CRITICAL ACCESS HOSPITAL ACCREDITATION

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CRITICAL ACCESS HOSPITAL ACCREDITATION

• Fall 2002 Teleconference Presentation

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JCAHO Contacts

• Kurt Patton, Executive Director, Accreditation
  Operations [phone] kpatton_at_jcaho.org
• Meg Gravesmill, Accreditation Operations (630)
  792-5813 mgravesmill_at_jcaho.org
• Laura Smith, Standards Development, (630)
  792-5098 lsmith_at_jcaho.org

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JCAHO contacts

• Darlene Christiansen, Survey Process, (630)
  792-5273 dchristiansen_at_jcaho.org
• Phavinee Thongkhong-Park, Survey Process, (630)
  792-5984 ppark_at_jcaho.org
• Mark Schario, Surveyor Management, (630)
  792-5706 mshario_at_jcaho.org
• Frank Zibrat, ORYX
  [phone] fzibrat_at_jcaho.org

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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 CAHs
• 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 CAHs 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 CAHs 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 CAHs
• Testing at 6 CAHs, 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

• 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

• MA.2 The chief executive officer provides for the
  hospitals compliance with applicable law and
  regulation and
• 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.
• 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 COPs 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 arepulled into
  the manual directly from COP language

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CAH STANDARDS EVALUATED ONLY ON SWING BEDS

• PE.1.4.2 Each residents 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 1s
  in COP linked standards

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CONVERSION SURVEYS

• The CAH must immediately prepare a 1 month WPR to
  clear any type 1s 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 1s 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 CAHs 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 TODAYS
PARTICIPANTS