ENTERPRISE RISK MANAGEMENT

Facing the winds of change in Joint Commission survey process

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By Susan McLaughlin

INTRODUCTION

Hurricanes Katrina and Wilma last fall not only caught theattention of the nation, but of the Joint Commission onAccreditation of Healthcare Organizations (JCAHO). This

year brings an increased emphasis on emergency managementalong with the onset of the totally unannounced survey process.

Changes and new elementsIn the standards themselves, there have been only a few minor language changes that are essentially “wordsmithing” in nature. For example, there are several instances where the word “facility”has been replaced with “building.” This year brings no changes at all to the scoring categories for the elements of performance or their measures of success (MOS) designations.

Effective July 1, 2006, there is a revised standard at E.C.4.20,Emergency Drills. The field review for this standard was put out forpublic comment before the major hurricanes, but their occurrenceserves to emphasize its importance. Language has been revised toclarify that if an organization uses a tabletop drill for a communityexercise (the only time a tabletop drill may be used for JCAHO purposes), two other “live” drills must be held during the year.

The time requirement of “at least four months, but no morethan eight months apart” has been removed to allow organizationsto more easily participate in community exercises and to use documented actual events toward the requirements.

There will be new elements of performance under the category“Scope of Exercises.” These are intended to strengthen an organization’semergency drills by requiring that realistic scenarios are used thatare derived from the hazard vulnerability analysis and that trulystress the system. An identified observer, who does not otherwiseparticipate in the drill, must be in place. Four core performanceareas must be monitored: 1) event notification, 2) communicationeffectiveness, 3) resource mobilization and 4) patient management.

Exercise critiques must be conducted, as has been the case, butthe process will have to be multidisciplinary to include administration,clinical representatives (including physicians) and support staff.Action is expected to be taken based on the critiques, and improvementsmonitored during the next drill. The critiques must be reportedback to the environment of care committee.

Unannounced surveysWith the survey process going to an unannounced format, a changeto the Periodic Performance Review (PPR) cycle was required; whenone doesn’t know when the survey will take place, it is impossibleto determine a mid-cycle point. Therefore, starting this year, anannual PPR (including the Plan for Improvement portion of theStatement of Conditions) is required and will be due at the anniversarydate of the organization’s previous triennial survey. If the unannouncedsurvey takes place within six months prior to the PPR due date, the PPR date will be adjusted.

Both parts II (Basic Building Information, or BBI) and IV(Plan for Improvement, or PFI) of the Statement of Conditions arenow available in electronic format. These are optional for use now,but must be used as of Jan. 1, 2007.

Annual submission of the PPR will include plans of action fornoncompliant standards along with any relevant MOS. The conferencecall with JCAHO staff will be optional. However, upon review of anorganization’s documents, JCAHO can initiate the request for a callif it is deemed necessary. Note that surveyors will validate the MOSdata at the time of the following on-site survey.

In the years 2006 through 2008, organizations can expect toreceive their unannounced survey during the year that they wouldnormally receive a triennial survey. Starting in 2009, surveys will beperformed by JCAHO between 18 and 39 months after the previoustriennial, increasing the unannounced aspect. The average surveyinterval will remain at 36 months.

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Because of the unannounced nature of the survey, it is essential that organizations develop breadth and depth of knowledge.

On the date of the unannounced survey, health care organizationswill receive an early morning e-mail notification directing them tothe “Jayco” extranet site, which can be linked to through the homepage at www.jcaho.org, to view surveyor biographies and credentials.Due to a number of surveyor impostors attempting to gain hospitalaccess during the past year, it is critical to check surveyor identifi-cation and credentials when they present themselves on site. Theywill carry a letter of introduction from the executive vice presidentof accreditation operations. Failure to make the appropriate verifi-cation can result in recommendations at EC.2.10.

Because of the unannounced nature of the survey, it is essentialthat organizations develop breadth and depth of knowledge. Oneindividual, for example, cannot be the sole holder of environmentof care expertise. Individuals must be trained to be competentbackups in the event that the primary person is unavailable at thetime of the survey.

LSC specialists

The Life Safety Code (LSC) specialist process is remaining constant.The specialists continue to survey in hospitals of 200 or more bedswith their scope limited to:

• EC.5.20, Life Safety Code compliance;

• EC.5.40, Maintenance, testing, and inspection of features of fire protection;

• EC.5.50, Interim life safety measures;

• EC.7.40, Maintenance of emergency power systems; and

• EC.7.50, Maintenance of medical gas and vacuum systems.

The LSC specialists report to the rest of the survey team any otherEC issues or problems that they identify, although they will not beresponsible for the scoring outside of the above scope.

Emergency management implicationsThe EC interview session will consist of about 30 percent surveyor-facilitated discussion about the seven environment of care areas,along with construction issues. The attendees at this meeting must beable to speak to all topics, and should include the person primarilyresponsible for emergency management along with organizationalleadership.

The remaining 70 percent will be spent doing an “EC observation,”or tracer. It is in this latter area that the greatest impact of theemergency management emphasis will be felt. In hospitals of 200or more beds, this exercise will begin in the incident commandcenter and include those individuals who would be based thereduring an actual emergency.

Questions about the structure and function of the commandcenter will be asked. Based on the organization’s hazard vulnerabilityanalysis, a scenario will be chosen for further evaluation. The surveyorwill describe the scenario and get the organization’s response to themanagement of key issues resulting from the scenario. Then theseleadership responses will be verified with staff members in keyroles. This will not only test the organization’s preparedness, but also the integration of emergency practices throughout.

This entire activity is anticipated to take between one and fourhours. In smaller hospitals, the EC observation will be incorporatedwith another tracer activity.

There will still be a tracer involved with infection control. Inlarger hospitals this will be a separate activity, but it will be includedin a patient tracer for smaller facilities. In addition to the clinicalstaff, facilities managers will also participate. Surveyors will beinterested in recent or ongoing changes to the physical facility with potential infection control impact, and this becomes a goodopportunity to present a case study involving preconstruction riskassessment (or infection control risk assessment).

Standards of complianceFollowing the on-site survey, health care organizations are requiredto submit evidence of standards compliance (ESC) within 45 days(reduced from a 90-day window) for those standards that receivedrecommendations. This evidence will either be corrective, describingwhat the organization has done to come into compliance; or it willbe clarifying, demonstrating that the organization was in complianceat the time of the survey, along with the reason the surveyor did nothave access to this information.

If the ESC is acceptable (and the organization did not receive anadverse accreditation decision), it will be accredited retroactive tothe date of the survey. If it is unacceptable, the organization receivesa designation of provisional accreditation, with another 45 days tosubmit acceptable ESC. It retains that status until acceptable measuresof success are received by JCAHO in four months. UnacceptableMOS can also lead to a requirement for their resubmission andadverse accreditation decisions. If the second ESC is unacceptable,the organization receives conditional accreditation.

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In addition to the above and the violation of an accreditationdecision rule, an organization may also receive either conditionalaccreditation or preliminary denial of accreditation based on thenumber of recommendations for improvement (RFIs). If the num-ber of RFIs is less than two standard deviations from the accredita-tion program mean, the organization will be accredited. A totalbetween two and three standard deviations will result in conditionalaccreditation, and three or more standard deviations will receivepreliminary denial of accreditation.

CONCLUSIONWith the standards themselves remaining constant (with the excep-tion of the mid-2006 changes to EC.4.20), there is much that ischanging for 2006 in the survey process. And, of course, the unan-nounced aspect will demand that we are constantly ready for a sur-veyor visit.

ABOUT THE AUTHORSusan McLaughlin is president of SBM Consulting, Barrington, IL,and a codes and standards consultant for the American Society forHealthcare Engineering.

Edited from Health Facilities Management Magazine, May 2006.Copyright ©2006 Health Forum.