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The hospital JCAHO Prep Team |
Working Together on Accreditation
JCAHO Prep Team honored with Teamwork Award
When Duke University Hospital last year faced a regulatory crisis involving two national accreditation agencies, the hospital's Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Prep Team had the prime responsibility for directing the hospital's response to the agencies' findings.
The stakes were important. Following a mismatched transplant involving Jesica Santillan, the hospital was under heightened scrutiny from JCAHO and the Centers for Medicare and Medicaid Services (CMS). Failure to respond to these agencies' concerns could lead to Duke losing federal reimbursement money for care of Medicaid and Medicare patients.
"We were profoundly affected as a team and as a hospital by the transplant event," said prep team member Anita Adams, clinical operations director of perioperative services. "Because we are so safety conscious, the fact that something like that could and did happen was devastating."
The JCAHO Prep Team was able to successfully lead the hospital's efforts to demonstrate full compliance with accreditation standards and regulations. This allowed the hospital to maintain its accreditation status with all regulatory agencies.
For its work, the prep team was honored this month with Duke's Teamwork Award, given to employees who work across university units to solve critical issues.
"Sixty percent of our patients are Medicare or Medicaid patients," Adams said, "so accreditation is a huge issue for us
Following the 2003 crisis, the JCAHO Prep Team next had to turn its attention to preparations for the triennial JCAHO accreditation survey. The preparations were different from previous years; as of January 2004 the standards and the survey process substantially changed. Directing the preparations without knowledge of the process proved challenging and required extensive collaboration within the team and throughout the hospital.
JCAHO's new survey process involves the tracer methodology. Under this approach, a patient is identified and followed throughout the organization. As the patient's experience is ‘traced' the surveyor evaluates the hospital's compliance with the applicable accreditation standards.
To help prepare the hospital staff and physicians for this new experience, the JCAHO Prep Team members conducted weekly practice tracers to familiarize hospital staff with this new process. Team member Wayne Thomann, an assistant clinical professor who is also the hospital's safety officer and director of occupational and environmental safety, said the teams focused on areas where gaps in compliance were noted and helped areas improve their performance. "We didn't impose solutions," Thomann said. "We worked with individuals to identify creative approaches to meet the needs of our patients while demonstrating compliance to standards."
The JCAHO Prep Team's efforts paid off with a successful survey rating. The surveyors left without finding significant problems, Adams said. "That's phenomenal in a place of our size."
As the JCAHO continues to change its survey approach, the JCAHO Prep Team's approach changes as well. In 2006, the triennial surveys will become unannounced.
To prepare, JCAHO Prep Team members will conduct its own periodic unannounced tracers. The tracers will be used to educate staff on the survey process and the standards. "Different JCAHO Prep Team members participate in the tracers assessing adherence to the standards. It is really a team effort," said Thomann.
The work of the JCAHO Prep Team continues throughout the year as they perform assessments, respond to new or revised standards and regulations, educate staff and physicians on the expectations and engage in activities that foster continual readiness for accreditation and regulatory visits.
"It is wonderful to be part of such an effective team. We come from departments located throughout the hospital but work well together for a common goal," said Adams. Thomann added, "We are confident that if we are happy with our performance as a hospital, then JCAHO and CMS will be pleased when they visit us."
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