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One facility's road to "accreditation with commendation." (Regency Manor Rehabilitation and Subacute Center; Joint Commission on the Accreditation of Healthcare Organization Accreditation and Commendation for long-term care and for subacute services)

Opting for a Joint Commission survey, this staff's hard work paid off

Understanding the differences between an annual State survey and a survey by the Joint Commission on the Accreditation of Healthcare Organization (JCAHO) is quite simple: there are no punitive ramifications to the JCAHO survey. The survey process pumps up the staff, and when accomplished, demonstrates to the community their leadership in providing quality care. For us to get there, though, we had a history to change.

Who would have thought it? In four short years, our staff at Regency Manor Rehabilitation and Subacute Center earned a JCAHO Accreditation with Commendation, both for long-term care and for subacute services. We say "who would have thought it" because, before 1992, our facility was a "county home," providing good care thanks to its excellent staff, but in an outdated physical plant. Thus when CommuniCare Health Services (CHS) acquired the center in late 1991, the center underwent a State survey, the results of which were not good. The Health Care Financing Administration's 2567 survey report takes about eight inches of shelf space, and constantly reminds us what the facility used to be. Regency Manor sits on 16 acres in east Columbus, Ohio, occupies 290,000 square feet and has 275 beds served by a staff of 300. Our center is divided into several distinct program areas: 64 subacute beds, of which 20 are dedicated to ventilator weaning and aggressive pulmonary care, and the remaining 44 to physical medicine and rehabilitation. The balance of Regency Manor's beds are segregated into three areas: a secured 64-bed dementia unit, a step-down medical unit and general long-term care.

CHS, based in Cincinnati, Ohio, owns and manages nine senior centers throughout the state. When CHS began entering the managed care market, the most common request heard from all carriers was that our programs be accredited by a recognized organization, such as JCAHO or the Commission for the Accreditation of Rehabilitation Facilities (CARF). Our management team opted for the JCAHO process so that we could accredit the entire center, rather than just one area of it.

Accreditation would, to us, mean the culmination of years of intense preparation. And it was well worth it, because it meant validating to ourselves, our customers and our community that we do provide the finest of care. More importantly, it would mean giving our staff the credit they richly deserve for the hard years they spent delivering quality care in spite of, rather than supported by, their surroundings.

So, the decision was made: JCAHO it would be.

In the early spring of 1995, we requested the Early Survey Process (ESP) instead of the Full Accreditation Survey. We chose this route because none of us had ever prepared for either the long-term care or the subacute survey process. With ESP, a JCAHO surveyor focuses strictly on the center's policies and procedures, leaving evaluation of our implementation of those policies and procedures to subsequent JCAHO accreditation surveyors.

After deciding on the ESP, we spent the next four months reviewing and rewriting, as necessary, all of Regency Manor's policies and procedures for long-term care and subacute services. We were in fact looking to the JCAHO process to help us define our subacute programs and assemble the "building blocks" accordingly, because the programs had been operational for only a short period of time. There wasn't much of a track record on which to base our outcomes assessment - and outcomes are the single most important component of the subacute continuum, especially for JCAHO accreditation.

An incredible number of staff hours were required for our staff to prepare. Some members found hiding spots, each lovingly referred to as "sanctuary", where they could complete their tasks without interruption. Others of us juggled even more responsibilities than we normally do, sometimes supporting each other by sharing our expanding work load.

Teams were made responsible for handling specific sections of the manuals. Meanwhile, education of each team member got top priority. We educated our "Partners In Care" through large and small group sessions around the clock, as well as through newsletter articles and one-on-one conversations.

While we knew that each team could handle the State survey process, there are many more nuances to a JCAHO survey. If a JCAHO standard was higher than one of HCFA's, then we chose a course ensuring that the higher standard would be met. A JCAHO form called the "cross-walk" proved most helpful in this, enabling us to compare JCAHO to HCFA requirements at a glance.

In preparing for the ESP, we discovered that we were already meeting about 90% of the intent of the requirements, but our policies and procedures didn't accurately reflect our delivery of care. We spent time working on this, but the ESP survey process itself helped. The surveyor was with us for three days and covered every single policy and procedure with a fine-tooth comb. This proved to be consistently educational - particularly since we were in a conference room for eight hours a day all huddled around our manuals. Our core management team - the Chief Executive Officer, Chief Clinical Officer, Chief Operations Officer and CQI Manager - were always there, as were various members of the team whose manual or manual section happened to be under review.

In the end we received JCAHO's "Provisional Accreditation." The ESP survey report noted only a few areas of concern, the major one being our physician credentialing and privileging. Our Chief of Medical Staff and the Chief Executive Officer set about writing and implementing a new program for this - and discovered this to be one of our more difficult tasks. Implementing a policy ensuring a "closed" medical staff posed major stumbling blocks. Some physicians were insulted by the fact that they would not be "grandfathered" into the staff, while others saw this as a way to promote quality. In any event, this approach signalled that we were moving down a more acute care-oriented path (and, as it turned out, there were no concerns about our physician credentialing methods when we went through the full survey.)

Another area requiring focused energy was moving from the Quality Assurance model, which is reactive, to a Continuous Quality Improvement model, which is proactive. As it happened, between our ESP survey in 1995 and our full accreditation survey this year, JCAHO changed its philosophy from Quality Assurance to Continuous Quality Improvement. This change challenged our staff the most. It meant intensive education was needed for all staff and management on the differences between the two approaches.

We knew, for example, that QA in our facility was driven by breakdowns in systems, which were then tracked statistically. For CQI, we had to teach our Partners in Care that they were responsible for driving the system. We began our "Q Tip" program. Any Partner in Care can report a perceived quality concern, and that report is forwarded to one of three teams: Quality of Life, Quality of Care, and Resident Behavior and Facility Practices. These staff/management teams then attempt to clarify and resolve the issue. All of this is overseen by the CQI committee. Our staff, in short, had to move from a reactive to a proactive mode.

The nine months between the ESP and the full accreditation survey seemed to fly by all too fast. Our teams continued to polish our policy and procedure manuals, and we did numerous mock surveys to ensure that we actually did what we said we did in all of those manuals.

On March 18, 1996, the surveyor for long-term care accreditation arrived. We learned that our surveyor had the second longest tenure of surveyors at JCAHO - a bit intimidating, but in fact proving to be beneficial, as the surveyor enriched us all with her humor and many educational opportunities. On day two, March 19, our subacute surveyor arrived.

For about four weeks we had been talking to both surveyors on the telephone in preparation for their visits. We had outlined the days so there would be as little duplication of effort as possible. However, since several issues cross over between long-term and subacute care, we needed to be prepared to shuffle staff from surveyor to surveyor, as necessary.

The difference between a state/Federal survey and a JCAHO survey became obvious to us: the previously mentioned lack of punitive consequences. JCAHO surveyors not only survey but also commend and educate. The staff asked, and received answers to, many questions, and generally enjoyed the entire process.

If we had to do it all over again, our only change would be to prepare for it much earlier. There is so much to do for an initial survey that in order to prepare for it and complete everyday tasks requires everyone to become more efficient time managers.

However, the worst part of the survey process was waiting for the results. It was with much anticipation that, 75 days later, we finally received our envelope with the JCAHO logo on it. We opened it and read the results to all our staff: Accreditation with Commendation.

We were elated and gratified. Our "family" had finally reached the point we had dreamed about. We had received confirmation of the professionalism of our staff and their common desire to continuously improve the quality of the outcomes of their care.

We also realized that JCAHO Accreditation was only another beginning. Each of us still has personal dreams and goals based on continuing our mutual success. Even so, we couldn't be prouder of anything than seeing the JCAHO logo and those three words, "Accredited with Commendation", imprinted on our walls, on our letterhead and in our minds.

Jeffreys B. Barrett, RN, LNHA, is Chief Executive Officer, and Martha A. Maite, RN, C, is Chief Clinical Officer of Regency Manor Rehabilitation and Subacute Center, Columbus, OH.
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Author:Maite, Martha A.
Publication:Nursing Homes
Date:Sep 1, 1996
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