JCAHO Readiness Program

Accreditation Readiness

Organized and planned accreditation readiness is not easy to manage or sustain. Many hospitals talk about sustainment, but few have been able to make it work effectively. Some have even conducted comprehensive self-assessments but most self-assessments have been less than effective.

Our customized approach outlines a specific plan that includes annual staff standards education and clarification and an in-depth Readiness Evaluation that leads to the basis of the required hospital self assessment, the Periodic Performance Review (PPR). Once the Accreditation Readiness Evaluation is completed, an implementation plan will be developed to assist in completing the PPR. This has proven to save both time and critical resources. A large number of staff can be educated to new standards and interpretations without the cost of time and travel. Our experience has shown that the more the staff knows and understand about the Joint Commission process the easier it is to maintain Accreditation Readiness.

Based upon identified need, selected consultants will visit the hospital to review corrective action plans, determine overall accreditation readiness and focus on “hot spots” highlighted by recent surveyor findings. This program can be customized to each individual hospital based upon size, programs, and identified deficiencies and still be sensitive to the hospital's financial constraints.

An Accreditation Readiness Evaluation report will be given to the hospital on the last day of the consultation. A day is spent going through each identified deficiency, guiding the Joint Commission Preparation Team with education relating to standard interpretation and effective solutions and effective implementation plans. The report format includes: Findings/Recommendation, Priority, Persons Responsible, Date of Completion and Status. This report then can be updated each time the team meets. It instills positive accountability into the readiness program. These updates can then be shared by e-mail with the consultants on a regular basis for review, comment and guidance.

One or more of our consultants will make preplanned visits throughout your survey cycle to assure continual accreditation readiness.

Onsite Tracer Training & Practice

More and more of the survey process is being conducted at the patient care level with the staff rather than Managers and Supervisors. Most interviews have been removed from the survey and it is a trip through the hospital following the patients’ journey. Some departments such as the Emergency Department, Critical Care Units and Radiology are visited 4-5 times during a survey. It is important that your staff understand how this in-depth process works and that they become familiar and comfortable with it.

The training program consists of three phases. Phase I is conducted in the classroom explaining rationally how it works and what the survey team will be looking for. This can be done in large groups. Phase II will consist of actually tracing a patient's journey. This is conducted with a smaller group and each tracer will take approximately one and one-half to two hours. Each attendee will have an opportunity to observe a tracer. Phase III will be for selected staff to actually conduct a tracer journey under the guidance of the consultant(s).

Periodic Performance Review Assistance

Based upon our Survey Readiness Evaluation, the results can become the foundation for your Periodic Performance Review (PPR) because completing the PPR can take much longer to complete than anticipated. This program can save critical staff time and assures that identified deficiencies are reviewed and corrected. We have consultants that have assisted hospitals in completing the PPR and can save your staff many hours of preparation and assure the accuracy of the PPR.

Unannounced Surveys

Our Accreditation Readiness Program is directed at not only stopping last minute preparation, but sustaining your JCAHO readiness program.

MANAGED PROGRAM FOR JCAHO SURVERY READINESS

First Quarter (Two Consultants, Three Days = Six Days)

2006 Standard Education – Split into at least two, two-hour programs to allow more staff to attend the sessions. Problematic standards and high focus standards from 2005 actual surveys will be covered.
Tracer Training Workshop to allow new staff added since last survey to become familiar with the Tracer Methodology. Two hours,
Two full days of Tracer Activities, in all areas, to be conducted by two consultants to cover all high focus problem areas and to identify hospital weaknesses since the 2005 survey relating to the 2006 standards.
Work with a team or Senior Management to develop and implement a Command Center approach to how the hospital will react, documents to have available, backup of key staff and appropriate Managers and Staff.
Develop written 2006 action plan relating to identified deficiencies.
Meet with selected staff to review specifically the Medical Staff Peer Review Process.
Evaluate Survey Readiness Team

Second Quarter (Two Consultants, Three Days = Six Days)

Follow-up the implementation of the corrective action plan developed in the first quarter.
Tracer Activities based upon continuing information received from the Joint Commission and consultant Surveyor contacts related to new standard changes, interpretations, and high focus problem areas being identified during actual 2006 surveys.
Incorporate into the consultation requests from the hospital.

Third Quarter (Two Consultants, Three Days = Six Days)

Continue to monitor compliance.
Tracer Activities based upon continuing information received from the Joint Commission and consultant Surveyor contacts related to new standard changes, interpretations, and high focus problem areas being identified during actual 2006 surveys.
Tracer Training Workshop to allow new staff added since last survey to become familiar with the Tracer Methodology.
Incorporate into the consultation requests from the hospital

Fourth Quarter (Two Consultants, Three Days = Six Days)

Continue to monitor compliance.
Tracer Activities based upon continuing information received from the Joint Commission and consultant Surveyor contacts related to new standard changes, interpretations, and high focus problem areas being identified during actual 2006 surveys.
Incorporate into the consultation requests from the hospital.

Year Two & Year Three

At the end of each year the consultants and the hospital will meet to develop the quarterly agenda for the following year. Year three will include a full unannounced Accreditation Readiness Review.

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