Accreditation

July 2006 issue

Accreditation Monthly, July 7, 2006

Please be on alert that as of July 1, 2006 your hospital organization should be in compliance with and ready for an unannounced JCAHO survey on the March 2006 Update 1 changes to the JCAHO Accreditation Manual. These updates may be found at www.jcrinc.com.

One change that I see as particularly worthy of your attention is MM.2.20. Two new Elements of Performance (EPs) have been added to MM.2.20. EP 3 is an "A" EP calling for creation of a policy covering the storage and handling of medication from the time a nurse or other authorized clinician first lays hands on the medication to the time the medication is administered. The policy must address at a minimum the storage, handling, security, and disposition (at end of shift) of medications during this time period. EP 4 is a "C" or performance EP that requires implementation of this policy.

Then there are the recently announced updates to the Human Resource and Medical Staff chapters that are available now in pre-publication form at www.jointcommission.org. These changes carry an effective date of January 1, 2007. I call your attention specifically to changes to HR.2.10 EP 1 and EP 2 that will require hospitals to commit in policy the "key elements" of orientation that must be addressed prior to the employee providing care, treatment or services. Obviously these "key elements" will vary for each job description. In the Medical Staff chapter, watch out for significant changes that expand the competencies to be considered in practitioner evaluations at appointment and reappointment, and emphasize continuing evaluation of professional practice.

Finally, JCAHO has released two new National Patient Safety Goals and one modification to an existing NPSG for hospitals along with a raft of subtle and not-so-subtle changes in the NPSG "Implementation Expectations." The new goals may be found at www.jointcommission.org and the 2007 NPSG Implementation Expectations at www.jointcommission.org. These changes and updates were also published in the July 2006 issue of JCAHO Perspectives and carry an effective date of January 1, 2007.

In this new release for 2007, JCAHO aims to describe the requirements and implementation expectations of each goal with greater clarity. Rationale statements have been added to most goals and the goals have been reformatted to resemble EPs found with standards throughout the rest of the accreditation manual. With this change, the goals will now be scored as "A" or "C" elements of performance with interesting implications. For instance, in the past, compliance with a goal was scored as an all or none; all were treated as if they were "A" elements (though some, e.g. dangerous abbreviation use, allowed clarification through audit). A single failure to address a requirement of a safety goal was sufficient for a finding noncompliance. Now, with many goals scored as a "C" EP, a rate of 80% compliance may be sufficient to avoid a finding and be scored in compliance. Finally, just as with the standards, a failure to adequately address a goal will now result in a Requirement For Improvement (RFI) and subsequent Evidence of Standards Compliance (ESC) report with some ESC reports requiring a Measure Of Success (MOS).
Our analysis of the 2007 NPSG Implementation Expectations, along with conversations we have had with JCAHO representative, lead us to conclude there will be further modification to the Implementation Expectations between now and January 1, but it none the less behooves organizations to compare and contrast processes in place to address the goals against these newly-stated expectations and identify any gaps in your NPSG plan design or performance.

Speaking on behalf of my colleagues at The Greeley Company, we would be happy to assist you in fine tuning your response to these changes and crafting specific policies and processes to fit your organization. It may also be time to schedule an Unannounced Compliance Test-Run visit by one of The Greeley Company mock survey teams. For more information, please call our Practice Manager, Sandi Reen at 888-749-3054.

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