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JCAHO ACCREDITATION
The motivation of healthcare organizations to perform well on Joint Commission Accreditation surveys is increasing due to the public release of information, marketing survey results, job performance standards tied to grid scores, and competition between organizations to achieve commendation.
Quality Systems Group provides accreditation assistance throughout the entire accreditation cycle including:
- Presurvey Evaluation
- Post-survey Response
- Onsite Survey Assistance
- Interim Compliance Assistance
- 2001 Standards Education
- Unannounced Survey Assessment
Accreditation services are available for all Joint Commission standards.
QSG staff are experienced and knowledgeable in accreditation of:
- Hospitals
- Home Care
- Ambulatory Care
- Behavioral Health Care
- Long Term Care
- Pathology and Clinical Laboratory Services
- Network Accreditation
- Preferred Provider Organizations
The pre-accreditation survey process is performed to simulate the actual JCAHO accreditation survey. An educative, interactive, participatory style is used with Board, Administration, Medical Staff, managers, employees, and contract services.
QSG performs pre-accreditation surveys, using an intense evaluation approach which provides the organization with an objective external assessment of systems strengths and weaknesses.
This evaluation provides an excellent framework to develop and improve organizational systems and functions. Additionally, our consultants facilitate action planning, provide a written report of findings and recommendations and assist with the development of implementation strategies.
Beneficial aspects of having the pre-survey performed include improved quality/reduction of non-compliance risks, avoidance of costly sanctions, reduced opportunities for negative press releases, improved systems, preparation of staff and leaders for the actual survey process, improved ability to prioritize and focus corrective actions, and provision of an administrative "snapshot" of organizational compliance.
Pre-surveys are:
- Tailored to meet individual organizational requests.
- Performed organization-wide or focused for a program, service, function and/or department to evaluate compliance with current accreditation standards.
- Provided as periodic scheduled reviews to ensure continual compliance readiness.
The pre-survey process includes:
- tours of departments for systems compliance.
- review of plans, policies/procedures, records and documentation.
- group interviews and education of leadership, employees, managers, physicians and patients.
- daily debriefings on specific presurvey findings.
- summation conference identifying potential high impact recommendations.
- action planning workshop immediately after the presurvey.
- cross functional strategic planning for correction of systems issues.
- availability of written report of findings and recommendations for corrective action.
Follow-up consultation and interim compliance reviews are provided both onsite and offsite.
Common areas for compliance activity include development, revision and review of:
- plans, policies/procedures, performance evaluations.
- performance improvement, education, infection control, risk management, utilization management and environment of care management.
- bylaws, rules and regulations.
- minutes and reports.
Education and training in:
- systems coordination and integration
- assessment and improvement of organizational performance
- improved patient care documentation
- meeting management and minute taking
- leadership, management and team building skills
Accreditation is a continuous process; therefore, Quality Systems Group provides ongoing accreditation assistance including:
- Education regarding continual standards, updates and scoring changes for 2001.
- Ongoing information regarding changes in survey focus, surveyors and survey process.
- Regulatory updates and status reports on schedules, decisions, activities and alliances.
Survey attendance and onsite support during accreditation visits is available and improves the results of the survey process. Benefits to the organization include having the consultants:
- keep the survey process effectively focused and objective.
- act as catalyst to leadership and staff in order to improve interactions with the surveyors.
- demonstrate the organization's commitment to the concept of accreditation.
- support leaders and managers who may be unfamiliar with the survey process.
- respond as extended facility resource for additional clarification of and compliance with the standards.
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