Archive for September, 2009

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.