Accreditation surveys are always challenging
Accreditation surveys are always challenging
Word of advice: Prepare, prepare, prepare
Accreditation surveys have always been tough. Now that two of the major accrediting organizations are expected to be given deemed status, these surveys will be more important and tougher than ever.
"Accreditation improves patient care and supports a standardization of care," says Eric Storch, LMHC, support services manager of Catholic Hospice in Miami Lakes, FL. The hospice’s two offices serve two large counties in the Miami area. Storch is guiding Catholic Hospice in its preparation for an upcoming survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. He also was involved in successfully preparing for accreditation at a previous hospice.
"Many third-party payers, managed care organizations, and insurers are looking to see if you’ve been accredited, because it’s a nationally recognized standard of care," Storch adds.
If your organization has never been through an accreditation survey, or if you need fresh pointers for your next one, you might learn something from hospices that have successfully navigated the process.
Storch and other experts suggest hospices follow these guidelines in preparing for a survey:
1. Write a time line.
Catholic Hospice outlined goals for eight months of survey preparation, Storch says. The goals are clearly stated. One for September, for instance, simply says, "Meet and assign each chapter in (the) manual."
The Hospice of Marlboro County in Bennetts-ville, SC, used a time line to highlight realistic goals, says Kevin Long, executive director of the hospice, which serves rural northeastern South Carolina.
Time lines are a practical way to tie work goals with a survey deadline. And they make the preparation process more manageable, Long says.
Their efforts paid off. The hospice was accredited with commendation by the Accreditation Commission for Home Care (ACHC) in Raleigh, NC, notes Tom Cesar, ACHC president.
2. Form work groups.
Hospices should develop work groups that are broken down according to various chapters in the accreditation manual, Storch advises. For a Joint Commission survey, for example, there might be 11 work groups, including a work group that covers the ethics chapter and a work group for infection control. There could be four to eight people in each group, depending on the hospice’s size.
Each group should have a team leader who is usually someone in a management position who coordinates the group’s work, Storch says.
Each work group looks at each standard in a chapter. They compare the standard to what the hospice has been doing in terms of compliance.
For small chapters, the work group could cover the standards jointly at group meetings. The group may want to divide standards and have members handle them individually when dealing with larger chapters, Storch says.
When groups find standards that are not covered in their hospice’s current policies and procedures, they may suggest the hospice revises or writes new policies.
"It’s important that all the leaders of the different work groups meet on a regular basis to discuss what’s going on," Storch says.
Some changes that affect one work group’s chapter may also affect another chapter. They will need to work jointly on changes.
Work groups could hold meetings every two weeks to start and, during the middle of the preparation process, they could meet once every month. Toward the end, they might again meet every two weeks. "I think it’s important to not have a lot of meetings because part of the process is to demonstrate quality care, so we can never lose focus of the fact that patients come first," Storch says. "Limit meetings to no more than an hour to an hour and a half."
3. Address key areas of concern.
Infection control is an area that needs a lot of attention, says Ruth Gent, MPH, vice president of patient/family services for Hospice and Home Care by the Sea in Boca Raton, FL. The agency was accredited with commendation by the Joint Commission, and Gent worked with another Florida hospice that was also successfully accredited. Gent and Storch spoke about how to prepare for Joint Commission accreditation in October 1998 at the Washington, DC-based National Association of Home Care (NAHC) conference in Atlanta.
"Infection control is a big area, and it’s a problematic area. No matter how well you think you’re prepared, someone can inadvertently slip up and not wash their hands at the right time," Gent says.
Staff competencies also pose problems, she adds. "Make sure you do evaluations and competencies in performing particular tasks that are associated with each job."
4. Make needed changes.
The Hospice of Marlboro County had not done a great deal with quality assurance projects before the accreditation process, Long says."We always felt we had a good product; we did various things, but we never had any vehicles to record and track and monitor. That goes back to the fact that we are a small and young organization," Long says.
However, the accreditation process forces hospices to improve quality assurance processes and assess, revise, and improve all forms and documentation, he adds.
5. Ask for help.
Several months into the preparation process, the Hospice of Marlboro County asked ACHC for help. A surveyor visited them to answer questions and to help get the hospice get back on track, Long says."We were starting to spin our wheels, and decided to get someone in here to give us some examples and illustrations so we could determine exactly what it was they were looking for," Long explains.
The best way to find out what a hospice needs to change is to check the accreditation organization’s manual, Storch suggests.
What’s in a hospice’s policy book should reflect standards found in the accreditation organization’s manual. Some agencies have even structured their policy and procedure manuals based on Joint Commission chapters."I don’t think that’s necessary," Storch adds. "The most important thing during the survey is that you need to be able to find that information easily."
6. Prepare staff for surveyor interviews.
Surveyors typically set up formal interviews with hospice employees. Agencies should make sure all employees are able to recite policies and procedures that relate to their jobs.
Employees also need to be aware that even during casual encounters with surveyors, they may be evaluated.
"The Joint Commission surveyors that I have been involved with have been very adept at informal interviewing," Gent says. "They engage you in a conversation; and in the conversation, they’re definitely looking for certain answers but you wouldn’t know it."
For instance, a surveyor may pass a nurse in the hallway and stop to ask what the nurse does and then say, "I see you have an alarm system in this hallway, do you ever have fire drills here? What do you do during a drill?" Gent says.
"The surveyors are amazingly quick and astute," he adds. "They could take a policy and procedure book, for instance, and in a short period of time they would find what they were looking for even when they were unfamiliar with the agency."
Long says he was surprised to find that surveyors are almost never off duty during the survey process.
Once, an ACHC surveyor checked the hospice’s off-hours response to patients by calling one evening and pretending to be a client. The surveyor asked to have the nurse call her back because there was a problem.
"It was a matter of minutes when the surveyor received the call back from the nurse, and she was very impressed with that," Long says. "But it really caught me off guard because I thought I had pretty well identified everything the surveyor would do.
Sources
• Ruth Gent, MPH, Vice President of Patient/Family Services, Hospice and Home Care by the Sea, 1531 W. Palmetto Park Road, Boca Raton, FL 33486. Telephone: (561) 395-5031. Fax: (561) 394-4515.
• Kevin Long, Executive Director, Hospice of Marlboro County, P.O. Box 474, Bennettsville, SC 29512. Telephone: (843) 479-5979. Fax: (843) 479-3711.
• Eric Storch, LMHC, Support Services Manager, Catholic Hospice Inc., 14100 Palmetto Frontage Road, Suite 370, Miami Lakes, FL 33016. Telephone: (305) 231-6250. Fax: (305) 824-0665.
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