Transcript Critical access hospital accreditation

CRITICAL ACCESS
HOSPITAL ACCREDITATION
Fall 2002 Teleconference
Presentation
Critical Access Hospital Standards
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JCAHO Contacts
 Kurt Patton, Executive Director, Accreditation
Operations (630)792-5810;
[email protected]
 Meg Gravesmill, Accreditation Operations
(630) 792-5813; [email protected]
 Laura Smith, Standards Development,
(630) 792-5098; [email protected]
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JCAHO contacts
 Darlene Christiansen, Survey Process,
(630) 792-5273; [email protected]
 Phavinee Thongkhong-Park, Survey Process,
(630) 792-5984; [email protected]
 Mark Schario, Surveyor Management,
(630) 792-5706; [email protected]
 Frank Zibrat, ORYX
(630) 792-5992; [email protected]
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PRESENTATION OVERVIEW
 Conceptual framework for the standards
 Standards development process
 Findings from test surveys
 Structure of the Accreditation Manual for CAH
 COP linkages
 Swing bed requirements
 Scoring CAH standards and the survey report
 Capping of supplemental standards
 Conversion from HAP to CAH
 CAH performance measurement (ORYX) requirements
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CAH STANDARDS
DEVELOPMENT
 Reviewed Medicare Conditions of
Participation (COPS) to identify provider
requirements
 Field observations and surveys at CAH’s
 Identified HAP standards and LTC standards
that crosswalk to COPS
 Created first draft and conducted test surveys
and field review.
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CAH ACCREDITATION
 Observations at CAH’s indicate that the level
of complexity and scope of services are more
than might be envisioned by the conditions
alone.
 Challenge was to design a standards manual
and survey process that adequately
evaluates the services, yet is still reasonable
in depth of preparation and cost.
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CAH ACCREDITATION
 Visits to 4 CAH’s for information gathering
 Development of a standards crosswalk
 Draft of a survey process built off small and
rural JCAHO model
 Plan for a process that is less than a 2X2
 Extension surveys at accredited CAH’s
 Testing at 6 CAH’s, accredited and
nonaccredited, in 5 states.
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CONGRUENCE WITH
CONDITIONS OF PARTICIPATION
 JCAHO Hospital survey process designed to assess
compliance with standards in the CAMH.
 JCAHO LTC survey process designed to assess
compliance with standards in the CAMLTC
 Both CAMH and CALTC standards can be cross
walked to Medicare COPS.
 CAH conditions combine features of CAMH and
CAMLTC.
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EXAMPLE OF A STANDARDS
CROSSWALK
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485.608 (a) Compliance with state law and regulation
MA.2 & MA.2.1
485.608 (b)
MA.2 & MA.2.1
485.608 (c)
MA.2 & MA.2.1
485.608 (d)
HR.2
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COPS/STANDARDS CROSS
WALK
 485.608 Condition of participation: Compliance with
Federal, State, and local laws and regulations.
 The CAH and its staff are in compliance with applicable Federal,
State, and local laws and regulations.
 (a) Standard: Compliance with Federal laws and regulations.
The CAH is in compliance with applicable Federal laws and
regulations related to the health and safety of patients.
 (b) Standard: Compliance with State and local laws and
regulations. All patient care services are furnished in
accordance with applicable State and local laws and
regulations.
 (c) Standard: Licensure of CAH. The CAH is licensed in
accordance with applicable Federal, State, and local laws and
regulations.
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COPS/STANDARDS CROSS
WALK
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MA.2 The chief executive officer provides for the hospital’s compliance
with applicable law and regulation and
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MA.2.1 The chief executive officer reviews and promptly responds to
reports and recommendations from planning, regulatory, and inspecting
agencies, as outlined by the governing body.
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Intent of MA.2 and MA.2.1
The hospital's chief executive officer provides for
• the hospital's compliance with applicable law and regulation and
• filing applicable legal documents and copies of the hospital's state
licensure or certification.
The chief executive officer is responsible for implementing governing
body policies. The governing body defines the chief executive officer's
responsibility for acting on reports or recommendations from planning,
regulatory, and inspecting agencies.

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CAH STANDARDS
DEVELOPMENT
 Field review critical of the extensive
supplemental expectations
 Developed “parent” standard and “offspring”
concept, e.g. TX.1, TX.1.1, TX.1.1.1, TX.2
 Added most parent level standard not already
identified through COPS
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CAH STANDARDS
DEVELOPMENT
 Circulated redraft to consultants and email
contacts who had inquired about
accreditation
 Presented to and approved by JCAHO
leadership
 Presented to and approved by JCAHO Board
Committees October 2001
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CAH STANDARDS and the
ACCREDITATION MANUAL
 Chapters and performance areas identical to hospital
manual – standards are different
 Policies, Sentinel events and APRs except ORYX are
identical
 Patient Focused Functions:
 Rights and Organizational ethics (RI)
 Assessment of Patients (PE)
 Care of Patients (TX)
 Education (PF)
 Continuum of care (CC)
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CAH STANDARDS and the
ACCREDITATION MANUAL
 Organization Focused Functions:
 Improving Organization Performance (PI)
 Leadership (LD)
 Management of the Environment (EC)
 Management of Human Resources (HR)
 Management of Information (IM)
 Surveillance, Prevention and Control of Infection
(IC)
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CAH STANDARDS and the
ACCREDITATION MANUAL
 Structures with Functions:
 Governance (GO)
 Management (MA)
 Medical Staff (MS)
 Nursing (NR)
 Glossary
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CAH STANDARDS and the
ACCREDITATION MANUAL
Major Differences
 Fewer standards per functional area
 Standards focus on COPS and major care
principles, less on prescriptive “how to” mandates
 Supplemental (not linked to a COP) standards are
capped at 3
 APR for performance measurement does not
require enrollment in a performance measurement
system
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CAH STANDARDS and the
ACCREDITATION MANUAL
 Major Differences – hard bound manual,
not designed to update 4 x year
 Most, but not all patient safety standards from
HAP were included
 New staffing effectiveness standards from
HAP were not included
 Pharmacist review of medication orders before
the first dose is dispensed is not included
 New Patient Safety Goals do become
effective January 1, 2003
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CAH STANDARDS FORMAT
 Some standards are reviewed in all areas of the
CAH.
 Some standards are only reviewed in the designated
swing bed area
 Some standards have an expanded intent statement
incorporating Medicare COP language
 Some standards link completely to a Medicare COP
 Some standards are JCAHO only and have no link to
Medicare COP’s – called supplemental standards
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EXAMPLE OF A SUPPLEMENTAL
STANDARD
 PE.1 Each patients physical, psychological,
and social status are assessed.
 Not linked to a Medicare COP
 Capped at a 3
 Evaluate in all patient care areas
 Type 1 recommendation will not adversely effect
deeming or conversion
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CAH STANDARDS LINKED TO
COPS AND FULLY MATCHED
 PE.1.3 and PE.1.3.1 – The JCAHO standard
as written in the hospital manual, and now the
CAH manual fully meets the intent of the
COP. No additional federal language needed
to be added to the intent statement.
 Linked to COP 485.635(b)(1)
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CAH STANDARDS LINKED TO
COPS WITH EXPANDED INTENT
STATEMENT
 PE.1.4 – PE.1.4.1.1
 However, some elements of the assessment of a
patient must be performed and documented by all
critical access hospitals and for all patients within
24 hours of admission, even on weekends and
holidays. These elements are:………pulled into
the manual directly from COP language
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CAH STANDARDS EVALUATED
ONLY ON SWING BEDS
 PE.1.4.2 – Each resident’s initial assessment
is completed within the timeframe specified
by organization policy or by law and
regulation, not to exceed 14 days.
 Corresponds to COP 488.20(b)(4)I and iii)
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CAH STANDARDS LINKED TO COPS ON
SWING BED UNITS AND NOT ACUTE UNITS
 RI.1.1.1 – Informed consent is obtained
 Corresponds to COP (d) (2)
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NEW CAH SURVEY TYPE
 Conversion Survey – this will be scheduled
when a hospital is authorized by the state
Office of Rural Health to convert to CAH
status. At the completion of the conversion
survey JCAHO will notify CMS that the
hospital has successfully passed the survey
and may be designated a CAH.
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CONVERSION SURVEYS
 Most hospitals (almost 700) that were going
to become a CAH have already gone through
the conversion process.
 The hospital seeking to convert must be
authorized to convert by the State.
 After the survey is completed, the hospital
may obtain a new Medicare provider number
as a CAH.
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CONVERSION SURVEYS
 At the conclusion of the survey a conversion
will not be approved if there are any type 1
recommendations against a COP standard.
 COP standards are marked in the
accreditation manual and report. These
standards can be scored a 5.
 All non COP standards are capped at 3.
 The surveyor must tell the CAH about any
type 1’s in COP linked standards
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CONVERSION SURVEYS
 The CAH must immediately prepare a 1
month WPR to clear any type 1’s against a
COP linked standard.
 The surveyor must tell the organization which
standards require an immediate response
 The organization is not approved as a CAH
until their clear the 1 month WPR
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CONVERSION SURVEYS
 At the time of the survey the CAH may not already
have swing beds, as they may not be authorized to
have swing beds until they are a CAH.
 A track record of compliance cannot be evaluated for
swing bed requirements in this case.
 Federal requirements mandate a one year full follow
up survey always be conducted after a conversion
survey.
 Resurvey due date is calculated off the first survey
 Convert 2002, 1 year survey 2003, no survey 2004, resurvey
2005
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CAH PRELIMINARY
REPORT
Critical access hospital accreditation
does not have the usual laptop support
at this time. A word based survey
report form has been created.
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CAH SURVEY REPORTS
 Central office staff will prepare a final survey
report and grid and mail it to the organization.
 If this is a conversion survey, at the time of
the exit conference, the surveyor will inform
the organization of any type I
recommendations.
 If this is the first CAH accreditation survey,
and the organization previously converted
through a state survey, type 1’s do not block
deemed status.
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CONVERSION FROM HAP
TO CAH
 Currently accredited and become a CAH –
notify the Joint Commission
 When next due for survey we will use the
CAH manual, not the CAMH
 No extension survey needed given the scope
of the CAMH survey
 The CAH program will be an initial survey
with a 4 month track record
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MIDSTREAM SEMI CONVERSIONS?
 Some critical access hospitals have
completed their conversion survey with the
state while accredited by JCAHO as a
hospital.
 These CAH’s may be due for 1 year state
follow-up survey
 If due for JCAHO survey, JCAHO will
schedule as a CAH and coordinate timing to
substitute for 1 year state follow-up if
possible.
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ADDITIONAL CENTRAL
OFFICE PROCESSES
 JCAHO will send reports to CMS central,
regional and state offices as needed
 Central office will prepare the grid and score
 Central office will tickler the 1 year follow-up if
needed
 Central office will coordinate with the state
office of rural health
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EARLY SURVEY OPTIONS
 ESO1- 2 surveys, the first results in PROVISIONAL
ACCREDITATION – Not deemed
 Use ESO1 if very unfamiliar with JCAHO
 ESO2 – 2 surveys, the first results in
ACCREDITATION. No track record assessed on the
first survey
 Conversion survey must have a 1 year full follow-up
 All surveys are assessed the fee
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CAH ORYX
REQUIREMENTS
ORYX-related APR
 Requires the use of a minimum of 6 performance measures per
applicable accreditation program
 NO REQUIREMENT to contract with a performance
measurement system and transmit measure data to the Joint
Commission
 For initial survey
 Provide surveyors with list of selected measures
 No data collection/analysis required
 For all subsequent surveys
 Share evidence of data collection and analysis and any
performance improvement activities that may have resulted
with the surveyors at time of survey
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CAH ORYX & CORE
MEASURES
REQUIREMENTS
 A CAH may use core measures if applicable
 Survey process for PI will include an
assessment of the measure selection
process, roles of leadership and medical staff,
use of data to manage care, display of data
and change activities
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SUMMARY OF SURVEY
FINDINGS
 55 organizations scheduled for survey
through 12/31/02
 Majority of organizations were previously
accredited by JCAHO.
 34 organizations have received their findings;
average grid score was 95.
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COMMON TYPE I
RECOMMENDATIONS
 HR.5* (staff meeting performance expectations in job
description)
 LD.1.3.2 (MS approves sources of patient care
provided outside the CAH)
 PE.1.2* (pain is assessed in all patients)
 TX.3.3 (controlled prep and dispensing of
medications)
 IM.7.7*(medical record entry dated, author identified,
and when necessary, authenticated.)
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COMMON SUPPLEMENTAL
RECOMMENDATIONS
 IC.4 (CAH takes actions to prevent or reduce
nosocomial infections)
 EC.1.5.1 (Life safety code)
 IM.7.7* (medical record entry dated, author
identified, and when necessary,
authenticated.)
 HR.5* (staff meeting performance
expectations in job description)
 PE.1.2 *(pain is assessed in all patients)
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QUESTIONS OR
SUGGESTIONS FROM
TODAY’S PARTICIPANTS
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