THE JCAHO SURVEY DAYS CHANGES – ARE COMING, NO, ARE HERE!

Over the past several years the emphasis on data used to describe processes has been the vanguard of JCAHO changes. These changes were apparent in the standards changes in the PI, IM and LD standards. The journal articles and educational sessions stressed graduating data into information to make "informed decisions" in care and management. One might have wondered what a survey would look like if it had an emphasis on data. Below are a few ideas that the JCAHO surveyors are projecting for the new year.

1. The surveyors will use "data driven agendas". This means that more observations will be made to increase the denominator numbers.

• For example, there will be more observations of patient care processes. Since there is a focus on patient safety, there will be a review of the medication use process. The surveyors will combine many standards by looking at one patient situation. An example would be observing the nurse administer a drug. There are several processes involved in that function. Determination that the patient assessment (PE) by the nurse shows the patient condition for administration of the drug (TX), i.e., Fosamax, a calcium sparing drug, must be given on an empty stomach with water only and the patient should not lie down for at least 30 minutes. In addition, the surveyor will observe for the nurse completing the patient education (PF) on the drug’s side effects, and that the nurse is competent to administer the medications provided by the unit’s scope of services (HR).

• This type of surveying requires much more time than previously required on each patient unit, thus many more interviews and observations can be carried out.
• The open medical record review must be understood by the unit staff as well as those who support the unit through their services, such as the therapies, respiratory, physical, occupational and speech, as well as nutrition and other services. Staff assist the surveyor when finding information in the open chart. Be prepared to have all staff notes easily retrievable in the record. If nutrition customarily carries their notes back to their office, make sure there is some area like an integrated document of some type to write an action plan or recommendation. If the other services and nursing cannot find the evidence of the nutritionist’s visit, it is hard to defend an integrated records, or collaborative approach to care.

• Other types of observation include watching staff including physicians, wash their hands between patients and questioning staff who are wearing gloves outside of patient care areas. Patient safety is a prevailing concept so keep answers focusing on that as staff are asked questions about separation of clean and dirty – supplies, food, linens, equipment.

• In addition, more than one surveyor may descend upon a unit, which adds more and more to the denominator. The surveyors aggregate their data to provide the final scoring of the observed and interviewed standards. The new scheduling allows much more time on each unit. Where just a year ago a unit visit might be under an hour, the new survey process requires twice that time. It is common to see 1.5 hour visits. For example, while moving through a maternity unit, it might take an entire afternoon from 1:00 to 4:00. There is also time in the schedule to allow surveyors to go back and continue their analysis of important findings that surfaced during the first pass of the survey process. These time slots will be listed on the survey schedule as "special interview/issue resolution or patient care visit". Expect patients and their families to be questioned. Do not feel left out when staff accompanying the surveyor is left outside. This is customary and adds respect to the patient being interviewed.

• Finally, ORYX data has graduated from a review of the data itself to an evaluation of the use and response to the data. Data are provided to make a difference – what difference did the organization make. Answers can range from, "we chose to do nothing" to "these are the findings from changes made…" If there were changes based on ORYX, be sure that the findings have been communicated to the area where the change occurred. It is very common to connect the initial interview information with validation at the unit level. An example might be "Length of Stay in Orthopedics" as an ORYX measure. If this is the story and stay has changed, be sure the Orthopedic unit knows about the change and can speak to "sustaining the gain".

2. Survey Process Changes.

• In the 2001 surveys look forward to seeing more of the surveyors throughout the day. Visiting staff on other shifts, namely evenings and nights has proven successful. So, the "off shift" will be a methodology used in the future.

• Also, four interviews will be eliminated. The Patient and Family Education, Continuum of Care, Medication Use and Nutrition, and the Anesthesia and Operative interviews will be incorporated into other interviews. For instance, the querying done in the unit interviews and other specialty interviews like medical staff leaders and directors will cover some of these topics.
• The Patient Care Interview will remain and findings from the Open Record Review will help fuel the questions. That is, if the surveyor’s experience shows very poor compliance with the facility’s use of the Patient Education Document, it will be addressed here. Also, if the screening criteria is not used and referrals are not made throughout the patient process, the Coninuum of Care questions will be consolidated into the Patient Care Interview.

3. Random Unannounced Surveys. Many organizations will not have a planned 3-year survey in 2001, however, the window for random unannounced surveys in now from nine to 30 months after the previous survey. So many organizations will have this type of survey to look forward to. There are a few things that can be prepared for, such as:

• There are fixed elements established by JCAHO. Those elements that are fixed tend to be previous recommendations from other surveys and how the action plan is being addressed. Is the organization finished with the action plan and in the monitoring mode, or has there been no action on the plan at all? Plus, there are always those predictable Infection Control and Management of the Environment of Care review elements like cleanliness and fire safety that are fixed elements.
• There are variable elements that take their direction from a variety of areas. For example, JCAHO will come supplied with data from their complaint "hot line", data from state surveyors. JCAHO reports they will have a conference call with HCFA to determine the priorities for 2001 and establish some elements to review with. Surveyors will be taken through medication review process training for use with number 1 above, the Survey Process Changes. This is consistent with using every opportunity to reduce medical errors and enhance the patient safety in healthcare today.

4. Assorted other survey issues.

• While preparing keep a focus on survey caps. That is the "training period" allowed by the JCAHO. While in training with a new standard the scoring is more lenient. For example, pain management has been "in training" throughout all of 2000, and will be fully scored, without caps in 2001. Also the new restraint standards are not capped, they will be fully scored in 2001.
• If a hospital is a Critical Access Hospital, that is a small rural facility with unique conditions of participation, the survey process will be tailored for them.
• An assisted living facility that is part of a hospital will be surveyed with the hospital.
• A long term care that has exclusionary criteria of an average length of stay less than 30 days and an average daily census of less than 20 should not pass the Consolidated Accreditation Manual for Hospitals (CAMH). Rather the unit will have a tailored survey with the hospital, using the Long Term Care (LTC) standards.
• There will be more indepth assessment of credentialing and peer review consistent with the changes in the standards introduced during the summer of 2000.

5. Survey Day Reminders

• Document review session. Do not put more into the document review than that requested in the survey guide book. It is laborious and time consuming to have to review excess material. Oftentimes, the survey element being searched for cannot be found due to all the extemporaneous material in the manual. Keep a runner handy in case material cannot be found.
• The daily briefings are set up for the surveyors to get clarification for their needs, not the facility. However, if there is a question about a finding, or the data has been found for a poorly answered question, disclose it during the briefings session.
• The Human Resources interview can be helped greatly by organizing the staff folders prior to the survey. Just separating hiring and benefits data from mandatory material like performance evaluations and education helps. Also organize in chronological order. Put the newest material on the top. Put a model personnel file together with tabs and landmarks "Post-it noted". This model can be used as a reference. That way if the annual mandatory document for 1999 is missing, at least the surveyor has a clue as to what he is looking for.
• Standardize what is being done at the multiple anesthesizing sites. Since all of the sites are going to be reviewed for their consistency and compliance to the sedation and anesthesia standards and patient rights issues, have staff criss-cross into each other’s units to see how care is conducted. By having the staff from other anesthesizing units check on each other they can see differences in practice. It is then easy enough to recognize the logic of the difference and document it, or change the practice.