The Fact on Fiction from the April 2004 issue of Perspectives

Tracer Methodology
In the January 5, 2004, edition of Inside the Joint Commission a special report on preparing for the Joint Commission’s new accreditation process suggests who should field questions during the tracer portion of an on-site survey: “A realistic mock survey at one hospital suggests that the best person for the job may not be the on-duty nurse, but rather charge nurses and case managers—those who are most at ease with surveyors and can easily thumb through patient records for dictated reports, lab results, and ED records.”

This direction does not meet the intent of the new accreditation process. Using the tracer methodology, surveyors will need to speak with staff members providing the direct care being traced so surveyors can assess how the organization ensures patient safety and quality. This will often be an on-duty nurse, rather than a manager. As is stated in the Shared Visions–New Pathways® chapter of the 2004 (and in some instances, 2004–2005) accreditation manuals for ambulatory care, behavioral health care, home care, hospitals, laboratories, and long term care, “Surveyors may request assistance from organization staff for selection of appropriate tracer individuals. As surveyors move around a health care organization, they will ask to speak with the staff members who have been involved in the tracer patient’s care, treatment, and services. If those staff members are not available, they will ask to speak to another staff member who would perform the same function(s) as the member who has cared for the tracer patient.” The goal of a patient tracer is to gauge compliance with relevant standards by speaking with those staff members who are directly involved in delivering care about how they perform their jobs.

The same article goes on to discuss the difference between patient and system tracers stating: “On the systems’ side, the focus will be primarily on global healthcare issues, like how the nursing shortage impacts your organization.”

In fact, a systems tracer does not primarily focus on global health care issues but rather will focus on tracing a particular system related to the delivery of patient care within a particular health care organization. Each year, different systems may be traced. For 2004, those systems are medication management, infection control, and data use. Life safety systems will be traced every year.

Periodic Performance Review and Unannounced Surveys
The February 16, 2004, issue of Inside of the Joint Commission includes an article beginning on page one about the Periodic Performance Review (PPR). Quoting a consultant used as a source, the article incorrectly states the following: “There’s also a big change in scoring. JCAHO now says you’ll get scored on the equivalent of a Type 1 that you report during your self-assessment, Elzer says. That differs from the original ruling that would have given you a free ride on the information that you turn in at the midpoint, Elzer cautions.”

The Joint Commission has not changed how standards compliance information will be addressed through the PPR. For any standard found out of compliance through the PPR, an organization will have to submit to JCAHO’s Standards Interpretation Group (SIG) a plan of action for how it will come into compliance with the standard and, if applicable, measures of success for how it will determine that it is meeting its plan. These actions result in no impact or change on the organization’s accreditation status or Quality Report. SIG will then review these plans and either approve them as is or work with the organization via a conference call to make appropriate changes. These plans will then get the official approval of SIG. At the time of the on-site survey, surveyors cannot challenge these plans in terms of design as long as the organization is following the plan it created. This has not changed. The only time a surveyor may issue a requirement for improvement for a standard addressed in the PPR is if the organization is not implementing its plan. This, too, has not changed.

In the January 5, 2004, edition of Inside the Joint Commission there is mention of self-assessments and unannounced surveys. The article that appears on page 8 states: “Two major components of the Shared Visions–New Pathways survey process will be phased in this year and next: healthcare organizations surveyed in July 2005 will be given the option to perform a Periodic Performance Review (PPR)—or self assessment—and then turn that data over to JCAHO. A pilot program starts this year, then JCAHO will expand the program to all hospitals in 2006.”

This statement is inaccurate. The PPR is not expanding to all hospitals in 2006, as the article states, but is already in effect for all ambulatory care, behavioral health care, home care, long term care, and hospitals. For those types of organizations noted above that are being surveyed beginning July 1, 2005, completion of the full Periodic Performance Review (PPR) or one of its options is a requirement. What will become effective in 2006 for all health care organizations are unannounced surveys.

There were a series of pilot tests of the PPR and its filing tool in the months leading up to its November 1, 2003, release on the “Jayco”™ extranet site, but no further pilot tests are planned. As was stated in the January 2004 issue of Perspectives, “The Periodic Performance Review (PPR) is integral to Shared Visions–New Pathways® and key to achieving continuous standards compliance and, thus, continuous provision of safe, high-quality care. The PPR provides for a compliance assessment at the midpoint of an organization’s accreditation cycle, preferably done by the organization itself. An option is available whereby the assessment is conducted by a Joint Commission surveyor(s).” The article on the PPR in the January 2004 edition of Perspectives ("Periodic Performance Review Key to Continuous Provision of High-Quality Care") offers comprehensive information on this requirement including the full PPR or the three PPR options an organization can pick from to comply with it.

Additionally, further clarification may be helpful in regards to the following sentence in the previously referenced IJC article that appears to be related to the PPR, “A pilot program starts this year, then JCAHO will expand the program to all hospitals in 2006.”

This may in fact be referencing the launch of unannounced surveys—discussed later in the IJC article. This unannounced survey process is being applied to a limited number of volunteer organizations in 2004 and 2005 and will become applicable to all health care organizations on January 1, 2006. For more information on unannounced surveys, please see Perspectives, May 2003, "JCAHO to Conduct Unnanounced Resurveys in All Accreditation Programs in 2006."

Priority Focus Areas
In the January 19, 2004, edition of Inside the Joint Commission, the following statement is made on page 1 in its report on the Joint Commission’s annual surveyor training conference: “You’ll also need to prepare for a survey that is guided primarily by JCAHO’s Priority Focus Areas (PFA)—13 categories upon which JCAHO bases its survey prep work, the source says.”

In fact, there are 14 priority focus areas (PFAs). They are: assessment and care/services (analytical procedures for laboratories); communication; credentialed practitioners; equipment use; infection control; information management; medication management; organization structure; orientation and training; rights and ethics; physical environment; quality improvement expertise and activity; patient safety; and staffing.

Clinical/Service Groups
The January 19, 2004, edition of Inside the Joint Commission also states, on page 3, “From your hospital’s PFA background, JCAHO then plans to pare down the list to four or five key topics, which it calls Clinical Service Groups (CSG), and then use those to guide the tracer process.”

To clarify, clinical/service groups (CSGs) and priority focus areas (PFAs) are different and distinct outputs of the Priority Focus Process (PFP). CSGs are not pared-down PFAs. When the Joint Commission prepares for a health care organization’s on-site survey, they rely on information about that organization—generated through the PFP—to discover both the key areas (PFAs) and populations served or services provided (CSGs) where a surveyor will need to concentrate during the on-site survey. The PFAs and CSGs are considered in tandem in the new accreditation process.

CSGs identify potential types of tracer patients. For example, if cardiology is a top CSG for an organization, a surveyor is likely to select a cardiology patient to trace.

Surveyor Preparation
In the same Inside the Joint Commission article, it states the following: “Surveyors have been told to view each standard with the following questions in mind…: (1) How do you plan for the standard, (2) How do you execute it, (3) What P&Ps do you have in place that cover the standard, and (4) What are the environment of care concerns.” It also goes on to quote a source about having physicians “tag-along with the survey process” to ensure that they give the surveyors the right answers: “That gives us the opportunity to prep that physician because we’ll know who will be the one showing [they surveyor] around.”

These statements do not correlate with the intent or the reality of the accreditation process. Surveyors are not viewing each standard in light of a series of questions; they are considering compliance with standards in relation to observations and findings uncovered as they trace patients and systems through a health care organization. Additionally, the intent of engaging physicians in the accreditation process is not to better prepare them to give the “right answer” to a surveyor but rather because physicians are important care givers. As is stated on page 9 of the January 2004 issue of Perspectives, “Physicians, by the nature of their role, are in a unique position to share meaningful insight into opportunities for improvement in organization systems and processes and to provide leadership for other staff members in the accreditation process.”

Furthermore, physicians have indicated that enhancing their engagement in the accreditation process is better accomplished by their meaningful involvement in an organization’s PPR, and in the development of plans of action and Evidence of Standards Compliance (ESC) submitted after a survey, when required. The Joint Commission agrees and, accordingly, has created a new Accreditation Participation Requirement (APR) specifying such. See the January 2004 Perspectives, "Periodic Performance Review Key to Continuous Provision of High-Quality Care".