Here They Come Again! — JCAHO Survey Advisory for 2006
By Karen Meno, BS, MBA, RD, LD, CPHQ
Today’s Dietitian
Vol. 8 No. 2 P. 12

You know they’re coming, but now you can’t be sure exactly when.

Beginning this year, all Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys will be unannounced. That means you get one day’s notice.

In addition to unannounced triennial surveys, JCAHO is also conducting random unannounced surveys of 5% of accredited facilities every year. These surprise surveys can occur as early as nine months after or as late as 30 months after your last triennial survey.

And there’s no “off season” anymore. Traditionally, surveyors had attended their annual training in January, so we wouldn’t expect them before mid-February. I had the opportunity to ask two surveyors how their new unannounced survey schedule is going to work and was told that survey teams could show up anytime, January through December. They may show up at your hospital tomorrow.

JCAHO is counting on this change to add to the credibility of survey results by allowing its surveyors to see your facility as it functions on a daily basis. Allowing no time for last-minute preparation will, they believe, end what many see as “gaming” the system.

In this article, we’ll explore how survey teams will function in 2006 and what you can do to prepare. Obviously, you must start by “hardwiring” key processes so they occur 100% of the time. Embedding the standard into your daily procedures is a must. It is imperative to be on top of new standards and standard changes. Before standards are put into place, the proposed standards are posted on www.jcaho.org.

Upcoming standards are provided in the semiannual Comprehensive Accreditation Manual for Hospitals: The Official Handbook with an implementation date in the future. Staying ahead of implementation dates ensures you are prepared for unannounced surveys.

The current JCAHO functions are categorized by Patient Focused Functions, Organization Functions, and Structures with Functions:

• Patient Focused Functions are Ethics; Rights and Responsibilities; Provision of Care, Treatment, and Services; Medication Management; and Surveillance, Prevention, and Control of Infections.

• Organization Functions are Improving Organizational Performance; Leadership; Management of Environment of Care; Management of Human Resources; and Management of Information.

• Structures with Functions include Medical Staff and Nursing.

• National Patient Safety Goals, a separate section, is updated annually.

This year, it appears that the Priority Focus Areas for the random unannounced surveys are Assessment and Care; Infection Control; Patient Safety; and the 2006 National Patient Safety Goals.

All standards are based on evidence-based research and real-life hospital experiences that have been substantiated with data. Thus, when preparing your policies and procedures, you should include a reference section at the end. This shows that your decisions and processes are based on research- or evidence-based medicine. Listing the JCAHO function under which the process is categorized is also recommended in the header or reference section.

Arbitrarily created policies and procedures are unacceptable—they must be supported by accepted industry standards. Researching literature, use of the Internet, and using experts as resources provide a platform to build your own processes. Often, you can improve upon the work of others while tailoring it to your own facility.

Many Web sites discuss the latest and best methods to provide patient care. A few sources are the Institute for Healthcare Improvement and 100K Lives Campaign at www.ihi.org, Leapfrog at www.leapfroggroup.org, and National Quality Forum at www.qualityforum.org, as well as your State PRO, which is contracted by the Centers for Medicare & Medicaid Services (CMS). (The CMS contracts an entity in each state to oversee quality for that state.)

Use the experts. By doing this, you ensure a smooth survey and limit your Requirements for Improvement (RFIs) and Supplemental Recommendations (SRs).

In foodservice, for example, temperature/refrigerator logs should also be kept daily. Logs must be complete with documented actions when temperatures fall outside of the acceptable range. Clinical nutrition recommendations should be communicated to physicians and nurses promptly.

Team Approach
Structure is important to ensure a state of constant readiness, and, because many processes are interdisciplinary, a policy and procedure review team is a great way to keep moving projects forward.

Ideally, this team would meet every two weeks. Each discipline could place policy and procedures on the agenda, with drafts of policy items brought to the group for fine tuning. This mechanism prevents the unexpected derailment of projects due to a lack of communication to directly involved areas. “Buy-in by all” creates a smooth transition when the new or revised processes are put into place. Each discipline can educate its own departments regarding process implementation.

Reinforce the changes via hospitalwide e-mails and newsletters. Minutes of each meeting should be kept and distributed to each team member, department director, and senior manager to keep everyone aware of the progress.

Practice Tracers
Another way to maintain a state of readiness is to use practice tracers. Identify patients in your main clinical systems. This depends on the types of patients and services provided at your facility.

If your patients are primarily older adults, select common diagnoses of this age group, such as acute myocardial infarction, congestive heart failure, or pneumonia. For surgical specialties, select the surgical types that you provide, such as coronary artery bypass graft, knee replacement, hysterectomy, or colon. Once selected, assign an interdisciplinary group to ensure that each step in your patient care process has been completed and documented. General patient and specialty tracers for infection control, data, and medication management are defined by JCAHO. Tracers move from department to department and follow the path the patient takes.

For example, the tracer may start in the emergency department, move next to the patient care unit of the intensive care unit, then move to a main floor, to surgery, to the postanesthesia care unit, and to a different unit; visits to respiratory therapy and pharmacy would certainly occur depending on the services used by the patient selected for the tracer activity. Clinical dietitians should be readily available to practice answering common surveyor questions about their specialty and demonstrate the adequacy of communication to other disciplines and documentation.

Pocket Resource Manual
Another strategy is to create a pocket-size resource book for employees to carry and have available at key locations. The booklet should be organized by the JCAHO functions and provide a handy resource for review and ongoing use. Hospitalwide information that all employees need to know (eg, contact information) should be in the booklet (eg, who your safety officer is). Each function contains related hospital-specific information, such as the advance directive process: Is it honored in the outpatient areas? Where are the forms?

If you are asked a question you cannot answer, you can at least say, “Let me check my information guide.” It is OK to tell a surveyor that you do not know, as long as you know where to look for the information.

Network for Success
Check with colleagues in other facilities who have been through surveys in the same calendar year. Developing relationships with colleagues at professional associations is critical. Sharing information can create successful surveys for all. Large hospital systems and corporations have an advantage since sharing of experiences is common.

Several new standards that go into effect for 2006 are as follows:

• Access. All employees must be educated on how they can contact JCAHO directly. Any concern regarding the quality of care or safety can be communicated via telephone or e-mail. Organizations have been directed to adopt a “no-retaliation” policy regarding those employees who report their concerns. Of course, the correct action is to discuss problems with your manager first and perhaps seek a second opinion for any gray areas or unclear interpretations of the standards. Serious concerns should be handled promptly to rectify any dangerous situations.

• Qualifications. HR.1.20 states that “...the hospital has a process to ensure that a person’s qualifications are consistent with his or her job responsibilities.”

EP #4 states: “When current licensure certification or registration are required by law or regulation to practice a profession, the organization verifies these credentials with the primary source at the time of hire and upon expiration of the credentials.”

You must verify the credentials of professionals hired on or after January 1. For professionals hired before January 1, you must verify at time of renewal of licensure or certification. The easiest way is to use your state’s online verification, print the information, and keep it in the employee file. If you are not in a licensure state, you must work through the Commission on Dietetic Registration.

• Food safety. PC.7.10, EP #17: Food and nutrition products are prepared under proper conditions or sanitation, temperature, light, moisture, ventilation, and security.

Most state health departments survey for these items quarterly, but you need to be prepared to show proof of compliance. Ambient room temperature charts are one mechanism. Protection of food products from tampering is a must. Securing the area is required for employee safety and food safety. Excessive moisture is a concern due to food preparation areas in close proximity to hot cooking areas and the dish machine. Structural redesign may be needed to adequately separate these areas.

Problem Areas
Several standards continue to be difficult for facilities to meet. In 2005, the following areas were shown repeatedly to be in noncompliance.

• Assessment: PC.2.120. The hospital defines in writing the data and information gathered during assessment and reassessment.

EP #1: The hospital defines the time frames for conducting the initial assessment. Nearly all facilities define the time frame—the problem is compliance. You must set your time frames at a level you can meet. It must also be reasonable to identify cases of malnutrition or areas of additional nutritional needs early. Quick intervention is critical to prevent problems.

EP #4: A nutritional screening when warranted by the patient’s needs or conditions is completed within 24 hours of inpatient admission. EP #4 most often falls under the jurisdiction of nursing for an initial assessment within 24 hours. The clinical nutrition staff may wish to facilitate this process by conducting a compliance study. Approximately 11% of RFI were cited for initial assessment delays.

• Information management: IM.3.10. The hospital has processes in place to effectively manage information, including the capturing, reporting, processing, storing, retrieving, disseminating, and displaying of clinical/service and nonclinical data and information.

EP #2: Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the hospital.

The official JCAHO “Do not use” list is: u, IU, qd, qod, leading decimal point (use a leading zero such as 0.5), trailing zero, MS, MSO4, and MgSO4.

Clinical nutrition staff who access and/or enter in the medical record should avoid use of these abbreviations when documenting. You should also alert others if you find that others have used them. All hospitals have a process to clarify these abbreviations—again, nursing is the front-line screener—but it is everyone’s responsibility to comply.

• Policies and procedures. Content and consistent implementation remains a difficult standard.

LD.390: The leaders develop and implement policies and procedures are consistently implemented.

EP #2: Processes as defined by the policies and procedure must be able to repeat at a high level of consistency.

The policy and procedure must cite evidence of standard compliance. Once defined, they must be carried out 100% of the time. These processes must be hardwired to occur consistently with check systems built in to ensure compliance.

• Environment of care. A top cause of RFIs, common citations include grounds and equipment maintenance, storage, blocked exits and hallways, safety policies and procedures, and life safety code compliance.

Routine internal surveys by foodservice managers are a must. A checklist is recommended to ensure consistent compliance. Monthly (or more frequent) audits are recommended. Keep records of audits on file. If a surveyor is about to cite you for a rare occurrence, you have data supporting your usual compliance.

• Interdisciplinary communication. JCAHO has increased its expectations. Patient safety errors due to poor communication are unacceptable. Surveyors expect to see good communication processes in place.

PC.550: Care treatment and services are provided in an interdisciplinary, collaborative manner. A collaborative, interdisciplinary approach to meeting the patient’s needs and goals helps coordinate care, treatment, and services and achieve optimal outcomes.

The mix of disciplines involved and the intensity of collaboration will vary as appropriate to each patient and the scope of services provided by the hospital. There are many correct ways to achieve good communication. Several methods to accomplish this goal include an interdisciplinary care plan, interdisciplinary progress notes, and a 24-hour current service/communication form placed at the front of the record daily—a communication form not part of the permanent record.

Other aids for communication include a status board that contains where the patient is located, as in taken to imaging or already seen by a consulted ancillary service (eg, the dietitian). Patient-specific goals should also be listed to ensure that many disciplines help support them.

Electronic notes are a challenge. All staff users must be able to quickly access the charting and recommendations of other disciplines. They must be able to show this to a surveyor when asked.

Patient Safety
The National Patient Safety Goals are updated annually. Retired goals are moved to other locations in the standards and are still scored. The 2006 goals are as follows:

• Improve the accuracy of patient identification. Use at least two patient identifiers, neither of which is the patient’s room number.

• Improve the effectiveness of communication among caregivers. For verbal or telephone orders or reporting of critical test values, the person receiving the order must complete a “read back” verification process. Establish a standardized list of abbreviations, acronyms, and symbols that are not to be used throughout the organization. Measure, assess, and, if appropriate, take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical test results and values.

• Implement a standardized approach to hand off communication. This should include an opportunity to ask and respond to a question. This is a new addition for 2006 and is critical to ensure patient safety when patient information is handed off from caregiver to caregiver, especially at change of shift, level of care, or location. This ensures that a complete update of history, prioritized issues, goals, and pending results are communicated.

• Improve the safety of using medication. Standardize and limit the number of drug concentrations available in the organization. Identify and review annually a list of look- and/or sound-alike drugs used in the organization and take action to prevent errors involving the interchange of these drugs. A new requirement is to label all medications, medication containers, or other solutions on and off the sterile field.

• Reduce the risk of healthcare-associated infections. Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. All food preparation staff must comply with current CDC hand hygiene guidelines, which include the use of available alcohol-based hand gels, no artificial nails, use of gloves, and good hand-washing technique (a minimum of 15 seconds).

Alcohol-based hand gel usage guidelines are less known. For gels, be sure to use enough, cover the entire hand surface area (including the back of the hand), and allow 15 seconds for optimal impact. All staff should be familiar with the guidelines and be able to verbalize them for surveyors.

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection. A Root Cause Analysis should be completed on all sentinel events or near misses.

• Accurately and completely reconcile medications across the continuum of care. Implement a process for obtaining and documenting a complete list of the patient’s current medications on the patient’s admission to the organization and with the patient’s involvement. This process includes a comparison of the medications the organization provides to those on the list.

A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

• Reduce the risk of patient harm resulting from falls. Implement a fall reduction program and evaluate the program’s effectiveness. All disciplines should participate in preventing patient falls. Be aware of what is happening to patients. Are they trying to climb over bed rails? Delayed staff response to call lights may result in falls. Be aware of your facility’s warning symbols used to designate fall risk. All disciplines must be trained in fall precautions.

Patient safety is the responsibility of all employees. Be knowledgeable regarding how your facility meets these goals and prevents errors or accidents.

In summary, key survey differences exist over past surveys. Obviously, there will be a less defined survey process. Any agendas distributed on the first day will be constantly modified based on daily findings. Tracer methodology discoveries will also define the remainder of the survey. If surveyors observe three or more deficiencies in any particular area, it is an automatic RFI. For example, three separate episodes of unsatisfactory hand hygiene will lead to a citation.

In 2005, Conditional Accreditation was given for approximately 10 or more RFIs (previously designated as Type I), and 13 or more RFIs placed the facility on Preliminary Denial of Accreditation. In 2006, the number of RFIs for Conditional Accreditation remains at 10 and 15 RFIs lead to Preliminary Denial of Accreditation.

Security
Believe it or not, there have been imposters. Off-shift survey visits—showing up unexpectedly on a weekend, for example—are still a possibility. But, due to several instances of counterfeit surveyors trying to gain access to facilities, most surveyors have suspended this practice. Still, when surveyors arrive, you should always validate their identity. Each should have a JCAHO identification badge, and you can call JCAHO to verify their names. JCAHO has also created a short-notice process, usually the day before a survey, for secure locations such as prison hospitals, Department of Defense facilities, and other security-sensitive facilities.

Be gracious about receiving any RFI or SR. Remember: We are on the same side and want the same thing: safe and effective patient care. Do not, under any circumstances, argue with surveyors. Calmly present any additional information as the survey progresses. Consider all identified issues as diamonds in the rough. It is your opportunity to improve safety and quality of patient care.

— Karen Meno, BS, MBA, RD, LD, CPHQ, is the director of quality resources for Largo Medical Center Hospital in Florida. She has lectured on total quality management at seminars across the United States.

Resource
Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations. 2005.

Preparing for Surveyor Q & A
Typical surveyor questions include the following:

• How do you communicate your nutrition therapy recommendations to physicians and nurses?

• How do you screen for malnutrition daily?

• Where is your current diet manual? Do the nurses know where these are located? Are they easily accessible?

• What is your process for educating patients on food/drug interactions?

Recently, I heard of a facility where the dietitian routinely reviews the patient medication profile to assess the need for food/drug interaction education, any impact on appetite, or the potential to cause nausea. Try to showcase any unique and innovative practices like that which sets you apart. The advantages of routine practice are many. You will be able to provide more confident, polished, and quicker answers. It shows that you can effectively communicate to other disciplines.

— KM

JCAHO-Speak
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) uses acronyms and definitions specific to the accreditation process. The more you use them, the better they like it. The following are key acronyms that will help you better communicate with surveyors and understand the survey process.

• PPR (Periodic Performance Review): An online self-assessment for all applicable standards performed by your hospital every 12 months. This self-assessment is submitted to JCAHO along with corrective action plans for any standards evaluated as noncompliant.

• ESC (Evidence of Standards Compliance): Confirmation or verification that illustrates or proves how an organization is in compliance with a standard. Policies and procedures, protocols, teaching outlines, logs, tests, observations, and data may prove compliance.

• POA (Plan of Action): A plan detailing the actions an organization will take to come into compliance with a JCAHO standard. A Measure of Success (MOS) may also be required.

• MOS: A numerical or other quantitative measure usually related to an audit that validates that an action was effective and sustained. It must be defined; often, systematic or random sampling is used. Data are usually submitted to JCAHO showing a track record of compliance. The Elements of Performance (EPs) that require an MOS are designated by a circle around the letter “M” in the Comprehensive Accreditation Manual for Hospitals: The Official Handbook. An internal-use-only MOS is recommended to show compliance of a new or difficult-to-meet standard.

• RFI (Requirement for Improvement): This was formally known as a “Type I” and “Supplemental Recommendation.” These are standards deemed to be noncompliant.

• EP: The scoring criteria used to assess compliance—a more detailed description than the standard description.

- Scoring: 0: Insufficient; 1: Partial; 2: Satisfactory.

- Partial and insufficient compliance scores lead to RFI.

• PFA (Priority Focus Area): These are processes, systems, or structures in a healthcare organization that significantly affect the quality and safety of care. Surveyors use the PFA to plan on-site survey activity and agendas.

The current PFA categories include infection control, medication management, information management, assessment and care/services, communication, credentialed practitioners, equipment use, organizational structure, orientation and training, patient safety, physical environment, quality improvement expertise and activity, rights and ethics, and staffing.

• PFP (Priority Focus Process): The process for standardizing the priorities of an organization’s survey based on information collected about the organization prior to the survey. The process helps focus the survey on areas critical to that organization’s patient safety and quality of care processes. An example is training and certification for dietitians.

• CSG (Clinical Service Group): CSGs are categories of patients/residents/clients or services that are either high volume for the organization or considered high risk or problem prone by JCAHO. Surveyors will use an organization’s current patient list by diagnosis to identify CGS to select patients to use in tracers.

— KM

Additional Tips
The following suggestions will help you succeed at your next survey:

1. Be confident in your demeanor. Only answer information asked in the question. Do not offer extra information.

2. Have a positive attitude and smile.

3. Go toward surveyors, not away. Don’t hide. There is a greater chance for success with a group to answer questions vs. an individual. There is power in numbers.

4. If you don’t know the answer, say so. But do know where to go to get the correct answer.

5. Know the processes that apply to you inside and out. Be prepared to answer questions about your job responsibilities, training, and your patients. Refer to specific policies and procedures by title or function. Be aware of hospitalwide policies and procedures that apply to all employees.

6. Pause before answering questions and reflect on the question briefly to ensure you understand it. You may ask the surveyor to repeat the question or ask it in a different way.

7. Give examples where appropriate. Mention quality improvement teams or committees and process improvement work. Emphasize teamwork.

8. Be ready to demonstrate what you know. Surveyors may wish to observe a specific task.

9. Be calm. Take deep breaths. Be very proud of your facility and what you do.

— KM

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Examination
1. At the beginning of an unannounced survey, you should validate the identity of the surveyors.
a. True
b. False

2. New standards are available for review prior to implementation at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Web site and often in the Comprehensive Accreditation Manual for Hospitals: The Official Handbook prior to implementation.
a. True
b. False

3. All policies and procedures should contain content references to show that evidence-based medicine was used in the creation of the policy.
a. True
b. False

4. If surveyors observe three or more episodes of noncompliance, it is an automatic Requirement for Improvement.
a. True
b. False

5. The following is true of the PPR (Periodic Performance Review):
a. It is an online self-assessment.
b. PPRs are performed every 24 months.
c. PPRs are submitted to JCAHO.
d. a and c only
e. All the above.

6. The types of tracers utilized by the JCAHO surveyors are:
a. general patient tracers.
b. infection control tracers.
c. data tracers.
d. medication management.
e. all the above.

7. ESC is an acronym for:
a. evaluation of community standard.
b. evidence of standard compliance.
c. evidence of confirmation scoring.
d. ESC is not a JCAHO acronym
e. evidence of serious complications.

8. A newer standard exists that requires a facility to educate all employees regarding the process of contacting JCAHO regarding any quality or safety concerns.
a. True
b. False

9. One of the new patient safety goals for 2006 is:
a. improving accuracy of patient identification.
b. implement a standardized approach to hand off communication.
c. reduce the risk of healthcare-associated infections.
d. a and c only.
e. all the above.

10. An MOS (Measure of Success) is:
a. a numerical measure that validates that an action is effective and sustained.
b. a systematic sampling that may be used.
c. is submitted to JCAHO to show compliance following an ESC.
d. done internally to ensure that they are meeting a standard.
e. all the above.