Accreditation

Former JCAHO exec talks survey, offers advice and tips

Briefings on The Joint Commission, May 1, 2006

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Editor's note: Kurt A. Patton, MS, RPh,served as executive director of accreditation services at the JCAHO for more than seven years until his retirement in December 2005. In that role, he worked with all types of accredited organizations seeking to be resurveyed and new organizations seeking to become accredited. He is now principal of Patton Healthcare Consulting, LLC, and a member of the BOJ advisory board. He is the author of an up-coming book and audioconference about handoff communication, both by HCPro, Inc.

BOJ: On which top three things should JCAHO coordinators focus today and why?

KP: First, we need to remember that the accreditation process has changed. We can no longer rely on our skill to write good policies and procedures and think that we will be successful on survey. The JCAHO now focuses entirely on execution and goes to the paperwork only when inconsistencies are identified. Writing good policies and procedures that are not implemented can actually do more harm than good in the new process.

Second, we need to more effectively use the self-assessment process-the periodic performance review (PPR). We can't sit in an office and view the task of conducting the PPR as one person's job or a paperwork exercise.

We need to identify techniques for getting out to the units, conducting tracers, and learning exactly how our staff serve patients and whether their techniques are compliant with the standards. The more thorough we can become at assessing our compliance, the more successful we will be on surveys, and more important, the care we provide will be safer.

Third, we must read about midstream changes that are announced by the JCAHO. The accreditation standards are not static. They and the survey process change all the time. Given the advent of unannounced surveys, you cannot plan to gear up or implement change every third year. You must be ready at any point in time for the survey.

BOJ: On which top three things should JCAHO coordinators expect to focus on next year and why?

KP: Two issues that we are currently aware of-the Life Safety Code® (LSC) and National Patient Safety Goals-will continue to be areas of focus. These are important areas of emphasis because they both involve either building, fire, or clinical safety.

By 2007, I believe that we may also see increased emphasis on the roles of leadership, medical staff, and governance. The JCAHO has been developing new leadership standards for more than a year now. The Leadership Accountabilities Task Force raised many important issues that are reflected in proposed new standards. I would advise JCAHO coordinators to keep track of these standards as they go through the last stages of the development process.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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