The Subacute Saratoga story.

Experiences and reflections of the first subacute facility to be surveyed by JCAHO 

By the end of March, approximately 20 subacute care facilities had been surveyed by the Joint Commission on the Accreditation of Healthcare Organizations in its new subacute accreditation program, and 50 organizations were in the process of being surveyed. However, the Saratoga, California-based Subacute Saratoga Hospital was the first to be surveyed under the new protocol, the first to see how it works and what areas are stressed, and the first to discover its differences from the more familiar long-term-care survey process.

In October, 1994, Subacute Saratoga was readying for its third JCAHO long-term-care survey when it received notice that, in January, the Joint Commission would initiate a program for subacute accreditation. Saratoga had, in fact, been a subacute-care-only facility since 1987, but it had continued to maintain its long-term-care accreditation. That was the only accredited status available to it, and the question of accreditation by the Joint Commission is one of the first asked by insurance companies, HMOs, and referring hospitals. However, since Saratoga now views itself as a subacute-care "hospital" rather than a traditional skilled nursing facility, JCAHO's announcement provided an opportunity to clarify the 38-bed facility's status which its managers could not pass up.

"I called the Joint Commission and requested that they forestall our long-term survey and give us just one survey for subacute care in January," explains Saratoga Subacute Vice President Connie Rolfe. JCAHO responded, and Subacute Saratoga proceeded to find out that, like subacute care itself, the subacute survey process is a world unto itself.

"This survey was more patient-oriented," notes Rolfe. "They talked to current and past patients and their families. I've been in this business a long time, and this was the first time I've ever had a surveyor come in and ask me for five discharged patients and then have that surveyor actually call those patients or their families to find out what the level of care was and how satisfied they were."

Other areas of concern included admissions and discharge procedures. "They looked at our pre-admissions screening, which they never did before," says Rolfe, "and they looked at our discharge planning very carefully to make sure that we had an outcome goal for patients brought in for subacute care. Outcome measures were definitely very high on their list. Skilled nursing facilities by tradition do a brief screening of patients. They get a phone call, take an inquiry, and say yes or no. In order to meet the new subacute standards you are going to have to start to have a more detailed program of pre-screening, really evaluating the patient before admission and then setting up goals for discharge."

According to Subacute Saratoga's President, Mike Zarcone, the subacute survey is more like a hospital accreditation process than a long-term-care survey. He points to the credentialing of physicians as an example.

"This is a huge deal for acute hospitals," Zarcone explains, "but is brand new to skilled nursing facilities. Basically, JCAHO is requiring that each physician go through a review process before becoming a member of a staff at a subacute program. They would like you to have a medical director who works with administration and, on an annual or biannual basis, reviews staff files for completeness - making sure a doctor's license is current and that he is still in good standing with a hospital where he has privileges - and makes recommendations to the governing body regarding privileging."

Susan Moore, Subacute Saratoga's Director of Patient Referrals, says that the overall concern for patient dignity was a major issue for the subacute survey. "They wanted to know what we did to preserve a patient's dignity and rights, and they wanted to hear from patients and their families whether it worked."

Having been the first to be surveyed, how does Subacute Saratoga feel about the process and what it strives to measure? In a word, positive.

"The Joint Commission's approach is totally different from that of the state when it comes in and does its annual survey," says Zarcone. "The Joint Commission is not coming here to find fault, to be disruptive, or to have the big hammer over our head. They are coming in with a positive attitude to help foster a better level of care for the patient. They want to find out what your process is and then provide you with assistance to improve it. Our surveyor was very knowledgeable and the whole process was one of help and guidance."

"I think the subacute survey was very definitely a positive, and I think it is good for all of us in the industry" says Connie Rolfe. "If subacute is going to become a recognized level of care, it is essential to have a set of standards, and what the Joint Commission is doing is setting the baseline for everybody. I like the direction in which they are moving, and I like their approach in terms of pre-admission screening, discharge planning, goal direction, quality improvement, and outcome measurement. This is all very, very positive and will help both the industry and the patients."

RELATED ARTICLE: A Word from JCAHO

JCAHO is concerned that subacute care facilities understand that its subacute accreditation is not a stand-alone accreditation. It is granted by the Joint Commission under either its 1994 Accreditation Manual for Long Term Care or its 1995 Accreditation Manual for Hospitals.

"The subacute protocol is not a Manual," explains Kathleen O'Connor, JCAHO's Manager of Long-Term Care Accreditation Services. "Saratoga's subacute accreditation comes under the long-term umbrella because accreditation must occur under a Manual's general administrative policies and procedures."

Once the decision to develop a subacute-care accreditation protocol had been made, JCAHO wanted to roll it out as soon as possible, with several factors influencing the initial setup. "We wanted to use our long-term care standards because this made it easier for nursing facilities to adapt," says O'Connor. Also, creation of a new accreditation category for subacute would have been time-consuming. Thus, says O'Connor, "the most efficient way to get a program on-line was to work under existing standards and modify the intent statements where necessary. That's what we did in creating the subacute protocol."

Organizations currently accredited by the Joint Commission can choose to have their subacute units surveyed for accreditation, but do not have to have them surveyed in order to maintain their long-term-care accreditation. Organizations not currently accredited by the Joint Commission must apply for either the long-term-care or the hospital survey in order to be eligible to apply for the subacute-care survey.

Demand for the new accreditation has been high. "We have hired 13 additional surveyors who are subacute experts, and if we need to hire more, we will," O'Connor says. "We have taken a lot of time and effort to make sure the subacute survey is not duplicative of the long-term-care survey."