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How to earn perfect scores from your JCAHO surveyor.

Picture yourself walking into an interview. You have spent most of your working life preparing for this job. You will have five minutes to present your training and accomplishments. If you don't make a good first impression, you will be rejected. This scenario is analogous to an inspection by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

In the past few years, JCAHO has shown increasing interest in laboratories' quality assurance (QA) initiatives. Partly as a result, labs have expanded their quality management (QM) and QA efforts, documenting that they provide superior services and facilitate the delivery of patient care. A good deal of a lab's resources is spent in implementing activities related to QM and assessment.

Although the commission accepts CAP accreditation in lieu of the technical portion of its inspection, a JCAHO surveyor will visit a lab to evaluate the quality of its services. Often such inspections are rushed; the surveyor, forced to review a massive amount of data in a short time, experiences sensory overload. The laboratorian assigned to act as spokesperson--usually the chief pathologist--must present the lab's QM plan in a few minutes. It had better be good.

* Basics. Structured documentation backing up a succinct, authoritative QM program described coherently and completely will earn a laboratory excellent marks. Getting to that point requires a firm understanding of the Joint Commission process.

Physicians who visit labs are from various specialities, rarely including pathology. Many have limited knowledge of standard laboratory operations and QM requirements. They tend to judge these activities along the lines of QM in other disciplines; for instance, they may ask to see case reviews for staff pathologists. Not fully understanding the goals of lab QM, they may concentrate more on form than on content.

We have found that surveyors prefer laboratorians to take the lead in demonstrating, through examples, that they are allowing the agency's 10-step process (Figure I). Designed by the agency in 1988, this process focuses on the need to define and study indicators, objective variables used to measure the quality and appropriateness of important aspects of patient care.

The following rundown of the process will concentrate on the nine steps that laboratories frequently omit, to their regret (Figure II). We learned about these neglected steps by attending many JCAHO meetings and seminars.

* Step 1: Assignment of responsibility. Even though the laboratory director is responsible for the quality of all lab services, he or she may delegate others to take charge of the QM program. JCAHO expects the QM plan to name any such employees.

* Steps 2-5: QM plan. The written plan should include a statement about each of the 10 steps. It must describe the lab's services fully, cite aspects of patient care under consideration, and list the indicators used.

Surveyors love details. They want to know why indicators were chosen, who is responsible for monitoring each one, how indicators are evaluated and how often, what trends or problems they have uncovered, and what actions have been taken to rectify problems.

To avoid last-minute scrambling, our lab maintains a notebook containing our QM plan and current information on the following: a description of each indicator; a chronological summary of each indicator, including dates on which it was discussed by the pathology staff; a chronological listing of minutes from our periodic pathology staff meetings at which QM was discussed; and summaries of what was learned and what actions were taken as a result of our QM program.

* Steps 7-9: Staff discussion. While many of the lab's QM activities are handled between section supervisors and the pathologist or doctoral scientist responsible for those sections, JCAHO requires that the pathologists review the lab's monitoring activities and evaluate the findings at least once a quarter. For each indicator, the pathologists must draw conclusions, make recommendations, take action to solve any problems uncovered, and set a time for remonitoring to assess progress. To facilitate these steps, we created a simple worksheet that allows room for the indicator at the top and asks questions such as these: What did the data show? How do they compare with the threshold? What needs to be done?

* Step 10: Communication with executives. In order to satisfy JCAHO, each hospital department, including pathology, must present an annual summary of its QM program to the executive committee and then to the governing board. The data, preferably shown graphically as well as verbally, should illustrate trends in the quality of care over a specified time period. The report should describe actions taken to resolve problems, opportunities taken to improve patient care, and the effectiveness of remedial actions.

Labs are expected to show JCAHO surveyors how all this information was communicated to hospital officials. Clearly, it is wise to organize and file these records for easy retrieval.

* Selecting indicators. An indicator may be a resource, a process, a clinical event, a complication, or an outcome. Suppose you wanted to check whether test results in your lab were accurate and being delivered expeditiously. You might study employees' performance on proficiency surveys and turnaround time (TAT).

Indicators cannot be monitored without target thresholds--preestablished performance levels that are medically justifiable and operationally achievable. If the TAT standard for Stat tests in your lab is less than 30 minutes, for example, achieving the defined threshold might require meeting that standard at least 95% of the time. No further study or remedial action would be necessary if monitoring indicated that performance met that threshold. On the other hand, TAT that was prolonged more than 5% of the time would call for improving performance. A worksheet containing the factors listed in Figure III helps us monitor indicators intelligently.

Professional as well as supervisory staff should be involved in choosing indicators. Including both groups will help insure that indicators relate to laboratorians' activities and are not merely busywork. Indicators over which employees have no control quickly become a source of frustration.

The commission has provided some guidelines to help lab professionals select indicators.

First, indicators should serve, directly or indirectly, as indices for measuring the quality of high-volume, high-risk, high-impact, or problem-prone activities related to patient care. A useful indicator can be monitored repeatedly and performance improved if it doesn't meet the laboratory's standards.

Second, indicators should represent most of the functional areas of the laboratory (order entry, for example); specimen collection, preparation, transportation, and analysis; and result reporting and interpretation.

Third, some indicators should be suitable for evaluating pathologists' performance. Our physician-specific QM data form helps us to assess physicians' clinical competence and to document reasons for recommending whether they should continue to receive clinical privileges (Figure IV).

Fourth, although two aspects of care and two indicators are sufficient to fulfill JCAHO requirements, it is advisable to include a few more. Don't go overboard, however, since every indicator must be documented, discussed, and evaluated on several levels. Three indicators per lab section, for example, would be too many.

* Documentation. Many of us routinely perform some of the JCAHO steps, or variations of them, in the course of a normal day, "documenting" these activities in our heads. Like inspectors from other regulatory agencies, JCAHO surveyors demand written documentation of compliance with requirements. According to agency philosophy, if it isn't down on paper, it was never done. Keeping this in mind, we must change some of our habits.

* Scoring. Unlike CAP, which passes or fails a laboratory for each requirement on its checklist, JCAHO uses a five-point system. Scores reflect the extent to which the lab has met the requirement in question and how long significant indicators have been in effect.

The overall group rating consists of the worst score attained--canceling any good ones for other elements within that category. For this reason, it is vital to do well on every standard. A perfect score indicates that the laboratory has complied fully with all agency regulations throughout the year preceding inspection. JCAHO scoring guidelines are listed in the agency's 1992 Accreditation Manual for Hospitals. The manual can be ordered by writing to JCAHO at 1 Renaissance Blvd., Oakbrook Terrace, IL 60181, or by calling (708) 916-5600.

* Preparation. A lab can never be overprepared for a JCAHO surveyor. We recommend participating in a mock inspection at least 18 months before the real thing. A dry run gives employees time to iron out unexpected problems. Although any person knowledgeable about the JCAHO inspection process could conduct the exercise, it's best for someone outside the lab--even better, outside the institution--to run the show. The staff should practice using the commission's jargon--indicators, thresholds, and so on--in their rehearsed presentations.

Keep the latest edition of the JCAHO Accreditation Manual at hand. JCAHO requirements change constantly, yet each inspection demands those in effect at that time. Review standards and requirements for each area of the lab long before the surveyor arrives. Pay special attention to the section on the 10-step monitoring and evaluation process. One convenient way to remain up to date is to subscribe to "Perspectives," a bimonthly JCAHO newsletter.

* Worthwhile efforts. Working hard to satisfy the JCAHO surveyor will reap many benefits for your laboratory. A strong QM program plays an important role in a lab's accreditation process while satisfying licensing and reimbursement requirements. Passing inspections promotes a positive image to the public.

Good luck with your next inspection. If you're prepared, luck won't be a factor.

General references:

Berte, L.M. Growing into laboratory quality assurance. MLO 22(2):24-29, February 1990.

Joint Commission on Accreditation of Healthcare Organizations. "Accreditation Manual for Hospitals, 1992." Oakbrook Terrace, Ill., JCAHO, 1992.
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Title Annotation:Joint Commission on Accreditation of Healthcare Organizations
Author:Baer, Daniel M.; Belsey, Richard E.; Schaefer, Beth
Publication:Medical Laboratory Observer
Date:Dec 1, 1991
Words:1585
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