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Accreditation Process Circa 2004

INTRODUCTION
In 1999 the Joint Commission issued a white paper entitled "The Possible Accreditation Process Circa 2003".  In that communication, the vision for a possible future accreditation process was set forth.  Fundamental to the future vision was enhancing the "credibility and relevance of the accreditation process in changing times."  In addition, emphasis was placed on creation of a model that is more data-driven, less predictable and more customized to the individual organization."  The 1999 vision also determined to "address growing concerns by accredited organizations regarding the value of Joint Commission accreditation, as judged by a cost benefit analysis."  To that end, it was suggested that the redesigned accreditation process should:

  • Increase the real and perceived value for accredited organizations.
  • Cause the public to have greater confidence that organizations are in compliance with standards at all times.
  • Be acceptable to deeming authorities and purchasers.
  • Decrease costs to accredited organizations.
  • Decrease costs to the Joint Commission.
  • Increase customer and staff satisfaction.

Support the perception among accredited organizations that accreditation is more of a service than a commodity.

The original white paper proposed the development, testing and evaluation of an operational model that would meet the goals set out by the vision and its guiding principles.   The purpose of this paper is to summarize the progress made in this regard and describe a new accreditation model, to be launched in 2004, that embodies the attributes and potential benefits defined in the original white paper.

ENHANCING VALUE – A DESIGN AND DELIVERY CHALLENGE
Value enhancements should involve both an increase in benefits and a decrease in costs of accreditation.  With this in mind, the new accreditation process has been designed to:

  • Assure the relevancy of the standards and the survey process to critical patient safety and quality issues.
  • Focus the survey on organization-specific critical processes and systems as opposed to rote assessment of standards compliance.
  • Develop and apply new surveyor skills in organizational systems analysis.
  • Improve the inter-rater reliability (consistency) of surveyors.
  • Enhance the consultative and educative aspects of the survey, including the dissemination of best practices.
  • Engage accredited organizations on a more continuous basis to promote operational action of the standards and elimination of unnecessary "ramp-up" activities and costs prior to survey. 
  • Provide a more efficient, non-duplicative survey process for complex organizations (to replace the current Tailored Survey Process).
  • Incorporate the use of technology to improve the ease and efficiency of interaction with the Joint Commission.

Let us now review the components of the future accreditation process and link them to the described value enhancements.  Certain accreditation process revisions and enhancements will be introduced in 2002; all will be in place by the conclusion of 2004.

THE FUTURE ACCREDITATION PROCESS

  1. Application and Scheduling Process

    Starting in 2001, all accredited organizations were assigned a designated account representative.  This individual, working with a team, has become the single point of contact for the accredited or applicant organization for all activities related to the accreditation process.  In addition, starting in 2002 and extending into 2004, all accredited organizations will be given password-protected access to a secure extranet site for the conduct of e-business with the Joint Commission.  From that site, organizations can request (apply for) a survey electronically.  After the initial data entry, all application fields will remain populated and require only periodic modification by the accredited organization in order to keep the information current, thus easing reapplication in the future.  Beginning in 2004, upon electronic submission of the application, the organization will be shown a customized listing of standards for which it is responsible as a function of the types of care settings and services delineated in its application.  Survey schedule dates and agendas will be negotiated electronically, if desired, and information exchanges such as reports, sentinel events, written progress reports, and other similar transactions will be able to be handled electronically.

  2. Streamlining of Standards

    In an effort to reduce any unnecessary documentation burden, the Joint Commission has engaged The Standards Review Task Force, which was convened last summer, will complete the final recommendations, identify numerous standards for deletion and consolidation and suggest the reorganization of other standards.  The recommendations will shortly begin to wend their way through the Joint Commission's usual process, but most are likely to be adopted in the end.  In addition, a new format for displaying standards has been adopted.  Under this new format, the standards will, for the first time, list the elements of performance that are the subject of evaluation by the surveyors in order to determine compliance.  Thus, the objectivity and consistency of the survey process will be greatly enhanced since organizations will know precisely what surveyors will be looking to establish compliance with individual standards.  Implementation of all of these planned changes will occur with the 2004 year.  Overall, this standards streamlining activity will increase the actual and perceived relevancy of the standards to critical areas of patient safety and quality while also providing greater efficiency, objectivity, and consistency in the survey process.

  3. Self-Assessment

    In order to free up time during the on-site survey – both to focus on critical performance areas and provide practical consultative support – a new self-assessment process will be introduced in 2004.   This self-assessment will be against all standards for which the organization is accountable.  Completion will be expected by the 18-month point in the organization's triennial cycle and the organization will be asked to attest to level of compliance with the standards.  In any area where the organization has down-scored itself, the actions taken or to be taken to come into compliance are to be included in a Statement of Correction that is to be submitted to the Joint Commission.  A Joint Commission surveyor or staff person will then participate in a telephone review of the Statement of Correction with the organization and provide assistance where needed.  At that point, no further activity will occur until the 36-month survey, at which time the surveyors will evaluate whether or not the Statement of Correction has been properly carried out.  The self-assessment activity will not lead to any change in accreditation score or status for the organization at the 18-month milestone.  At the time of the 36-month survey, there will be a validation exercise covering all standards involved in the Statement of Correction and a random sample of other standards.  The organization's scoring for all other standards will be accepted as is.

  4. A New Survey Agenda

    The incorporation of self-assessment into the accreditation process will permit the creation of a new survey agenda that will have four basic components.

    • Specific time slots devoted to in-depth discussion and consultation regarding patient safety, the use of data in performance improvement (as in core measure performance and the analysis of staffing), emergency preparedness, and/or other topics that become relevant over time.
    • The validation of the self-assessed process, as above.
    • An opening and closing conference plus a leadership interview.
    • Use of actual patients as the framework for assessing compliance with selected standards.   This so-called tracer methodology will involve the selection of charts at random by the surveyors at the beginning of the survey, followed by a series of visits to units, sites or departments in the exact sequence experienced by the patient chosen.  Staff in the various units will be interviewed with regard to specifics pertaining to the care of the patient under consideration, and relevant standards will be surveyed as applicable to the particular case.  Guiding these activities will be pre-survey data collected and interpreted by a web-based application known as the priority focus tool, which is described below.

  5. Priority Focus Process

    By 2004, the Joint Commission will have completed development and testing of a priority focus tool.  This is a web-based application capable of integrating data from a variety of sources and recommending areas of priority focus for the on-site survey in relationship to critical processes.  Data such as prior accreditation history and recommendations, intra-cycle survey findings, complaint history, sentinel event data, ORYX core measure data, state agency communications, self-assessment data, and publicly available Medpar data, at a minimum will be entered.  The priority focus application will analyze the data using defined rules and algorithms that will be made available to all accredited organizations.  The output of the process will be a series of priority critical processes in a given organization as well as a demographic description of services provided and populations served.  The latter will provide a framework for the selection of records during the on-site survey.  This process will do much to individualize the survey process and make it more relevant to a given organization.   It should also virtually eliminate any bias or habit.  Any organizations having the same profile will have a consistent and predictable set of priority focus areas that correlate with the most important aspects of safety and quality in the organization.

  6. Decision and Performance Reports

    By 2005, and possibly by 2004, the Accreditation Decision Report and Performance Report framework will be one and the same.  The categories of performance to which standards are aggregated will be revised to become more meaningful and relevant to important areas of quality and safety.  The linking of existing standards to the new performance categories will be cross-walked in the new standards manuals and be transparent to all accredited organizations.

  7. New Approach to Complex Organizations (Tailored Survey Process)

    An integrated survey process which eliminates redundancy and duplication of effort will be available by 2004 for application in those organizations currently surveyed under more than one accreditation manual.   Common standards which apply to multiple programs (e.g., Hospital, Home Care, Long Term Care) will be surveyed only once by generalist surveyors at a single setting.  Specialty standards applicable only to an individual program will be surveyed by specialist surveyors, and the entire survey will occur at the same time.  The efficiencies derived from this approach will allow a shrinkage of the total number of surveyor hours/days needed to survey a complex organization and the resultant savings will be passed on to the customer.  In addition, a new and significantly more efficient approach to long term care survey will be offered in recognition of the fact that long term care organizations must undergo an annual state evaluation regardless of their accreditation status.

SURVEYOR DEVELOPMENT
Skill building and maintenance within the surveyor cadre is the key to realizing the potential benefits of the new survey design.  Understanding organization systems analysis flows from understanding how to "connect the dots" of standards compliance deficiencies into a credible picture of underlying systems vulnerabilities.  Communicating this to the organization is the art form that results in truly valuable information for the CEO and his/her staff.  Since analysis is dependent on a thorough and credible evaluation, enhancing the skills of surveyors in flexible yet consistent and accurate standards compliance interpretation is also critical.  To achieve these goals in surveyor development and consistency, the following initiatives are being undertaken.

  1. Surveyor Certification

    In January 2002, all surveyors were required to complete the first-ever surveyor certification examination.  The Joint Commission is the first and only accrediting body to certify its surveyors by this methodology.  The examination was prepared in conjunction with a national organization expert in the development of standardized tests.  Surveyors are required to successfully complete the examination in order to survey for the Joint Commission.  Surveyors who fail the exam cannot be the surveyor of record in any organization and must undergo a remedial program of study and preceptorship until they successfully complete the exam.  Any surveyor unable to do so within three attempts, will no longer be eligible to survey for the Joint Commission.  Subsequent to the general certification exam, each surveyor will also take a program-specific certification examination. The first of these examinations will be administered in January 2003.  All surveyors will be required to re-certify at five-year intervals.

  2. Formal Training In Organizational System Analysis

    At the 2003 Surveyor Conference, and in an ongoing distance-learning curriculum for the entire year 2003, surveyors will receive specific education and testing in systems theory, organization behavior, and evaluation techniques under a program administered by a major graduate school of management.

  3. Observation

    Starting in 2002, surveyor supervisors and mentors will observe surveys for the purpose of on-site evaluation and support of surveyor skill development.  This effort will continue and expand in the future as appropriate.

  4. Measurement and Feedback

    Starting in 2002, the following data sets are being aggregated and reported to surveyors and their supervisors for the purpose of surveyor development.

    • The profile of each surveyor with regard to recommendations given by standard and by score, with comparisons to the means.
    • Aggregate data with regard to surveyor performance reported by each surveyed organization on each surveyor in the evaluation completed after each survey. 
    • Aggregate data with regard to successful revision requests by surveyed organizations as a percent of total reports.   Tracking these data by surveyor and in the aggregate creates another quality control mechanism and permits identification of areas for future surveyor development.

  5. FAQs and Clarifications

    Starting in 2001 and continuing into the future, the Joint Commission has posted a growing list of frequently asked questions and standards clarifications on the Internet that is available to all.  These focus on standards compliance issues for which there has been confusion or variable interpretation in the past, and define the specific interpretation so that debate on the subject is eliminated and surveyor variability or inconsistency is minimized.

CONCLUSION
Since 1999, the Joint Commission has devoted much effort to listening to the field and to addressing all key areas where accredited organizations have identified opportunities for improvement.  The redesigned accreditation process and its effective management and operation should go a long way towards increasing benefits and controlling costs.  The new design targets enhancements in relevancy, consistency, focus, and meaningful consultation during the on-site process and the accreditation process as a whole.  It does so without increasing survey length and provides for selected reductions in costs.  The launch of these innovations over the next two years is viewed by the Joint Commission as a further milestone in the continuous improvement of the accreditation process.  These efforts reflect an on-going commitment to make accreditation more of a service than a commodity and to increase its value to all stakeholders.