Information management central to JCAHO surveys
Information management central to JCAHO surveys
Management is about more than record keeping
Hospitals preparing for surveys by the Joint Commission on Accreditation of Healthcare Organizations should pay close attention to improving organizational performance, says Eric Silfen, the former chief medical officer at Reston (VA) Hospital Center who now oversees the hospital’s outcomes research division. "That carries the bulk of the quality of care improvement initiatives and establishes the guidelines for that process," he says.
Nancy Cuccaro, quality management coordinator at Huntington Hospital in Long Island, NY, takes a similar view. She says her staff are establishing a new structure for Joint Commission surveys. "We are not calling it Joint Commission preparation. We are calling it continuous survey readiness." In part, that’s because of the Joint Commission’s plan to potentially perform surveys every 18 months instead of every three years. She says that prompted Huntington to establish the continuous survey readiness program.
But she also points out that Huntington deals not only with the Joint Commission but with the New York State Department of Health and an assortment of other licensing and accrediting bodies that visit the facility. "This incorporates many more people than it would if we were only talking about the Joint Commission," she explains. For example, the preparation includes ambulatory care sites, clinics, physician office sites, as well as labs and radiology, which sometimes are surveyed separately by other agencies.
Cuccaro says Huntington is also establishing a reporting structure with smaller groups reporting directly to a senior administrator who functions essentially as an adviser. The advisors, in turn, report to the board of directors in order to promote a constant flow of information, including any survey results. The hospital also plans to include a board member and a senior medical staff officer in the preparation process.
"Another increasingly important area right now is the area of information management," says Silfen. With the expanded ability to record, store, and broadcast clinical information and all of the attendant problems surrounding privacy and confidentiality, that has turned into an area that is impacted by all of the other Joint Commission required standards, he says.
"It is more than just record keeping," Silfen explains. "It is how clinical information is transmitted, used, stored, and configured throughout the health care organization." For example, he says, hospitals must address how the Internet will be used as they link physician offices as well as ambulatory surgical centers and outpatient clinics to the hospital. In short, he says, the challenge for hospitals is how to transfer information and keep it confidential and secure and still leverage the opportunity for clinical information that is outside "the four walls of the hospital" to improve overall patient care.
"That is a tremendous area that still is un-charted," Silfen adds. Not only does it involve the Health Insurance Portability and Accounta-bility Act, but the double encryption of information that is required when it is being transferred electronically. "The potential for improvements in processes is very significant, but we have to struggle with the standards the Joint Commission has for specific indicators and metrics for measurement," he explains.
"This is an area that is becoming even more encompassing," adds Silfen. In the past, the focus was mainly on completeness of the medical record and whether all the data elements were there. But now it is starting to spread over a number of areas it had never touched before because patients’ clinical records can be updated and carried forward almost as quickly as they move through the health care system, he explains.
Cuccaro says it is also critical to find ways to educate staff at all levels about common Joint Commission issues. She says that includes disseminating information and involving key staff members in seminars and information sessions. Kristine Hegman, quality improvement coordinator at St. Mark’s Hospital in Salt Like City, adds that hospitals must begin this process by getting buy-in from physicians.
"Simply telling physicians that their surgical wound infection rate is going to be reviewed will not do much good if they do not understand the importance of it," she argues. "You must get physicians to appreciate the significance of the issue without making it look punitive."
Instead, Hegman says hospitals must help physicians understand exactly how these measures will improve patient care. Often the best way to do that is to let the physicians help select the areas that require improvement, she says.
"On the other hand, you don’t just let them pick whatever they want," she adds. "The areas selected must require improvement and experience enough volume to make them representative of a large group of physicians."
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