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JCAHO moves to accredit SCUs.

The Joint Commission on Accreditation of Health-care Organizations faced a remarkable dilemma when it developed a new survey protocol for dementia special care units. The Joint Commission felt SCUs must be evaluated differently than the rest of the facility, but the lack of empirical research indicating what makes an SCU beneficial for dementia residents--or not--made it impossible to prescribe what an SCU should be. Further, given the remarkable creativity and flexibility seen in many SCUs, the JCAHO wanted the new protocol to support and encourage innovation, not suppress it.

So, for the ten percent of nursing homes with SCUs, as well as the many more that are contemplating them, the Joint Commission is offering a new opportunity and challenge: Beginning January 1, 1994, the JCAHO will use a new survey protocol to evaluate SCUs. JCAHO Associate Director of Long-Term Care Services Anna Ortigara, R.N. helped develop the protocol and coordinated the pilot testing. In this interview with Nursing Homes associate editor Irene Mathews, Ms. Ortigara discusses how JCAHO will evaluate SCUs and where this effort is expected to lead.

Mathews: How was the protocol developed?

Ortigara: This was a very slow birthing process. Our long-term care surveyors reported seeing more and more dementia or Alzheimer's special care units in facilities, and they wanted to know if they should do anything different. And that started the discussion.

We held a focus group in 1987 with members of the Alzheimer's Association, direct care providers and professionals, people from the Joint Commission and family members. We started talking about developing a protocol, and asking what are the components of a quality special care unit? The protocol went through five drafts. At each stage, there were 70 reviewers of the document nationally, including experts on Alzheimer's disease, people who ran programs, family members, Alzheimer's Association leadership - in general, a wide array of people. The goal was to get a real consensus because we had an overriding philosophy of this protocol. We don't want this protocol to tell people what a special care unit has to look like, or set a document in place that tells people "the walls have to be pink and you have to use music with no words."

At the end of the four years the protocol will be re-evaluated--either refined and made a part of the survey process, or eliminated because the SCU approach no longer exists.

Mathews: Is the Joint Commission's goal to challenge the basis of SCUs?

Ortigara: Estimates are that 50-70% of people who live in nursing homes are cognitively non-intact, and the number one reason is Alzheimer's. SCUs are springing up all over the place. Some people don't think that you should have a special care unit--they think these people should be integrated within the whole facility. Others think the SCUs are the way to go because you can really develop specialized programming.

Our official position is we don't know which view is right. We don't think it's been proven yet. But they do exist. And if a nursing home has a special care unit for people with Alzheimer's, then we ask: are you providing quality care? If you say it's specialized, what is specialized. What's your programming? What's your mission and philosophy? There's a wide range, from absolutely wonderful units that do wonderful stuff, to nursing homes that have a unit with a locked door and a sign on it that says "Alzheimer's unit." Is that a special program? No. And yet some of these places are charging people extra money per day to be in that unit.

Mathews: What went into the design of the Dementia SCU Protocol?

Ortigara: We went to the long-term care standards manual and specifically selected the standards we feel require a different intent for an SCU than for the rest of the facility. If the standard would be pretty much interpreted the same way through the organization, it's not included in the SCU protocol. That is, of all 1,300 standards we use, including the planned technology standards, the rules about medical records, the life-safety code, and the nutritional standards related to how the kitchens run, we look at 465 of the standards differently on the Alzheimer's unit.

For instance, resident's rights are very specific regarding dignity and a person's freedom of movement. For people who are cognitively non-intact, we still believe you have to support people's dignity and self-esteem and freedom of movement. In the SCU, you have to create a structured environment that promotes residents' self-esteem and dignity and at the same time maximizes their safety.

The surveyor might look at elopement--do you have a lot of incidents of elopement? Do you have high incidences of restraint utilization? The surveyor might talk to different people, review documentation, look at family complaints or complaint incidents within the facility, touring the unit and actually observing how care is delivered.

Mathews: How will the protocol improve the care delivered to nursing home residents in SCUs?

Ortigara: For instance, we have a whole section on staff development and staff education. It provides a framework for staff people to be oriented to the unit, to the program, to the disease and its manifestations, and to behavioral approaches to help minimize agitated or difficult behaviors. What is the role of the program coordinator? We think that's very key. How did you select staff? How have they been oriented, how do they receive ongoing education? Do you have a quality improvement program that's really looking at indicators that are specific to this unit and this population. How are families involved on this unit?

Hopefully, if the facility picked up this document and they looked at the standard, looking at the intent would give them a framework to set up a program. The protocol will evaluate how the facility fulfills its own stated intent or mission. You determine the mission and philosophy of the unit and the admission criteria. You might, as a facility operator, decide you want people in the middle stages of the disease, or people who are very active and moving. Or you might decide to create a unit that is more hospice-oriented.

There are all sort of approaches. We want to give people a framework but we want them to be creative, to try things. We don't know what's going to work unless you try it.

Mathews: How would the protocol be scored?

Ortigara: The criteria are scored very specifically, on a scale of one through five. For example, we ask you to show us your mission statement and then, when we're on the unit, we'll want to see if is it actualized. Does the staff follow that philosophy and that mission?

When you think about it, every health care facility is somewhat different in the way they deliver care and that doesn't make one right and one wrong, necessarily. Different people deliver care in their own style and that's okay, as long as they are meeting the intent of the standard.

Each standard has its own scoring guideline, which are the criteria. On policy and procedure, we'd ask whether you have a policy on resident's rights and a policy for elopement? If they have a policy and procedure, and they follow it, that's good. That's a one. A three might be having a mechanism in place to quickly respond to the emergency; perhaps everybody knows the system and actually does the appropriate activity, but it's never been written down. A four would be that there's a written policy, but nobody knows it. And five would be not written and they don't do it. Four is a bad score. It's pretty significant. It's good that they went to the planning of writing it, but then they have to orient their staff to it.

Mathews: How long would the review take and at what expense to the facility?

Ortigara: The average is about 3.3 days, based on number of encounters, number of beds and occupancy. The cost of the survey is based on the size of the facility. We accredit the entire facility and use the special care protocol as a component of the overall survey. So I don't have a price for just the special care unit. It's a whole organization-wide cost. On average, it would be about $4700, and is done once every three years.

Mathews: How does this coordinate with the state survey?

Ortigara: It doesn't. It's independent of the state survey process.

Mathews: What effects do you think the protocol will have?

Ortigara: We know that 60-70% of the people in nursing homes are cognitively non-intact, and that they're not on special care units. Nevertheless, the protocol can help improve all the care in nursing homes. Because this protocol makes an organization think about how they might develop a special care program, it can't help but spill over into the way they look at delivering services to the people with dementia throughout the facility.

We saw just that with the pilot testing. Even our surveyors found that they were looking at how the organization delivered services to all their cognitively non-intact people a little bit differently after having learned how to use the protocol. A lot of the questions do apply across the organization. How is staff trained to interact with residents who are cognitively non-intact? If they're not working in the special care unit, but in the rest of the facility, and half the people they're taking care of are cognitively non-intact, then don't they need the same training? Don't they need the same support? Don't the residents need specific programs?

Mathews: What will happen at the end of the four-year trial period for the protocol?

Ortigara: I don't know. We don't know what will happen to the whole field in four years. How we do Alzheimer's care in nursing homes might be totally different. The whole movement in long-term care is to move these people out of nursing homes and put them in group homes and assisted living. In four years, with health care reform and all the changes in reimbursement structures, these people might not even be in nursing homes. You can't prophesize.

Mathews: Meanwhile, what should interested nursing homes do to get their units surveyed and accredited?

Ortigara: Call the long-term care program at the Joint Commission at (708) 916-5721 and we'll give them all the information and the specifics. If they want more information about the dementia protocol, they should call me at (708) 916-5720, and I'll talk with them.
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Title Annotation:Joint Commission on Accreditation of Health Care Organizations; special care units
Publication:Nursing Homes
Article Type:Interview
Date:Sep 1, 1993
Words:1749
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