Watch out for things that go "bump" in the night. As the 1999 JCAHO standards are looming on the edge of 1998 and are being considered for implementation soon, we see things getting back to "tasks". Look around you organization or department to see if improvement is a process that includes many topics for improvement or a punch list of "tasks" to do.

There are three things to consider when arming your staff with a ghost-buster for these standards.

1. Keep steady the concept of the improvement process - which simply is:

1. develop something that addresses the issue,
2. implement the action plan to those who need to know and
3. evaluate if they did what was developed.

The JCAHO expects project to be completed when surveyed in 1999. Don't show a good "idea" heading for improvement. The principles in the standards require

1. the need for group analysis of data,
2. a shift in the picture presented by the data,
3. and sustaining of the new direction.

There are no caps that can present a buffer to protect you from the dark. In order to have this level of work accomplished, one can see that time is a critical element here. Even if the team "speed cycles" the improvement process through to completion, the "sustaining behavior" will need to be measured long after the staff is on to the next project. That measure will need to be planned into the project at the onset.

2. Identify performance measures. The 1999 measures are not new, however they have been subdivided into required and optional measures. However, ORYX isn't in either list.

The required list houses:

1. the historical medical staff review issues such as - blood, drug, surgical case, medical record, and others.
2. the operational issues include:
3. safety plans and performance standards including their information system,
4. leadership effectiveness and processes deemed important and others.

The optional list houses:

Quality controls, Risk management, Staff opinions and needs, Autopsy results, Financial data, Infection control surveillance and reporting and

Performance measures related to accreditation and other requirements.

3. What will the surveyors survey? From the JCAHO surveyor point of view we will not know if they will exert their biases about what they like to see measured or if they will accept the skeleton version of required measures selected.

Although there are less prescriptive standards from the JCAHO, there is more accountability on those in the organization who dictate how the resources are used. Those decision makers (at staff, management or administrative levels) will need to recognize both clinical and operational issues will meet the 1999 "optional measures".

The quality office is not the manager of these required and optional measures of improvement, they are but guides through the dark. Learn about the latitude that the "optional measures" encompasses. For example, an "optional measure" is quality control. A lab or radiology tech would probably not consider the quality control program on equipment as an "optional" measure. Nor do the external regulators, CLIA or the nuclear regulatory agency of the Federal Government. In 1999 these and other such "optional" statements stated by the JCAHO are really required by the organization as "the way we do business".

The Corporate Compliance Programs are taking lots of organizational resources in time and people. There are studies being done in the high risk areas that were established by the Office of Inspector General (OIG) and the Department of Justice (DOJ) such as:

• Billing for services not rendered;
• Providing medically necessary services;
• Upcoding and DRG creep;
• Billing outpatient services for inpatient stays;
• Duplicate billing and unbundling of tests.