The joint commission is coming! The joint commission is coming!

IN THIS ARTICLE ...

Discover why one physician executive thinks the new, 2004 JCAHO standards are a vast improvement over those of the past.

The emphasis here at the Joint commission has shifted (from new standards every year) to further evaluation of standards now in place. (1)

A few short years ago, the Joint Commission onAccreditation of Health Care Organizations (JCAHO) was on the verge of becoming a relic of the past. But under the leadership of Dennis O'Leary, JCAHO re-invented itself.

The Joint Commission's change, evidenced in its new 2004 standards and survey procedures, is a rocket boost into the 21st century. At the age of 50, JCAHO may just now be hitting its stride and is poised to continue its importance as the health care industry's national conscience.

Physician executives, always key players in preparing for a Joint Commission survey, may be amazed at new challenges presented by JCAHO beginning January 1, 2004.

Change is constant

In 1919 the American College of Surgeons (ACS) designed and implemented the first program to accredit U.S. hospitals. In 1951 the American Medical Association, American College of Physicians and American Hospital Association joined ACS to form the Joint Commission on Accreditation of Hospitals (JCAH), now known as the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

In its survey and accreditation exercise, the Joint commission measures compliance with standards designed to promote professional and organizational performance that are dependable from the viewpoint of patients and their family members.

The physician-hospital interface has always been a major emphasis in Joint Commission surveys. Each year the Joint Commission, in what some call the "annual manual," updates standards with which accredited hospitals must comply.

Clearly, change is a constant at JCAHO, much to the chagrin of individuals responsible lot survey preparation. But there is change, and then there is change.

Usually, JCAHO only tinkers with existing standards and survey procedures. But beginning January 1, 2004, as a result of its Agenda for Change followed by its just-completed Shared Visions-New Pathways initiative, JCAHO's standards and survey procedures will be truly reformed. (2)

In fact, if you follow the current stylish practice of assigning code names to special projects, a good name for Joint Commission survey preparation might be Operation Copernicus.

Copernicus was the Polish astronomer who discovered in the 16th century that the earth is not the center of the universe. A difficult and disturbing period ensued because people who had assumed that the whole world revolved around them did not like the idea that it does not. But as others confirmed Copernicus' views, the beginnings of modern astronomy were built on the foundation he laid.

Shocking advances made in the newly formatted 2004 JCAHO standards and planned matching survey procedures will disturb us in a difficult transition period, but should eventually deliver a once unthinkable result.

For the first time, effective JCAHO preparation may directly benefit patient care because survey strategies must emphasize knowing what is actually going on with patients, and spending far less time sitting in committees developing lengthy paper trails.

The overall trend of changes at JCAHO is to make the survey and accreditation exercise increasingly data-based, increasingly focused on concurrent clinical and organizational activities and increasingly patient-centered.

What's new

JCAHO's 2004 standards manual does not contain a lot of new requirements. Changes locus on simplifying and clarifying existing standards, not changing the basics with which we are familiar such as effective individual leadership, credentialing, performance improvement, patients' rights and organizational ethics, governing body orientation or adequate staffing.

Also, there are no nasty surprises. Some try to read between the lines of JCAHO standards, apparently suspicious that the Joint Commission wants to trap us into doing poorly in the survey much like some teachers who put trick questions on tests. That is not the Joint Commission's style.

In recent years, JCAHO has been very open and forthcoming about what is expected of us and wily. Furthermore, the new standards are not a prescription we can follow exactly and assure ourselves of accreditation. JCAHO's intent is that we think about our own activities, select effective and efficient ways of doing things and demonstrate results to surveyors.

Noteworthy changes in JCAHO's 2004 standards and survey procedures include:

* The 2004 JCAHO standards manual contains 56 percent fewer standards. Details amounting to micro-management are gone.

* A new--numbering system is used that gets rid of lengthy standards designations like MS 3.1.6.1.7. The standards are numbered in increments of 10. MS 1.10, MS 1.20, etc.

* Four patient care chapters from previous manuals are integrated into one chapter in the 2004 manual. Old chapters titled "Assessment of Patients," "Care of Patients," "Education," and "Continuum of Care" are combined into a single chapter titled "Provision of Care." The intent is to focus on actual patient care instead of just meetings and stories about patient care. Indeed, a theme that first appeared in the 1996 JCAHO manual continues verbatim: "Caring for patients is the nucleus of activity around which all health care organizations revolve." (3)

The following new standardized format is used in JCAHO's 2004 standards manual:

* The standard is briefly stated.

* A rationale for the standard is given. That is, the importance of the standard is explained and the intended impact of the standard is reviewed.

* Elements of performance are listed. That is, activities mechanisms, and systems necessary to accomplish the intent of the standard are described. These are key compliance elements that surveyors will be looking for. In fact, surveyors will now have this exact list on laptop computers and will use the list to score compliance. This is a giant step toward solving the decades-old problems of inconsistent surveyor performance and inconsistent accreditation decisions.

* Crosswalks are provided that demonstrate what has happened to previously existing standards. Scanning through the crosswalks is interesting, but the best way to prepare for the survey is not to study the crosswalks. Rather, focus on the simple statements in the 2004 standards manual and decide on the simplest and most effective ways of accomplishing the familiar tasks described.

* Tracer methodology is a new survey method to be used starting January 1, 2004 not instead of, but in addition to, other survey methods. Surveyors will track a current patient's path through various health care services received such as dietary services, laboratory studies, surgery, administration of medication, nursing care and communication between attending physician and consulting physicians. A major focus of the new tracer survey method is assessing interdepartmental communication and sharing of relevant data about a patient. This emphasis on communication may be motivated at JCAHO by their finding that lack of communication between caregivers is the most*common cause of sentinel events. (4) Lack of communication between caregivers is also a common thorn in the side of defense attorneys in malpractice cases. One impact of preparing for surveyors' use of the tracer method should be further clarification of relative roles of caregivers, including physicians.

Preparing for a survey

To assure success, survey preparation methods must change quickly to accommodate JCAHO's new sharper approach to the survey and accreditation exercise. For example:

* Survey preparation need no longer be a frustrating search between the lines of ambiguous standards, hoping to divine what the Joint Commission really requires and what they will accept as compliance. This process, which veterans have long called "nit-picking the standards" is a thing of the past because the bulky ambiguous language that occasioned the nit picking is gone.

* We will no longer have a chance to select only our most charismatic physicians and personnel to participate in the surveyors' site visit. Surveyors will question whoever is working in patient care areas and other workplaces that they visit.

* Surveyors will be looking for an actual slice of life. What is in patients' records on this unit today? How well are staff members from various clinical disciplines communicating? Is staffing adequate? (We can coach all personnel to avoid certain things, like complaining to a JCAHO surveyor about too much downsizing!) How well do physicians communicate with nursing staff and technicians responsible for different aspects of the patient's care?

* Performance improvement activities must be relevant and productive. For example, how is accurate recognition of the patient's working diagnosis con firmed? A good clinical pathway is no good for the patient if we have set the patient on the wrong path. What are reasons for observed departures from generally acceptable practice guidelines?

Overall, JCAHO's new approach may be an example of "Be careful what you ask for." Many criticized JCAHO for a failure to motivate improvements that truly make a positive difference to hospitalized patients and their families. JCAHO accepted this challenge, big time!

Like many other issues dealt with by physician executives, satisfying JCAHO now requires a genuine understanding of patient care as well as good management skills.

References

(1.) Dennis S. O'Leary, MD, president, Joint Commission on Accreditation of Health Care Organizations. Foreword, 1997 Hospital Accreditation Standards, JCAHO. Oakbrook Terrace, IL. 1996.

(2.) www.jcaho.org, Pre-publication copy of 2004 JCAHO Standards

(3.) www.jcaho.org, "Introduction to MS 2, Management of Patient Care, Treatment, and Services," 2004 JCAHO Medical Staff Standards.

(4.) www.jcaho.org, Sentinel Event Statistics.

Richard E.Thompson, MD, is adjunct instructor of ethics at Drury University, Springfield, Mo. and president of Thompson, Mohr and Associates. Previously, he was an adjunct instructor of ethics at the Ethics Institute, St. Petersburg College,