional accreditation is given. Conditional accreditation provides an additional four-month period in which to correct the deficit. After the four-month period, another focused survey is conducted. Failure to pass this focused survey results in a recommendation to deny accreditation.(jIf a facility had its original survey and received a type I recommendation during one calendar year and must submit to a focused survey that occurs during the following calendar year, the focused survey will be based on the standards that were in effect at the time of the initial survey. DOROTHY FOGG,RN, MA PERIOPERATIVE NURSING SPECIALIST CENTER FOR NURSING PRACTICE Notes 1. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” Perspectives 12 (JanuaryFebruary 1992) 1,5. 2. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” Perspectives 12 (March/April 1992) 5. 3. Joint Commission o n Accreditation of Healthcare Organizations, “Agenda for change: New accreditation process model for 1994 and beyond,” Agendu f o r Change Overview Accreditation Process Improvement (December 1992). 4. Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change Q & A: The survey process and surveyors,” Perspectives 12 (NovemberDecember 1992) 13,14. 5 . Joint Commission on Accreditation of Healthcare Organizations, “Agenda for change: Q & A,” 1, 5. 6. Joint Commission on Accreditation of Healthcare Organizations, “Failed second generation deficiencies to result in conditional accreditation,” Perspectives 11 (November/December 1991) 12.