The Yellow Brick Road to Oz (or, Confessions of a Joint Commission Surveyor)

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon

It takes courage to ask an outsider to come in and look at your imaging department or facility, and to be willing to accept responsibility to improve performance. But it also takes courage to be the surveyor, reveals Cathie Norins, field representative, ambulatory care accreditation program, The Joint Commission Accreditation, Ambulatory Care. “It takes courage to share the observations honestly and take the organization to the next level,” she says.

imageCathie Norins

Norins described the dreaded site visit, shared some of the challenges inherent in compliance (and therefore areas of focus for the Joint Commission), underscoring the fact that accreditation can serve as risk management tool. She did this during a dual presentation with Michael Kulczycki on Monday, Key Concepts to Use When Seeking Accreditation—How to Beat the Odds in Meeting the CMS Mandate for Accreditation

In explaining that the process is not an evaluation of a person, a piece of equipment, or even a treatment, she says: “What we are really looking at is evaluation of your health care delivery system and its reliability.”

Norins sought to disabuse the audience of the misconception that a Joint Commission visit is an exercise in judgment, instead characterizing the visit as one step in developing a “feed-forward” action plan for quality improvement. “We come to you as a systems analyst and one step in our partnership is that onsite visit,” she explains. “The longer we get to know you, the more we will tailor that survey to your needs.”

Here’s what to expect of the visit. The surveyors will:

1. Randomly select patients to shadow to observe the care process, based on the types of studies you are dong , the life cycle of patients, whether you administer contrast. If a multi-site organization, they will visit at least 12.5% of sites.
2. Observe how the whole system works for each patient, concentrating on teamwork and relationships, communications and the information flow.
3. Pay close attention to the design of your processes.
4. Look at the consistency of the system on a 24/7 basis.
5. Map what they see.
6. Look at your infection control processes, and medical management policy
7. Assess the safety of the environment of care (security of equipment, fire policies, etc).
8. Look at how you are meeting the national patient safety goals (NPSFs), including patient identifiers, hand hygiene, and communication of critical test results.

Norins advises that surveyors are currently paying close attention to how sites are managing infection control. “I am highlighting infection control because this is one of the biggest areas of difficulty in compliance that I am seeing and my colleagues are seeing the same thing,” she reports.

To understand how your site is managing infection control, surveyors will:

1. Assemble individuals involved with the process. They do not require that you have a committee, but they do require that you have a plan.
2. Seek to understand how the infection control processes were planned, designed, implemented, and monitored.
3. Assess the effectiveness of your program.

The five most common compliance problems the commission is observing are:
1. No one is responsible for infection control.
2. The person designated as responsible does not have qualifications and defined responsibilities. “We don’t tell you want they are, you have to decide that,” Norins says.
3. No infection control plan in place.
4. No resources allocated to infection control.
5. No evidence of infection control policies in human resources files (implication being that if there are no violations, the plan is window dressing).

“We do see numerous standalone policies and procedures related to infection control,” Norin reports, including to policies related to OSHA’s blood-bourne pathogens. But frequently there is no integrated, coordinated plan.”

She reports seeing situations in which there is a lots of data collected, but no planned system for implementing and monitoring.

“You get into the DRIO syndrome,” she notes. “Data rich, information poor.”

Clearly, this is an area of increased scrutiny, so pay attention to these imaging risk areas:

1. Training and monitoring of hand hygiene policy.
2. Patient identifiers.
3. The communication of critical test results.
4. The infection control policies of contracted services, such as linen management, housekeeping, leased facilities, waste management.
5. The particular risk