Organizations not affiliated with the Joint Commission produce products and sponsor education programs related to JCAHO accreditation. At times, the information provided in these products and programs is confusing, misleading, or inaccurate. In addition, questions posed to JCAHO by accredited organizations often identify these types of misperceptions in the field. The Fact on Fiction
column identifies this misinformation with the intent of preventing confusion and correcting erroneous impressions in the field. This column is included in
Perspectives
on an “as needed” basis, whenever misleading or inaccurate information on JCAHO initiatives is published. Questions about JCAHO initiatives can be directed to perspectives@jcaho.org or SharedVisions@jcaho.org.
Periodic Performance Review
In discussing the options available to health care organizations under JCAHO’s Periodic Performance Review (PPR), the February 16, 2004, issue of Inside the Joint Commission states about option 3 that organizations will “forgo the PPR altogether and invite a one-day survey onsite.” Option 3, which was discussed in the January 2004 issue of Perspectives, is one of the options available as a part of the PPR process and thus does not “forgo” this element, as Inside the Joint Commission states. Moreover, the on-site survey offered under PPR option 3 is usually one-third the length of an organization’s triennial survey, which does not necessarily translate to one day. More information on PPR option 3 will be available in the June 2004 Perspectives.
Priority Focus Areas
The February 16, 2004, issue of Inside the Joint Commission also states that “tracers come from your hospital’s Priority Focus Areas, which is an ‘organizational record’ of who your major patient groups are.” Priority Focus Areas (PFAs) are not patient groups; rather, PFAs are processes, systems, or structures in a health care organization that significantly impact an organization’s quality and safety of care. JCAHO’s 14 PFAs were most recently listed in the April 2004 Perspectives. It is clinical/service groups (CSGs) that JCAHO classifies as groups of patients or services in distinct populations served by an organization.
Questions from the Field
The hospital field posed the following questions to JCAHO staff. JCAHO’s official responses are provided.
Question: We’ve heard that no staff files are being reviewed during the competency assessment discussion of the new on-site survey process. Is this true?
JCAHO Response: No, this is not true. Surveyors will look at an organization’s staff competency as a system and at how that system is playing out on the unit floors. Surveyors will do a focused review of staff files based on the tracers they conduct. As indicated, they will ask to see the personnel files of staff involved in the care of patients being traced. If a surveyor finds an issue that he or she thinks warrants further review the surveyor may ask to review more staff files to investigate that issue. In that way, how an organization manages competencies is also assessed by reviewing a few files.
Question: We have concerns about the consistency of the survey process from organization to organization when there are no longer standard survey “tools” or “protocols” being used by all surveyors.
JCAHO Response: By design, the tracer methodology approach negates the use of any standardized “tools” or “protocols,” which were better known as probe questions. Surveyors will ask staff questions unique to the care delivered to the patient being traced. Questions will be focused on how staff members do their jobs, not around their knowledge of the Joint Commission’s processes. If the actual staff member who cared for a patient is not available to answer such questions, the surveyors will ask a staff member who performs the same functions how he or she would approach that patient’s care. This approach will better evaluate an organization’s performance rather than how well an organization is able to prepare its staff to respond to standardized probe questions. Thus, the evaluation process is quite consistent, but the PFAs and unique patient experiences will be organization-specific.
Question: Does the new accreditation process require an extra day of survey to complete?
JCAHO Response: No. The Joint Commission did not change its rules for how survey length, surveyor days, and survey fees are determined. As such, an organization’s survey length will be determined by information supplied in their application using the same rules as in the past. An organization’s survey length might increase if it added more services than it had under its previous survey. In addition, because JCAHO is now integrating the surveying of complex organizations so that all components of a complex organization are surveyed at approximately the same time, an organization may have more days of survey in a row rather than days spread out over a period of time for different components of their organization.