Tips on Getting Ready to Welcome the JCAHO

Tips on Getting Ready to Welcome the JCAHO

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Tips on Getting Ready to Welcome the JCAHO

HI 9/18/001

You’ll know the time is near if you walk past the health information management (HIM) department and see a frantic look on the HIM director’s face. It’s probably coming up if you witness a doctor being chased down a hospital corridor by an HIM supervisor armed with a pen and a clipboard. And it’s definitely time for a survey by the Joint Commission on Accreditation of Healthcare Organizations when the hospital bulletin board bears the salutation, “Welcome Joint Commission Surveyors.” Of course, for HIM professionals, knowing some of the survey trouble spots in meeting information management (IM) standards gives them an advantage, helping the facility avoid potential deficiency citations known as Type I violations that require corrective action to maintain accreditation.

The Trouble Spots
Preparing for the on-site, triennial Joint Commission survey involves more than just sweeping up in the medical records department and making sure all of the files are there. “It’s a tall order, because the management of information chapter involves all of the documentation that is required in the record,” said Pat Staten, MA, RN, associate director at the Joint Commission. “It involves policies and procedures surrounding confidentiality of that record and who has access to that record.” One of the main components surrounding this concept is found in IM.3.2.1, the standard that requires specific data collection.

According to the Joint Commission, Staten explained, IM.3.2.1 directly affects patient care. “IM.3.2.1 requires medical records to be reviewed on an ongoing basis for completeness and timeliness of information.” Staten emphasized that it is an “ongoing process” involving “various disciplines” within the organization.

Keith Olenik, MA, RHIA, systems director of HIM at St. Luke’s Shawnee Mission Health System in Kansas City, MO, is well aware of the requirements this standard entails. “The biggest issue we deal with is incomplete records,” said Olenik. “If it was just a matter of the HIM staff working harder, we could do that, but we’re reliant on physicians for information.” Olenik has witnessed many approaches to this problem, from chasing doctors down the hall to issuing memos noting the information needed. “We try to be proactive in our approach to the incomplete record process,” he explained. “I don’t want to be critical of [physicians]. They are busy. They have their own priorities and, quite frankly, documentation is just not one of them.”

Steve Bryant, practice director for accreditation and regulation compliance at the Greeley Company in Marblehead, MA, often sees this dilemma in his role as consultant to HIM directors preparing for Joint Commission surveys. Emphasizing what Staten referred to as cooperation from “various disciplines,” Bryant said, “HIM professionals complying with IM standards are required to do a concurrent review, but the standard also says that this review is multidisciplinary and collaborative in nature.” As he explained, “The IM standards hold the HIM department accountable, but the reality is, without a collaborative approach, the hospital is vulnerable here.” According to Bryant, “The medical staff, nursing, rehabilitation, nutritional services and social services should all participate in the review process.”

I.M.7 Standards–the Clinical Components
Staten described the IM.7 standards as, “Standards that talk about all the clinical components required to be in each medical record.” This is another area that can prove tricky for HIM departments.

IM.7.7 is the standard that requires the signing of verbal orders. In addition to handling triennial surveys for the Missouri facility, Olenik is in charge of the process at three facilities in Kansas. As Olenik explained, “Kansas law requires that verbal orders are signed within 24 hours.” Because Joint Commission standards piggyback state law, accreditation hinges on this stringent requirement, and Kansas is not alone. “I know a lot of hospitals subject to the 24-hour requirement,” Olenik noted. “They have to jump through hoops to comply.”

Bryant recognized this difficulty, adding, “Some physicians who cover weekend shifts may not be back for a week.” By allowing colleagues to authenticate an order, as Bryant suggested, “Hospitals believe that it’s more important to validate the order than to have a prescriber do it 14 days later.” This course of action may raise compliance concerns with Health Care Financing Administration (HCFA) requirements, but as Bryant explained, “The rationale for that decision would be justified because patient care is what matters here.”

Another tip Bryant gives in complying with this standard is for hospitals to develop what he called “aggressive strategies” to reduce the amount of verbal orders. Bryant knows of hospitals that have restricted verbal orders to telephone orders, limiting exceptions to the operating room and the emergency room.

Whatever the solution, Bryant suggested involving physicians in the policy making process. “Whether it’s a protocol to allow colleagues to authenticate or an education program to reduce verbal orders, Bryant stressed, “Physicians who participate in developing a solution, buy into that solution.”

Guess Who’s at the Door
“Survey readiness is being prepared at any given time,” said Staten. “You’re giving quality care throughout the year, not just when the Joint Commission comes.” This is the thinking behind the Joint Commission’s January 1 implementation of the new unannounced survey policy, stating that no advance notice will be given prior to a random survey. In addition, the window of time during which surveys can occur has been widened, and surveys can now occur nine to 30 months following the organization’s triennial survey.

Scary as this may sound, Bryant claims that random surveys don’t pose the largest threat to facilities. “The random survey process only affects 5 percent of accredited hospitals.” On the other hand, Bryant said, “Joint Commission is contemplating moving the survey cycle to 18 months across the board.” In addition, “they will want data submitted to them on a regular basis, and part of that data certainly would include medical records statistics.”

As Olenik speculated, this could prove problematic for some facilities that “let some things slide,” knowing that surveyors look at the 12 months preceding the survey, essentially leaving two years following the survey unchecked.

Dealing with Surveyors
Based on the intent statements the Joint Commission supplies for each standard, Olenik believes the examples give clear ideas of what each standard means. And yet, “Each surveyor is different and they all have their own little spin on the standards,” he observed.

“I have seven Joint Commission surveys I go through every three years, and every surveyor is different.”

Bryant’s advice to HIM professionals dealing with fastidious or misinformed surveyors is to remember, “Surveyors are human beings. They have their biases and their opinions.” If it’s evident that the surveyor’s objectivity is skewed, Bryant tells clients, “Your best defense is to know those IM standards, and if need be, educate the surveyor as necessary.”

Olenik agrees. “You really need to question the surveyors if you know something is incorrect or being misinterpreted,” he said. Communication appears to be the key component, and as Olenik stressed, “If you explain how you are in compliance, you might be able to make a change and avoid a deficiency or a Type I.”

Linda Gross is an editorial assistant with ADVANCE.

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