December 22, 2008

Cleaner and Clearer
By Lindsey Getz
For The Record
Vol. 20 No. 26 P. 20

Starting next month, The Joint Commission’s Standards Improvement Initiative introduces several tweaks designed to make the standards less ambiguous.

The Joint Commission’s Standards Improvement Initiative began in October 2006 and is part of the commission’s ongoing quality improvement and patient safety efforts. The initiative’s focus areas include the review and revision of standards, rationales and elements of performance, changes in scoring and the accreditation decision process, and adopting a new look to the various accreditation manuals. While no new standards were added for 2009, the standards and elements of performance were rewritten and a new numbering system was instituted. Because these standards guide the safety and quality of care efforts in more than 15,000 healthcare organizations nationwide, The Joint Commission believes that it must continuously assess its standards to be sure they are relevant in an ever-changing healthcare environment.

These improvements, including both format and language changes, will go into effect in January for phase 1 programs, which include ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. Phase 2 programs (behavioral health, laboratory, and long-term care) will follow suit with improved standards being implemented in 2010. However, the numbering system, changes in the manuals, and the revised scoring method will be instituted for phase 2 programs in January.

“It’s definitely a whole new ball game, but the standards themselves have not been changed,” says Perot Systems’ Kathleen Catalano, RN, JD, who recently presented on the topic at the annual AHIMA conference and exhibition. “The Joint Commission wanted to respond to customer needs and concerns, so it reviewed and improved all standards. That meant clarifying vague language, reorganizing, refining scoring, and deleting standards that were repetitive or unnecessary. Chapters have also been added where they were needed. All of this was a major effort to be certain the standards make sense and are easy to navigate.”

What’s New
The Joint Commission reports that one of the main reasons behind the changes was to improve standards by deleting those that were redundant or not essential, consolidating similar standards, and clarifying the language. In addition, reorganization was centered on program specificity. As has always been the case, The Joint Commission recognizes the differences in program-specific basics. Due to this fact, accreditation manuals for the various programs accredited by the commission are available to account for the dissimilarities in programs such as ambulatory healthcare, behavioral healthcare, hospital, or critical-access hospitals.

“The Joint Commission even went as far as hiring someone with a PhD in English to help them with these revisions,” says Catalano. “They felt that making the standards more clear was the only real way to have the impact needed. And to ensure that there was nothing vague, they used this person to go through all of the wording and make appropriate corrections.”

To rearrange the standards in a method that would make more sense to the user, chapters were reorganized and new ones created. The idea was to add specificity to chapters and pull out standards that were not relevant to the chapter in which they previously appeared. During the review process, The Joint Commission found a lot of repetition among chapters as a result of trying to initially create a systemwide approach to standards. A deletion of redundancy was necessary to keep standards clear.

Still, the commission was able to keep a sense of connectivity by linking various chapters and standards. At the end of a particular chapter or standard, users will be guided to see a related requirement rather than repeating the information. With these changes, the commission believes the manuals will be easier to navigate.

The six new chapters are the following: “Emergency Management,” “Life Safety,” “Transplant Safety,” “Waived Testing,” “Equipment Management for Home Care,” and “Record of Care, Treatment, and Services.” Ideally, the new chapters will make standards easier to find. “The new chapter ‘Record of Care, Treatment, and Services,’ for instance, is where all standards regarding medical record documentation can now be located,” explains Pat Brown of Pyramid Healthcare Solutions and a copresenter with Catalano at the AHIMA conference. “Previously, the standards for medical record documentation were located in various chapters in The Joint Commission manuals, making them hard to find.”

In addition to revised wording and new chapters, beginning in January, there will be two scoring categories rather than the current three, adds Brown. The commission believes this will make the process simpler. “Currently, there are A, B, and C categories,” Brown explains. “After January, there will only be A and C categories for scoring. Frequency-based elements of performance will be scored by the number of times the [elements of performance] are not met.”

Another component of the Standards Improvement Initiative is the development of electronic versions of the comprehensive accreditation manuals. The E-dition, which was recently released by Joint Commission Resources, a not-for-profit affiliate of The Joint Commission, offers HIM professionals a new, time-saving way to access and focus on standards that help improve patient care. It features a profile-filtering tool that allows users to reduce the number of standards and elements of performance displayed to only those that apply to the organization’s services. Users can further filter the display based on additional criteria that reflect particular areas of focus. Other features include the following:

• regular updates to the site that provide users with the most current standards information;

• history tracking (for hospital, critical-access hospital, ambulatory, office-based surgery, and home care programs only), with its side-by-side comparisons, indicates the progression of a standard over time; and

• full text searching to locate standards by particular topics.

All Joint Commission-accredited organizations will receive one free, single-user license to the E-dition for their accredited programs, or they may upgrade to a site license allowing unlimited users or purchase additional single-user licenses.

Survey Preparation
In terms of how these modifications will affect the way healthcare organizations prepare for surveys, there will not be much change, according to Catalano. “I think they will use the same process,” she says. “The only difference would be the fact that the standards have been moved around and reorganized.” A history tracking report for each standards manual chapter is provided on a CD-ROM that is included with all paper manuals and is a feature of the E-dition.

For many, the improvements will simplify the survey process. “The changes should make it easier for organizations to perform their self-assessment and to better measure the quality of care and services provided by organizations,” says Brown.

 The HIM department’s role in the survey process will be to provide delinquent medical records, statistics, and any additional information concerning access, storage, privacy, and security of medical record information as requested by The Joint Commission surveyors during the survey, notes Brown. “It is not common to have surveyors visit the HIM department but also not unheard of,” she says. “For instance, if there are any concerns noticed by the surveyors regarding transcribed documents, such as history and physicals within 24 hours of admission, the surveyor may ask to meet with HIM staff to explain the process from dictation to filing on the medical record and/or to review the reports of ongoing compliance with the standard. [HIM usually monitors and reports the presence of the history and physical.]”

But the most important role for HIM is ongoing review of the organization’s compliance with the information management standards regarding availability, privacy, security, and reliability of medical record information. Adds Brown: “As more electronic systems are used to produce and disseminate medical information, the HIM professionals need to be at the forefront when systems are planned and implemented to ensure that Joint Commission standards are met and scored appropriately.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.

What’s It Mean in the HIM Department?
The Joint Commission’s requirements have far-ranging effects throughout the hospital. For HIM professionals, there are several chapters in particular that affect their job responsibilities:

• The “Information Management” chapter addresses information needs in a broad sense, including issues surrounding security, privacy, data storage, and retrieval specifically for health information.

• The “Record of Care, Treatment, and Services” chapter focuses on the requirements of a medical record and medical record management.

• The “Leadership” chapter lists resources for managing data and information and offers recommendations for using information in decision making and to improve quality and safety.

• The “Performance Improvement” chapter covers the ins and outs of the information that is required to be collected and analyzed as part of the performance improvement process.

• The “Provision of Care, Treatment, and Services” chapter details the requirements for the necessary types and timing of patient assessments (that eventually result in a medical record entry) and documentation and orders related to the use of restraint and seclusion.

— LG

Joint Commission Report Promotes Healthcare Reform
In a recently released report, The Joint Commission offers guiding principles and actions for hospitals of the future to meet the challenges of older and sicker patients, patient safety and quality of care, economics, and the workforce. The report, “Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future,” contends that hospitals must respond to these challenges in new ways, as escalating healthcare costs are hitting record highs and the conditions and care needs of hospitalized patients are growing more complex.

The report is the work of an expert panel comprising hospital executives and clinical leaders, as well as experts in technology, healthcare economics, hospital design, and patient safety. The roundtable analyzed how socio-economic trends, technology, the physical environment of care, patient-centered care values, and ongoing staffing challenges will impact the hospital of the future.

“The importance of hospital-based care will not diminish in the future, but hospitals will have to meet the high expectations of the public and all stakeholders in an increasingly challenging environment,” says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission. “As they have been in the past, hospitals must be equally transformative as the future unfolds. The Joint Commission urges hospitals and public policymakers to use the principles in this report to achieve that aim.”

The report recommends action in the following five core areas:

Technology Adoption
IT plays a major role in improving healthcare quality and safety and can help support the migration of hospital-based care into the community and even the home. The technological transformation of healthcare also invites the redefinition of the hospital, according to the report.

Citing that HIT adoption rates in the United States lag a dozen years behind other industrialized countries, including the United Kingdom, Germany, Denmark, Australia, and Canada, the report states that many U.S. hospitals may still need to be convinced of HIT’s value.

According to the report, while there is strong evidence supporting claims that such HIT systems yield significant benefit for the safety and quality of healthcare, there has been insufficient research conducted to support their return on investment, while the level of required investment can be substantial. “Initial implementation costs may range from several hundred thousand dollars for initial implementation in a physician office to millions in a community hospital to tens of millions of dollars in an academic medical center. Annual maintenance of the systems can cost tens of thousands to several million dollars,” the authors wrote.

“Many are also wary of the work flow disruptions that a full-scale IT implementation can cause. Enhancing work flow and care process redesign needs to be part and parcel of the implementation plan. Failure to do so can serve to codify already broken or defective care processes. Involving clinical staff who will be using the technology—at the patient’s bedside, in the office, pharmacy, lab and home—in its development and providing follow-on training are key to its success,” the authors wrote.

To address technology in the hospital of the future, the expert roundtable suggests the following:

• make the business case and sustainable funding to support widespread HIT adoption;

• redesign business and care processes in tandem with HIT adoption;

• use digital technology to support patient-centered hospital care and extend that care beyond the hospital walls;

• establish reliable authorities to provide technology assessment and investment guidance for hospitals; and

• adopt technologies that are labor saving and integrative across the hospital.

Economic Viability
For hospitals to be economically viable in the future, the report suggests that hospitals, healthcare stakeholders, and policymakers pursue the following principles:

• align performance and payment systems to meet quality and efficiency-related goals;

• use process improvement tools to increase efficiency and reduce costs;

• pursue coverage options to ensure patient access to, and affordability of, healthcare services; and

• address how general acute hospitals and specialty hospitals can both fulfill the social mission for healthcare delivery.

 Patient-Centered Care
According to the report, achieving patient-centered care should be driven by the following actions:

• make adoption of patient-centered care values a priority for improving patient safety and patient and staff satisfaction;

• incorporate patient-centered care principles into the activities of hospital oversight bodies and transparency initiatives;

• address barriers to patient and family engagement, such as low health literacy and personal and cultural preferences;

• eliminate disparities in the quality of care for minorities, the poor, the aged, and the mentally ill;

• improve the quality of care for the chronically ill through coordinated, multidisciplinary care; and

• use robust process improvement tools to improve quality and safety.

Staffing
To address the demand for certain healthcare professionals and to meet the needs of patients in the future, the report makes staffing recommendations such as expanding health professional education and training capacity to accommodate the growing demand for healthcare workers and creating workplace cultures that can attract and retain healthcare workers.

Hospital Design
Although many studies have revealed hospital design characteristics that work for improving patient safety and healthcare outcomes and providing a supportive environment for hospital staff, most new hospitals are not being built “safe by design.” To achieve this goal, the report calls for actions such as improved safety with evidence-based design principles such as single rooms, decentralized nursing stations, and noise-reducing materials and allowing for design flexibility in the building to accommodate advances in medicine and technology.

The full report can be found at www.jointcommission.org.