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Prepare now for changes in 2004: The JCAHO's self-assessment tool

Ambulatory Safety Monitor, January 2, 2003

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Organizations will fix their own problems with the JCAHO's new Web-based assessment program. The self-assessment guides you through all of the standards by asking you questions in various areas related to care. For example, one question the tool asks is, "The essential information needed to determine an individual's eligibility for acceptance for care, services, and setting is defined." You enter responses such as "always," "usually," and "sometimes."

Organizations will undergo this exercise 18 months into the triennial cycle, and will then send their own correction plan to the JCAHO, based on the results of their self-assessment. The JCAHO will then help you tweak your plan as needed, and approve it when it is acceptible. This process will not affect your survey score. At 36 months, the JCAHO will check your progress and score you.

Ambulatory organizations, and other JCAHO-accredited facilities, will receive the self-assessment software by the fourth quarter of 2003.

Note: Although the JCAHO won't require organizations scheduled for survey before July 2005 to submit the self-assessment, they will receive the self-assessment tool software to help them prepare for survey and become familiar with the revised standards, according to the October Perspectives. Also, organizations applying for first-time accreditation will receive the tool for learning purposes. The JCAHO will expect them to complete and submit the self-assessment in its entirety at the 18-month point after a successful initial survey.

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