Keeping It Clean for JCAHO
By Robbi Hess
Today’s Dietitian
Vol. 7 No. 6 P. 52

JCAHO will be performing unannounced visits beginning next year. Those in the field say it’s a change that represents a new challenge to meet requirements.

With the implementation of JCAHO’s new accreditation process, “New Visions-New Pathway,” this is a time of great change in the healthcare industry. Along with those changes come trepidation and risk as the new survey processes go live.

The result of the new process is a complete paradigm shift from one focused on survey preparation and score achievement to one of continuous systematic and operational improvement by focusing to a greater extent on the provision of safe, high-quality care, treatment, and services.

JCAHO spokesman Mark Forstneger notes that one goal of the organization’s new accreditation process is to focus on the evaluation of standards compliance on actual patient care experiences rather than rote assessment of compliance with regulations.

“This process provides the [surveyed] organization with a more accurate, credible evaluation of what it’s doing well and what it could do better,” he says.

Unannounced Visits = Constant Vigilance
One of the most drastic changes facing healthcare facilities is the shift from announced to unannounced JCAHO visits, set to take effect January 26, 2006. In the past, healthcare facilities received prior notice of an impending triennial visit and many spent considerable manpower and overtime hours sprucing up facilities and making sure all the i’s were dotted and the t’s crossed. The requirement is for a midcycle periodic performance review, which will occur at the 18-month mark or halfway through the 36-month accreditation cycle. Note that starting in 2006, JCAHO will require an annual periodic performance review. The annual update will involve submitting a summary statement of standards-related opportunities for improvement that were discovered and corrected over the previous 12-month period.

Julie Hensler-Cullen, director of education and quality at Pennsylvania’s Moss Rehab and Einstein at Elkins Park, part of the Albert Einstein Healthcare Network, says hospitals will need to be in a state of constant readiness.

“The surveyors want to make sure healthcare organizations are providing quality care for every patient,” she explains. “A healthcare system certainly wants to make sure that if a prior JCAHO visit noted areas in need of improvement, those deficiencies be addressed and improvements in place before the next visit.”

At Einstein, there is a JCAHO preparation committee that meets to stay on top of standards compliance.

“Even before unannounced visits, there was no downtime in working on standards,” Hensler-Cullen says. A subcommittee reviews chapters of the accreditation manual to see what the newest issues are, what new concerns have been raised, and how the organization will go about meeting those requirements.

“Continuous readiness has become a chant for us,” Hensler-Cullen says. “I would say that staff and administrators have a bit of trepidation about the new survey processes but recognize JCAHO is making it a safer place for patients—and that’s really the bottom line.”

Yosef Dlugacz, PhD, senior vice president of quality management at New York’s North Shore-Long Island Jewish (LIJ) Health System, agrees that the only way to plan for unannounced JCAHO visits is to be constantly prepared.

“Typically, when you had advance notice that JCAHO was coming, people would spend a lot of resources in preparation—overtime for cleaning, checking equipment, and medical record review. Everything was last minute,” he says. “Now, everyone is thinking differently. The delivery of care always has to be perfect. Charts have to be maintained with immediacy.”

Dlugacz believes one drawback to unannounced visits will be that surveyors will find more deficiencies. The long-term benefits, however, will be in the overall health and care of the patient—and that, he says, is critical.

The surveyors’ ability to visit any part of the hospital and pull a chart and follow the history of the patient from the time of admission until discharge will be a good indicator of overall hospital practices and the quality of those practices, Dlugacz says.

“The surveyors will not only be looking at the quality of the charting but at the quality of the care the patient received,” he explains. “From communications in the chart to the way a diagnosis is made to whether a healthcare provider identified all the risk factors will be noted. Rather than conducting a random examination of a chart, the surveyors will interview doctors and nurses and possibly patients to interact with them.”

For the past two years, the North Shore-LIJ Health System has undertaken mock surveys utilizing the tracer methodology to gauge their progress and work out any potential problem areas.

Ruth Ragusa, RN, vice president of organizational effectiveness at New York’s South Nassau Communities Hospital, says that prior to the advent of unannounced visits, her healthcare system historically scored in the 96th percentile overall and received scores of 99 to 100 in the home care and behavior health areas.

“We’ve obviously always done our best to meet the standards because it just makes good sense,” she says. “We look at the requirements as the gold standards of what to strive toward.”

Unannounced visits will certainly be a challenge, Ragusa agrees, but she says it will be more a challenge in terms of the disruption of a business day.

“When three to five people converge on your facility for a survey, it may be a challenge to coordinate all the resources that go into a survey on short notice,” she says. “But the unannounced visit sends a good message to the patients and also keeps staff on their toes. We’ll just have to work out the logistics.”

Getting a Head Start
Administrators at Methodist Healthcare in Tennessee kicked off a campaign to emphasize cleanliness within their seven facilities even before they knew of JCAHO’s unannounced visits. Administrators say the monumental effort has paid off.

“When patients come to our facility, their perception of our cleanliness leads them to their perceptions of the care they will receive,” says Janice Marks, vice president of affiliated services. “Our initiative is to take our facilities from good to great.”

Robert Silver, chief operating officer at Le Bonheur Children’s Medical Center, an affiliate of Methodist Healthcare, says the campaign focused on the customer service side of cleanliness as it directly relates to infection control.

As a way to meet its new standards, the healthcare system brought in an outside company to train staff in self-inspections and provide the organization with a baseline from which to work.

“Because cleanliness is subjective, we spent a lot of time discussing what made an environment clean and we looked for a metric with which to measure it,” Silver says.

Committee members charged with the cleanliness campaign videotaped rooms throughout the seven facilities and reactions to the rooms’ cleanliness and appearance were gauged.

“We’ve worked to train the inspection teams in each of the facilities to have the same mind-set and commitment to performing inspections,” Silver explains. “Consistency is a priority in this initiative.”

As part of the project, maps of every room in all seven buildings had to be compiled. “We needed to do this so when we are undertaking the quarterly top-to-bottom cleanings and inspections, we can track the progress,” Marks explains. “Even though it’s taken us more hours than we anticipated, this team has not wavered from its commitment to this initiative.”

In addition to having healthcare facilities that exceed cleanliness standards, Marks explains that the initiative allows administrators to identify trends and issues.

“Cleanliness has now become the fabric of our every work day,” Marks says. “And going in to 2006 with unannounced JCAHO visits, we will be prepared.”

Patient Tracking
Using a tracer methodology, JCAHO surveyors will use actual patients as the framework for assessing standards compliance within a healthcare facility. Forstneger explains that during the survey, surveyors select patients randomly and use their medical records as a road map.

“As surveyors trace a patient’s experience in a healthcare organization, they talk to the doctors, nurses, and other staff who interacted with the patient,” he says. “Surveyors also observe doctors and nurses providing care and often speak to the patients themselves.”

Hensler-Cullen says her organization is going to utilize tracers themselves. “We’re going to have a train-the-trainer approach as was demonstrated to us so we can independently and departmentally monitor ourselves to gauge our processes,” Hensler-Cullen says. “I think the Commission is on the right track, especially with the tracer process.”

Ragusa says the tracer methodology will be a more meaningful measure of the hospital’s strengths and weaknesses in caring for patients. “It will be a challenge and I’m sure areas for improvement may come to the surface, like communication issues,” she says. “However, it’s a much better way to measure how a hospital performs and how patient care is handled.”

Getting It All Done
Other than pest control services, none of the individuals interviewed would consider outsourcing procedures to keep their facilities JCAHO-compliant.

“We aren’t adverse to hiring a consultant to come in and help like we did with understanding the tracer methodology,” Hensler-Cullen says. “But I think we do better with having our permanent staff being responsible for meeting the standards. There is a joint commitment between staff and administrators to see it gets done.”

As for outsourcing, Dlugacz doesn’t believe in it. “You need to develop accountability, and that has to be implemented at the bedside,” he says.

“We would never consider outsourcing,” Ragusa says. “The process isn’t about paper. Sometimes people get bogged down in paper. You have to make your processes your very own, and when you do that you are constantly on top of it. It’s an everyday practice, not an abstract concept on a piece of paper.”

Healthcare facilities are required to send in a self-assessment form before the surveyors come on site.

“The people on staff who are responsible for those processes in the hospital are completing the assessments, and if they find they aren’t doing something 100% of the time and when the surveyors come and look at 10 patients and find we are only doing a process for seven, they [the surveyors] are going to see that we’ve moved up a notch before their next visit,” says Hensler-Cullen. “The opportunity to perform a self-assessment, identify areas in need of improvement, and being held accountable for those improvements keeps us ever vigilant.”

Getting—and Keeping—the Bugs Out
While healthcare organizations may be willing to take on the task of meeting requirements for JCAHO with in-house staff, they also know where their strengths lie. And for many of them, hospital staff are not equipped to keep up with pest management services. That’s where companies like the Steritech Group come in.

Eric Eicher, president and chief operating officer of the pest prevention division at Steritech, says the company offers high-quality, environmentally friendly pest prevention services. What Steritech does is look for ways to minimize future introduction of pests into the environment, thereby providing its clients with a pest-free environment.

“Looking for ways to minimize pesticide application involves working with customers through structural storage and sanitation recommendations,” he says. “We also work with clients to correct conditions that make the property conducive to pest infestation.”

Removing food, water, and shelter sources can go a long way toward discouraging pests. “A hospital can’t tolerate any level of pest infestation,” Eicher explains. “Patients’ bodies aren’t up to fighting yet another potential infection that could be caused by pests.”

Is it economical for hospitals to outsource pest management services? “One of the problems with in-house pest management is the staff becomes stagnant,” Eicher says. “The cost of an outside program is less than an in-house program and is always much more effective.”

When asked whether JCAHO’s move to unannounced hospital visits would affect the way Steritech operates, Eicher says no. “Our program has to be set up and perfect all the time. There is no chance it could be set up the day before it is needed,” he says. “JCAHO changes won’t affect the way we operate.”

Meeting and Exceeding the Standards
Surveyors will be evaluating compliance with JCAHO infection-control standards by tracing patient experiences and systems processes, according to Forstneger.

“If an organization does not comply with a standard, it receives a ‘requirement for improvement’ and must demonstrate compliance to maintain full accreditation,” he says.

Hensler-Cullen explains that there are hundreds of standards and the main ones are the national patient safety goals. “Those tenets guide our processes with the ultimate goal of providing safe, quality care,” she says. “It should always be safety first.”

Forstneger says hospital accreditation standards number more than 250 and address everything from patient rights and education, infection control, medication management, and preventing medical errors to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects and uses performance data.

When asked whether there are any changes he would like to see in the JCAHO regulations, Dlugacz said he wasn’t certain. “I think this new method is going to be good for the patients even though it might be difficult to comply with,” he says. “I think it will take years for hospitals to comply with these methods, but it’s worthwhile and I’m happy about it. In the past, standards focused on policies and now they are more patient-focused.”

If she could request any changes in the way JCAHO operates, Ragusa says it would be to request a bit more lead time when there are changes to requirements. “There have been times when there hasn’t been much lead time and that causes a dilemma in implementing those changes. Incorporating changes into staff practice takes time,” she says.

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.

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