The Ongoing Transformation of The Joint Commission

Hospitals anticipating a visit from The Joint Commission can expect the survey process to be unlike surveys that they have previously experienced. Most of the discernable changes are related to the realignment of Joint Commission with the Centers for Medicare and Medicaid Services. (CMS) The Joint Commission remains committed to surveying by tracer methodology, however, in order to meet the CMS required “volume” of records reviewed, Joint Commission must meet the minimum “30 record”  requirement.  (“20”  for small general acute care hospitals)
 
Hospitals using Joint Commission for deemed status need to be aware of this minimum record requirement.  Surveyors will be required to review closed records if tracer activity and system tracers do not yield the required volume.  Clients that have recently experienced this have noted both a more focused intense review of medical record documentation as well as a report that reflects documented evidence of the individual record reviews. In the past Joint Commission Survey reports reflected statements such as “based on review of inpatient records.” Now, the final report will be more specific and may reflect documentation such as – “a patient record reviewed on med/surg unit A,” followed by each individual record and finding being listed separately.

A review of a closed medical record may result in a number of other issues “surfacing” such as changes in current policy to the policy that was in place during the admission being reviewed; for example, during the survey, the current pain assessment policy may require the assessment to take place more or less frequently than the policy required during the care period of the closed record. Other issues might include form completion requirements,  staff competency requirements, dating and timing of orders, etc.  Consider adding to your Survey “preparation” process, the accessibility of archived policies, files, and consider identifying staff that can speak to previous practice, if there has been recent re-engineering of processes.

PPR CHANGES COMING!

Complete revision of the PPR appears to be a reality. What we heard from Executive Briefings was that the torturous process of filling out the PPR will be eliminated as a requirement; however the tool will remain available for those organizations that wish to use it for self assessment purposes. There will be no more option 1-4; however some of the nuances of the options will be available. There was some contradiction in the information provided regarding this, and we’ll just have to wait and see what shakes out. A question was raised about retaining the current PPR option that allows identification of an issue with an action plan for correction, providing immunity if the issue is discovered during survey, however, there was no clarification from the podium.

The proposed new process will be mandatory for each organization (which would seem the current option 1 with no call would be eliminated.) This new process consists of “touch points”. At specified time periods (currently proposed are 6 months, and 18 months) the organization will have an option of an onsite visit from TJC or a telephone call with TJC (with the organization’s representative and a member of SIG.) The purpose?

• At the six month time period after the final survey report was posted, the contact would be to assure the ESC/POC was working and that survey issues were resolved, that there was customer value, and that the customer value assessment (something new that we’ll get to shortly) checked, survey feedback obtained, an update of the electronic application and a selection of the 18 month option (onsite visit or call.)
• During the 6 to 18 month period (the time between the two calls or onsite visits) the organization must complete what the organization feels is important for that organization in the PPR (this is in writing in the printed materials distributed.) During this time period the organization is to assess structure standards (documentation/policies), previous problem areas (PPR pre-populated – what the organization feels is important) and organization risk points (PFA/S3 data)
• At the 18 month time period an onsite visit or call with the organization representative and a member of SIG is held where top issues of organizational concern, issues from “like” organizations, top issues from the organization’s outcome data (S3, sentinel events, etc.), implementation ideas and leading practices that TJC has gleaned from other organizations and wishes to share, the electronic application update and customer value assessment (CVA) are discussed.
• There is no charge for this process. The “touch point” PPR process is mandatory and will replace the traditional PPR process.
• The “touch point” PPR process is framed under “shared responsibility for continuously meeting quality standards”, and currently, is in draft stages. There is an understanding that some, if not many, of these issues have change slightly.

Special Note: Pat Adamski from TJC (who is consistently informed, realistic and takes a very common sense approach to the standards (probably because she is a nurse  ) stated that late submission of a PPR in the current environment (before the “touch point” revision implementation) will not result in provisional accreditation status. Pat stated TJC will “work with the organization” if they are running behind, however the organization should alert the representative about the delay, and communication is a must.

Those are the proposed changes folks. What the take away was, is that TJC is trying to get more real value from the PPR process. We’re glad they are trying and this points to their new “customer centered” focus. How well this process will work will unfold as the months progress.

News from Executive Briefings

During the Executive Briefings held by The Joint Commission on Friday, September 25, 2009 in Los Angeles, several interesting issues were announced, some key elements of the National Patient Safety Goal revisions were clarified and much information was presented. During the ensuing weeks, we will be providing information on “take aways” from the briefings and what these may mean to your organization. First out of the gate however, is a follow-up to our Center Member Audioconference held on September 17, where reference was made to possible changes in the survey scoring process and the PPR. It seems, from information provided during the briefings, that both of these issues have merit.

Scoring:
Supposedly there are no “magic numbers” that result in adverse action, even though the surveyor days/bands have been published. According to all speakers, there never have been specific numbers that rendered an organization immediately into adverse action (other than the level 2 direct impact or immediate threat findings.) Notably, all speakers concurred that the issue of number of direct impact RFIs tipping an organization into adverse action has been a misconception by the industry since the publication of the “bands”.

So what is important with number of direct impact RFIs? Trends and significance of the RFI(s). An organization supposedly can net a large number of direct impact RFIs (over the identified “band” level) and not be placed in adverse action if the RFIs did not negatively trend toward any particular issue (for example the RFIs didn’t trend toward patient safety or leadership, life safety, mediation management or performance improvement.) What would the accreditation status be in the scenario of say, 17 direct impact RFIs for a small hospital if they were unrelated and did not trend toward a given issue? Fully accredited with RFIs. However, rarely are RFIs unrelated and it can be assumed a larger number of RFIs may well trend negatively in some given area. That is why the preliminary reports are submitted to Chicago for SIG review (no more stopping at your account rep first) and determination.  Each report is to be reviewed individually, with accreditation status rendered on the individual merit of the report. Obviously, if there are few direct impact RFIs, there is little for the organization to worry about.

So, what were the surveyor bands all about? What was the purpose in publishing them if they didn’t have any real meaning? Were they just “guidelines”?  That question was not answered.

A follow-up note here about accreditation report turn-around-time. From the podium: TJC must turn an accreditation report around to the client organization and post within 10 working days (per CMS requirements), however TJC is now showing a posted report TAT of 2 -3 days. That means all organizations that wish to clarify any RFIs should start the clarification process as soon as possible as lead time for data gathering and auditing has been reduced.

PPR:
There are significant changes afoot with the PPR with the previous options 1-4 “going away” to be replaced with a mandatory “touch point” process where the organization “touches base” with TJC either via onsite presence or telephone call with the account rep and a member of SIG at specific time periods (six and eighteen months post survey). The PPR changes are not final yet, the Joint Commission is still conducting some fine tuning. We’ll have more information for you on the details of the proposed PPR changes later this week.

Turn-Around-Time on TJC Survey Reports

  Used to be a healthcare organization would have weeks (….and weeks) before their TJC report was reviewed by the powers that be in Chicago, scrubbed, and posted to the organization’s website. Now, however, TJC has an approximate goal of a ten day turn around time (2 weeks) to get that report reviewed and posted. And we’ve seen client reports posted as early as 7 days! What does this mean to you? Less time to work on your clarifications. When an organization seeks to clarify RFIs (or elements of performance under a given RFI, even if the standard won’t be removed), TJC allows a 10 working day (excluding weekends and holidays) time frame. Clarifications must be submitted within the 10 day period. Prior to 2009, we advised clients to wait until the final report was posted before implementing an “all hands on deck” approach to their clarifications; primarily because some of the findings were expected to be changed during the TJC “scrubbing” process, and the organization could be working on a clarification that would not come back in the posted report. Lately, with the rapid turn-around-time of the posted report, if an organization waits to collect data needed for the clarifications, they may find themselves running out of time. Some of the audits required to clarify category “C” elements of performance can be very time consuming, as can researching a given finding for an “A” category element of performance. So we recommend organizations review the preliminary report, and start the clarification process early for any findings that are scored correctly (i.e., under the correct element of performance, under the correct standard – for example, if the surveyor cited the hospital for an untimely H&P under the RC standard, the issue belongs under the PC standard and has been incorrectly scored.) We’ve seen very little changes in the scrubbed and posted reports, and, with the stepped-up posting turn-around-time, your organization may benefit from an early start.

TJC March 2009 New and Revised Standard Changes

Thursday, March 26, 2009 the Joint Commission released revised 2009 Release of the Revised 2009 Accreditation Requirements for the Hospital Accreditation Program. This revision is in response to the 165 new and revised elements of performance released January 5, 2009, specifically developed to further align the Joint Commission with the CMS Conditions of Participation (due to the need to accomplish the deeming authority which TJC is looking to renew in July of 2010.) In an audio-conference the week of the March 26th, TJC clarified the March  document noting a reduction to 87 new and revised elements of performance, from the January release. This new March release and reduction to 87 elements of performance does not include the category of EP (neither category A nor C are listed), and whether the EP is scored as a direct impact (level 3) or non-direct impact (level 4) EP. How these will be scored will be forthcoming with no date provided by TJC at present, but take heart, once the determination is made, there will be yet another posting of the changes, this time with the scoring categories. [more]

Hold Off on Credentialing Changes!!

There are two versions of the 2009 CMS changes made by the Joint Commission: the version that was emailed on January 6 and the version currently posted at the Joint Commission web site. (It took us a very long time to find the posted version: it’s NOT under standards, it’s under “What’s New.” Go figure!)

The bottom line is that the changes to MS.13.01.01 that were in the January 6 email are not on the web. Is the change to MS.13.01.01 in? Is it out? Is it under discussion? We’ve asked the Joint Commission but they have not yet responded.

In the meantime: do not make any changes to the way you credential or privilege Nighthawk and other remote diagnostic-only practitioners! Wait for clarity from Oakbrook Terrace.

A Handful of New FAQs

Over the last month or so the Joint Commission posted a handful of new or revised frequently-asked questions or FAQs to help clarify expectations of the standards. You can find these under the “Standards” then “Standards FAQs” tab at the Joint Commission website (http://www.jointcommission.org). The following is a synopsis of the changes. (We encourage you to read the official FAQs for yourselves.) Overall, we found these limited revisions to be quite helpful and on target. [more]

165 New Requirements … So What?

We’ve completed an analysis of the January 2009 additions to the accreditation manual. There are 165 brand new (or revised) elements of performance. A significant percentage of these requirements (60 or 36%) may have an impact on current practice at your hospital. We’ll be blogging about each new requirement we believe has the potential for significant impact. In the meantime, we’ve attached an analysis of these new EPs for your review.

Will the Joint Commission Score the New Requirements Now?

On January 6, 2009 the Joint Commission released 165 brand new elements of performance intended to bring existing Joint Commission standards in line with the Medicare Conditions of Participation. In the February, 2009 issue of Perspectives, the Joint Commission said that the new requirements were “schedule for July 1, 2009 implementation but are subject to change pending further Joint Commission discussions with CMS.”

We wonder what these discussions have yielded, because some of these new requirements were already being cited on surveys taking place in January, 2009!

Clarification of TJC S3 Scoring

Have you noticed your TJC S3 score rising? Has it risen markedly over the last two quarters? If so, you may have some questions that you’ve had trouble answering. Hopefully, we can provide some insight that will prove helpful. In discussions with the folks back in Chicago overseeing  S3 scoring (who have been most helpful), there was a bump in Quarter 2 ‘08 reported data that most hospitals felt, which was due to data from SCIP measures. TJC had neglected to factor in the SCIP ORYX (core measure) outcomes into the scoring system as they have with all other ORYX measures. So, suddenly, quarter 2 ‘08 reflected this data and caused a sudden (and in many cases, distinct) rise in S3 total. Another issue with rising  S3 scores is the fact that only the negative outliersfrom all ORYX measures are counted in the S3 scoring.  [more]