“maintaining accreditation: meeting the challenges of compliance” aatod 20 th anniversary...

“Maintaining Accreditation: Meeting the Challenges of Compliance”

AATOD 20th Anniversary National ConferenceOctober, 2004

Mary Cesare-Murphy, PhDExecutive Director, Behavioral Healthcare

Accreditation

Megan Marx, MPAAssociate Director, OTP Accreditation Project

Joint Commission on Accreditation of Health Care Organizations

OTP Surveys Conducted 1/1/04 – 8/31/04

–Twenty (20) OTPs received “No Requirement(s) for Improvement.”–Forty-seven (47) OTP surveys had Requirement(s) for Improvement, with an Evidence of Standard Compliance (ESC) due as follow-up.

2004 CAMBH Chapters with Non-Compliant Standards

Chapter # of Non-compliant Standards

RI – (Ethics, Rights & Responsibilities) 17LD – (Leadership) 7

APR – (Accreditation Participation Requirements) 7HR – (Management of Human Resources) 37PI – (Improving Organization Performance) 11IC – (Infection Control) 2MM – (Medication Management) 11IM – (Information Management) 14EC – (Environment of Care) 5PC – (Provision of Care, Treatment & Services) 45

2004 OTPs Most Challenging Standards

Chapter Count Not Compliant

Specific Recommendation

HR 9 HR.3.20 The organization periodically conducts performance evaluations.

HR 6 HR.3.10 Competence to perform job responsibilities is assessed, demonstrated & maintained.

HR 5 HR.4.10 There is a process for ensuring the competence of all practitioners permitted by law & the organization to practice independently.

APR 5 APR 8 – The organization provides notice of an upcoming full survey and of the opportunity of a PII.

2004 OTPs Most Challenging Standards con’t.

IM 7 IM.6.50 – Designated qualified personnel accept & transcribe verbal orders from authorized individuals.

PC 10 PC.2.110 – A nutritional screening is done, & when indicated, an in-depth nutritional assessment is performed.

PC 7 PC.3.100 – The assessments includes the client’s religion and spiritual orientation.

PC 5 PC.4.20 – The care, treatment & services may begin before full plan is formulated.

RI 11 RI.2.160 – Clients have the right to pain management.

OTP Surveys Conducted 2002 - 2003

– One hundred forty-two (142) OTPs received “Accreditation with Recommendations for Improvement”.

– One hundred thirty-seven (137) OTPs received “Accreditation with Full Standards Compliance”.

– Six (6) OTPs received “Conditional Accreditation”

Individual-Focused Functions:RI – (Rights & Responsibilities & Ethics)

PE – (Assessment)TX – (Care)

PF – (Education)CC – (Continuum)

Organization Functions:PI – (Improving Organization Performance)

LD – (Leadership)EC – (Management of Environment of Care)HR – (Management of Human Resources)

IM – (Management of Information)IC – (Surveillance, Prevention, Control of Infection)

PS – (Behavioral Health Promotion)

2002 – 2003 OTPs Most Challenging Standards

Chapter Count Not Compliant

Specific Recomendation

HR 20 HR.4.1 – Organization has a process designed to ensure the competence of licensed independent practitioners.

HR 19 HR.4.13 – Clinical responsibilities for licensed independent practitioners are approved by the governance function.

HR 17 HR.4.1.4 – There is a fair hearing & appeal process for addressing adverse decisions about granting, renewing, or revising clinical responsibilities for licensed, independent practitioners.

IM 19 IM.3 – Uniform data definitions & data capture methods are used whenever possible.

2002 – 2003 OTPs Most Challenging Standards con.’t

PE 33 PE.1.8 – Pain is assessed in all individuals served.

PE 18 PE.1.7.3 – A psychosocial assessment or social history is completed & entered in the clinical/case record for each individual served. As indicated, the assessment includes information on the individual served, including conflict or problems involving religion & spiritual orientation.

TX 23 TX.1.6 – The plan of care includes specific objectives for the goals identified in the plan.

TX 20 TX.2.2.1 – Medications are appropriately controlled during preparation & dispensing.

Comparison of overall trend(s) & identification of problem areas within OTPs:

• Standards most frequently cited in OTP’s consistently came from the Assessment/Provision of Care, Treatment and Services and the Management of Human Resources sections of the standards.

• Standards cited concerning licensed independent practitioners, assessment of patients religious or spiritual orientation and pain management were prevalent in OTP survey findings from both 2002-2003 and 1/1/04 – 8/31/04.

Approach to OTP Education

• Accreditation education efforts for OTPs should be focused on Assessment/Provision of Care, Treatment and Services and the Management of Human Resources to improve standards compliance.

• If funding is awarded, Joint Commission will offer more topic specific learning opportunities utilizing user friendly distance learning formats in an effort to provide education to more OTPs.

Periodic Performance Review

Periodic Performance Review (PPR)

• Facilitates a more continuous accreditation by incorporating an additional mid-cycle evaluation.

• Provides for educational opportunities


• Is an accreditation participation requirement.

• Will be completed between the 15th and 18th month point in the accreditation cycle.

• Findings with an approved plan of action not subject to citation during a Random Unannounced Survey during approved timeframes.


• A surveyor on-site cannot overrule an approved plan of action.

• During on-site survey, surveyors will request and review measures of success identified at time of 18-month PPR.

• Process includes three options as well as full PPR.

Characteristics of Full PPR

• Areas of non-compliance self-assessed by the organization and scored using the JCAHO extranet tool.

• Findings submitted electronically to the Joint Commission using the extranet.

• JCAHO staff review plans of action and measures of success and conduct interactive phone call.

Tips for the PPR

• Read the user guide.• Check applicability table.• If unsure of applicability, leave unscored and discuss

with standard representative.• Develop separate plans of action and measures of

success (when required).• When it doubt, score it out – material for discussion.• Take full advantage of conference call time for

questions.

Guidelines for Sampling for PPR

• When assessing category “C” Elements of Performance (EPs) these guidelines are recommended:30 cases for a population up to 100 (If

population is less than 30, sample all)50 cases for a population of 101-50070 cases for a population over 500

Plan of Action

• For each standard evaluated as “Not compliant” the organization willDescribed the planned action for each

element of performance (EP) marked as partial or not compliant

Develop a measure of success

Measure of Success (MOS)

• A numerical or other quantitative measure usually unrelated to an audit that validates that an action was effective and sustained

• Submitted via extranet

• Submitted on an electronic form with space limited to a brief indication of numerical measure – expressed as a percentage

Benefits of Periodic Performance Review

• Employs same tool as used by surveyors

• Expands intra-cycle interaction with JCAHO

• Supports continuous operational improvement

• Assists organization in quest for 100% compliance, 100% of the time

Link Between Period Performance Review and On-site Survey

• At triennial survey, time will be devoted to reviewing measures of success

• Surveyor will ask for data related to each measure of success

• Track record requirements remain

• Surveyors do not see the organization’s specific performance review or action plans

PPR Option One

• Organizations will attest that after careful consideration with legal counsel, they have decided not to participate in the Full PPR

• Organizations will self assess compliance with standards, develop plans of action and measures of success (MOS) as applicable

• Organizations will not submit PPR data to JCAHO

PPR Option One

• Organizations will not be able to use extranet tool to score compliance, but will be able to view and print all standards and EPs

• Organizations will be able to submit standards related issues for discussion with JCAHO staff during an interactive, scheduled phone call, but no inference relative to compliance will be made

PPR Option Two

• Organizations will attest that after careful consideration with legal counsel, they have decided not to participate in the full PPR

• An on-site survey will take the place of self-assessment activity

• Survey length will be approximately one third of usual triennial survey

• Organization will submit plans of action and MOS(s) for surveyor identified areas of non-compliance

PPR Option Two

• Conference call with JCAHO will be scheduled to review and approve plans of action and MOS(s)

• Organizations will be charged a fee to cover costs of the on-site survey

PPR Option Three

• Organizations will attest that after careful consideration with legal counsel, they have decided not to participate in the Full PPR

• A limited on-site survey will be conducted at the midpoint of the accreditation cycle

• Following the survey the organization may elect to participate in a conference call to discuss standards related issues

• At the time of the trienniel survey the surveyor will receive no information relating to the organizations Option 3 survey findings

Using Data to Improve Program Performance

• Planning is the key to preventing performance measurement mistakes

• Ask the following questions: What data should be collected? Why should the data be collected? What data are already available? What are the sources of available data? How will the data physically be collected? How will the data be used?


• Consider the following common mistakes and tips to avoid these errors in your organization:

• Mistake 1 – Insufficient planning before collecting data

• Tip 1 – Determine which strategic measurement areas are high priorities


• Mistake 2 – Insufficient resources to support data collection

• Tip 2 – Enlist leadership to ensure that adequate resources are available

• Mistake 3 – Data integrity• Tip 3 – Assess the completeness of the data


• Mistake 4 – Extensive data collection• Tip 4 – Break data collection into manageable

projects

• Mistake 5 - Data collection “silos”• Tip 5 - Investigate data sources and instruments

already in place.


Facts = Data

Data Combinations = Measures

Analyzed Measures = Information

Applied Information = Improvement

Improvement generates knowledge


• Follow these steps to avoid common pitfalls in data collection:

1. Review the specific purpose of your outcomes focused improvement project & determine what information, measures and data are necessary to achieve that purpose.

2. Review the specific information you need, specify performance measures that will generate that information & identify the data that compose these measures.


3. Define indicator data elements.

4. Determine the sources for all needed data.

5. Create your data collection instruments.

6. Determine the most effective data analysis strategies by considering what type of data need to be collected and how they will be used to improve performance.

7. Document your data collection plan.

8. Pilot test the data collection tool and analysis strategies.

Using Data to Improve Program PerformanceThe Three “T’s”

• TRENDData over time on indicators

• TARGETRange of performance of each one

• TOGETHERLook at indicators in combination

Joint Commission Benchmark January 2003 pgs 1,7


Types of Measurement

1. Administrative Measures – Productivity

2. Comparison Measures – Benchmarking

3. Process Measure – Access, Satisfaction

4. Functional Measures – Improvement

5. Fidelity Measures – Following processes


Administrative Measures

• An administrative measure is an indication of how well your agency is following its mission, vision and values.

• It is also a measure of how well your agency is doing.

• Productivity or resource utilization is one example.


Productivity Examples

• Direct Service Percentage• Billed Service Percentage• Show Rate/Keep Rate• Percentage of Improvement Rate• Revenue per staff


Comparison Data

• Allows you to compare how your agency is doing in terms of other agencies.

• Any number of areas you might choose to compare.


Process Measures

• A process measure looks at how well your processes are meeting your goals or standards.

• Examples:– Rate of meeting intake timeliness– Show rate of initial appointment– Show rate for second appointment after intake


Process Measure Examples

• Emergency Services Use• Length of stay per diagnosis• Time of first appointment• Time between first & second appointment• Percent of consumers receiving first appointment within

48 hour of request• Keep rate

– First appointment, subsequent appointments


Functional Measures

• A functional measure is an outcome measure.• It can be as complicated as a formal, fee based

measurement with national norms– Brief Symptom Inventory (BSI)

• It can be as simple as a “home-made” measurement using a Likert scale


Construct a Likert Measure

• List the functional elements that are important in the person’s life.– Supervisors and staff with experience with the population can

help insure that the measure will have meaning.

• Decide on a rating scale.– “0 to 10” is an 11 point scale, “O to 3” is a four point scale

• Add descriptors to the rating to help staff know how to score the person– 0 = not present, 5 = some present, 10 = totally present


Construct a Likert Measure

• Train staff how to use the scale• Implement the scale• Chart pre-and-post treatment scores as a

comparison outcome measure.


Fidelity Measures

• Fidelity is a concept used in formal research• In a treatment setting, ‘fidelity’ measures the

extent that staff have followed your treatment guidelines.

• Fidelity measurement is important in establishing a relationship between your treatment methods & functional improvement/outcome.


Fidelity: Sample Question

Fidelity can be simple “Yes/No” questions to each part of your treatment protocol.

Were required lab tests current? y/n Was the practice protocol followed? y/n Did the physician sign the treatment plan? y/n


Readily Available Outcome Measures

1. Beck Depression

2. Beck Anxiety

3. CAP – Children’s Attention Problems, for Attention Deficit Hyperactivity Disorder (ADHD)

4. Conners (for ADHD)

5. Yale Brown Obsessive Compulsive

6. Michigan Alcohol Screening Test (MAST, for addiction)


Selecting the Measures

• Organizational Context• Matching measures to your needs

Measure what reflects your vision and mission


Organizational Context

• Organizational culture committed to data based decision making

• Technical & management systems interdependent & well integrated

• Support by top levels of management


Measures and your Mission

• QualityHow do you know people are improving or at least

maintaining functional level?

• CoordinatedHow can you tell if people can get needed services?

• ResponsiveWhat is your access goal? What is your actual access

rate? Difference?????


Matching Measures to your Needs

• For example, measure what:Reflects your population baseWill help you improve outcomesWill help you improve financial status


Measures You Can Use:

Data Based Decision Questions

• What diagnosis do you prescribe the most medications for?

• What are you most common diagnoses?• What are your highest risk categories?• Who are your most frequent users of high cost

services?


Measures You Can Use:Data Based Decision Questions

• Which measures tell you about how your consumers are doing? High risk, high volume, problem prone

• Which measures tell you about how your agency is doing? Access, productivity, length of stay Grievances per level of resolution Incident reports per level of involvement HIPPA related privacy/security violations


Measures You Can Use:Data Based Decision Questions

• Measures related to organizational safetyEnvironment of Care (e.g., test results) Infection Control RatesRequired Lab Tests (e.g., medication specific)

• Measures related to quality of your meetingsAgenda? Minutes? Time for each agenda item?

Timely attendance?


Measures You Can Use:

Data Based Decision Questions

• Measures related to documentation review process Adequacy of documentation Quality of documentation Fidelity of processes

• Benchmarking with other providers How do you compare with sister agencies?

• Staffing effectiveness Relationship between staffing and service provision


Implementing Measures

• Other considerationsBoard & administrative supportStaff trainingMeasurement “Champion”Emphasizing the benefits of measurement

Joint Commission on Accreditation of Health Care Organizations

Mary Cesare-Murphy, PhD

Executive Director, Behavioral Healthcare Accreditation

630-792-5790

[email protected]

Megan Marx, MPA

Associate Director, OTP Accreditation Project

720-348-0672

[email protected]

“maintaining accreditation: meeting the challenges of compliance” aatod 20 th anniversary...

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