A new course for JCAHO accreditation: interview with Marianna Kern Grachek, MSN, CNHA, CALA.

Many facilities that have tried accreditation claim the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveyprocess is vastly preferable to the "gotcha" policing of the OBRA survey system. However, the Joint Commission has found that since the implementation of the Medicare PPS in 1998, some long-term care organizations have pulled out of accreditation as a result of financial constraints. Since PPS, JCAHO s Long Term Care Accreditation Program has lost market share and currently accredits 14% of LTC Facilities nationwide. The basic problems identified by facilities were the cost and time involved in preparing for and undergoing a JCAHO survey; facilities experiencing financial difficulties were saying they could no longer afford discretionary activities such as accreditation.

JCAHO's market research revealed that, although LTC organizations valued accreditation, they preferred a less costly and streamlined accreditation process that would not be duplicative of the state agency survey. As a result, the Joint Commission recently revised its accreditation approach in general and created another option for LTC accreditation. The new accreditation approach, called "Shared Visions/ New Pathways" (SV/NP), will apply to all of JCAHO's accreditation programs. SV/NP, which goes into effect January 1, 2004, is a paradigm shift that moves the accreditation process away from survey preparation to ongoing readiness and continuous standards compliance.

To address the need for a less costly LTC accreditation process, JCAHO launched the "Medicare/Medicaid Certification-based Long Term Care Accreditation" option in January 2003. This incorporates about 70% fewer standards than the traditional LTC accreditation option and has a designated one-day survey fee regardless of facility size. The new option dovetails with--rather than duplicates--the OBRA state surveys.

Recently Marianna Kern Grachek, MSN, CNHA, CALA, executive director of JCAHO's Long Term Care Accreditation Programs, clarified and explained these changes in an interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: Would you explain why JCAHO is taking these initiatives now?

Grachek: With "Shared Visions/New Pathways," the Joint Commission is making a paradigm shift in the accreditation process from one that focuses on survey preparation to one that focuses on ongoing standards compliance and systems improvement. This shift essentially moves the accreditation process away from one that emphasizes "exam and score" toward one of achieving excellent operational systems that enhance patient and resident care. In essence, the shift moves the accreditation process from being a "snapshot" of compliance to one that is a "movie" showing ongoing standards compliance.

Peck: JCAHO launched its new LTC accreditation option earlier this year. Was there a particular reason it was initiated?

Grachek: Basically, since the implementation of PPS in LTC, the LTC accreditation program saw a reduction in the number of accredited organizations. Although LTC facilities realized the value of the JCAHO accreditation process, we learned that, with less and less discretionary income available at LTC facilities, many were having trouble maintaining voluntary accreditation. The issues they wanted JCAHO to address were survey topics that were duplicative of those on state agency surveys and those Oryx performance improvement requirements that were perceived to be redundant with the MDS Quality Indicators.

Peck: How about the specifics?

Grachek: The traditional LTC accreditation program has 383 standards; when we crosswalked these with state survey F tags, we found 112 standards that didn't crosswalk. These standards are the basis of the new Medicare/Medicaid Certification-based Long Term Care Accreditation option. As would be expected, these standards do not address such issues as care and treatment, continuity of care, and infection control, which are essentially covered by state agency surveys. The new LTC accreditation option focuses on the development and implementation of systems and processes, and focuses on areas not covered by the state agency survey, such as safety, performance improvement, resident and family education, provider credentialing and privileging, and pain management (insofar as the treatment system supports residents' rights). JCAHO also reduced the survey length to one day, made it available to organizations of all sizes, and kept costs constant at $4,300. Also, this remains a three-year accreditation, albeit substantially based on Medicare/ Medicaid certification.

Peck: You say this is an option. Is the traditional three-day survey still available?

Grachek: Yes, it is. There are those organizations that value a "top-to-bottom" JCAHO review. There are also those facilities that are more involved with sub-acute and managed care that prefer the traditional LTC survey because of its clinical elements, which the new abbreviated survey doesn't have. This is particularly true in the Northeast, especially Massachusetts, where more than half the facilities have JCAHO accreditation because of their involvement with managed care. About two-thirds of the surveys scheduled for 2003, though, have been for the Medicare/Medicaid option.

Peck: What are some of the characteristics of the abbreviated survey?

Grachek: The Medicare/Medicaid option still has the opening conference. We also include a high-level document review, including the QI Facility Profile report, resident safety and performance improvement systems, as well as staff management and the availability of diagnostic services. This abbreviated survey reviews the state agency survey's 2567s to see where problem areas might lie in the facility and what the facility is doing about them from a performance improvement viewpoint. Our surveyors will talk with residents and families, as appropriate. In 2004, as part of the SV/NP initiative, surveyors will use a tracer methodology approach to identifying standards compliance. Tracer methodology starts with a particular resident's situation and traces the resident's facility experience back through admission, assessment, care planning, provision of care, and documentation of that care.

Peck: Will the abbreviated survey process be available to assisted living facilities seeking JCAHO accreditation?

Grachek: No, it won't, because assisted living facilities do not receive a federal certification survey, as do the skilled nursing facilities. The new abbreviated LTC survey option rests substantially on the facility's annual Medicare/ Medicaid certification survey, which is not performed in assisted living.

Peck: Will there continue to be random unannounced surveys?

Grachek: Yes, about 5% of surveys performed by the Joint Commission between 2003 and 2005 will experience a midcycle unannounced survey. In 2006, SV/NP will move to 100% unannounced surveys, eliminating the need for midcycle unannounced surveys. Interestingly, JCAHO has noted some reservations about this planned move to unannounced surveys from accredited facilities, indicating that they appreciate announced surveys as consistent with a collaborative, helpful process rather than one that represents a punitive "gotcha" approach to surveying. The purpose of unannounced surveys is to eliminate the "ramping up" process that is associated with JCAHO surveys.

Peck: You mentioned earlier that LTC facilities no longer have to participate in Oryx transmission requirements?

Grachek: That's correct. Requiring LTC facilities to subscribe to a performance measurement system was an expensive proposition for our facilities. The reality is that JCAHO had initiated this requirement prior to the federal government's requiring electronic transmission of MDS data to the state agencies in 1997. So, now that national transmission is in place for LTC, JCAHO has created an option for the LTC field requiring that the organization have the MDS Quality indicator Profile and related performance improvement plans on-site. Some of the larger organizations, though, will continue to maintain their own performance measurement systems so that they can measure Quality Indicators among their provider sites.

Peck: "Shared Visions/New Pathways"--the overall shift in the accreditation process--begins in 2004, and the LTC manual will be issued this month. Will elements of SV/NP, other than those we've already discussed, work their way into the LTC accreditation process?

Grachek: Yes, all of the SV/NP components go live for LTC in 2004. However, for assisted living surveys, some of the key elements will be delayed until the new accreditation manual for assisted living is released in 2005. For example, the priority focus process (PFP), which enables surveyors to focus on specific problem areas in a facility before survey, and the 18-month (accreditation midpoint) facility Periodic Performance Review (PPR, aka self-assessment) will not be implemented until 2005 for assisted living. We don't have all the technical components together yet to implement these changes in the assisted living arena.

Peck: There are many aspects of this change that we don't have the space to address. Where can readers go to get more complete information about these initiatives?

Grachek: They can contact me at [phone] or [e-mail], or they can access the JCAHO Web site at www.jcaho.org and click on both the SV/NP and LTC survey options.

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