JCAHO unveils streamlined, consistent surveys
JCAHO unveils streamlined, consistent surveys
Changes focus on self-assessment, patient stay
Promising that surveys will become more streamlined and patient-focused, the Joint Commission on Accreditation of Healthcare Organizations unveiled a new accreditation process, set to begin in 2004.
The Joint Commission said surveys will be more objective and consistent, with consolidated standards that encompass fewer scorable elements and rely less on document review. Surveyors will be required to pass a certification exam and their own performance will be tracked.
Hospitals will conduct a self-assessment midway through the three-year accreditation cycle that will largely guide the survey process. That change will promote continuous quality improvement, and "it will shift the basic ownership of the accreditation process from the Joint Commission to the organization," announced Dennis O’Leary, MD, JCAHO president.
The new process may be a welcome change for employee health professionals, who struggle to second-guess the focus of a particular survey team.
"I would think a self-assessment would be very useful," says JoAnn Shea, MSN, ARNP, director of employee health and wellness at Tampa (FL) General Hospital, which recently completed an accreditation survey. "It would allow the institutions to write the positives up and also write up their opportunities: We have challenges here, but here’s what we’re doing about it.’"
A surveyor zeroed in on sharps injuries, particularly in the operating room (OR). Shea had analyzed her sharps data and discovered that 33% of the hospital’s bloodborne pathogen exposures occur in the OR, as do 26% of hepatitis C exposures.
Although the hospital has reduced exposures elsewhere in the hospital with safer devices, the OR rate has remained stable. Shea is implementing new instrument-passing rules and is looking for new devices that will be acceptable to the surgeons. The surveyor gave the hospital a supplemental recommendation — one that does not affect the score but provides incentive for change. "We’re going to have a meeting and come up with some better recommendations to decrease our exposures in the OR," she says.
It’s not clear how the new accreditation process will impact employee health. The Joint Commission has issued National Patient Safety Goals and plans to focus on individual patient experiences in its new accreditation process. But in a press conference, O’Leary insisted that worker safety is still a part of that focus. "One of the indices of an overtired, overworked nursing staff is an increase in needlestick injuries," he said. "I think it really speaks to the fact that a safe, healthy staff are more likely to provide safe care for patients. That’s why we build those connections into our process."
In the new process, surveyors will select patient records and follow records through their care, talking to nurses, physicians, and other health care workers.
"With this new process, surveyors are on the floor talking to physicians while the physicians are doing the procedures," explains Charles R. Young, MHA, administrator of Shriners Hospitals for Children in Spokane, WA, which pilot tested the new process. "Our clinicians were animated in their discussion of how well they like the new process, how it got them more involved."
Katherine West, MSEd, CIC, a Mannasas, VA-based infection control consultant who helps hospitals prepare for Joint Commission surveys, asked how new Health Insurance Portability and Accounta-bility Act privacy regulations might affect the Joint Commission plans. But she says plans to certify surveyors and create more consistency are badly needed. "There’s been no continuity and consistency in what they said, their level of training, what they surveyed for," she says. "It’s a real plus if they’re going to be looking at exactly the same things the same way."
Promising that surveys will become more streamlined and patient-focused, the Joint Commission on Accreditation of Healthcare Organizations unveiled a new accreditation process, set to begin in 2004.Subscribe Now for Access
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