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SESSION 128IMPLEMENTING ACONTINUOUS SURVEYREADINESS MODEL

COPYRIGHT © 2000 BY THE HEALTHCARE INFORMATION AND MANAGEMENT SYSTEMS SOCIETY. 40

Amy Black Emerging Solutions, Inc.Alpharetta , GA

Charlene RobertsChildren’s Healthcare of AtlantaAtlanta, GA

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INTRODUCTION

The exit conference has just ended with the Joint Commission survey team and your organizationbreathes a huge sigh of relief. Among the congratulatory remarks and the pats on the back, anothersentiment is heard. “We are never doing this again. Let’s keep up with things this time. We always saywe will but we never do!”

Sound familiar?

Often organizations with the best intentions of maintaining their compliance with JCAHO standardsfind themselves 6-12 months out from their triennial accreditation survey with major deficienciesagain. Priorities change, positions are cut, leadership changes are made and soon no one is watchingover their accreditation status.

Years ago, putting together a massive preparation effort at the last minute may have worked, buttoday with the JCAHO updating their standards on a quarterly basis and raising the bar each time, thefocus really needs to be on continuous survey readiness. Otherwise, the costs to the organization aretoo great. Last minute efforts are usually expensive, ineffective, and bring too much stress to theorganization. Compliance with the standards needs to be a way of life in order to reap the benefits ofthe high performance culture that the JCAHO standards are meant to support.

On October 4, 1999, the Joint Commission implemented their new policy for random unannouncedsurveys. Accredited organizations are now at risk for these one-day interim surveyor visits anytimebetween the 9th and the 30th month following their triennial survey. While in previous years organi-zations were given 24-hour notice, the new policy makes it clear that no notice will be given. Thefocus of the interim surveys will change annually depending on what data concerning problem areasis generated from triennial surveys conducted nationwide the previous calendar year. Consequently,standards that were not focused on during an organization’s triennial visit may indeed be the focusduring a random survey. Currently 5% of all accredited organizations undergo a random interim sur-vey, however, it has been speculated that random surveys will be stepped up by the JCAHO inresponse to the recent criticism they received from the Office of the Inspector General.

Quarterly standard updates, random unannounced surveys, the lifting of scoring caps, and the pres-sures of cost containment for healthcare providers point to the need to be proactive with regards tosurvey readiness. A continuous survey readiness model can be the solution for most organizations.This was the solution chosen by Children’s Healthcare of Atlanta, one of the largest pediatric health-care systems in the country. A nine- point Continuous Survey Readiness (CSR) plan has been put inplace to maintain the organization’s standard compliance at a high level and eliminate massive prepa-ration by linking accreditation standards to everyday operations.

The purpose of this paper is to describe the components and outcomes of the Continuous SurveyReadiness model implemented at Children’s. Background information leading to the implementationof the model will be covered, the general approach used to develop and implement the model will bepresented including a description of the nine components of the model. In addition, the resultsachieved to date will be detailed as well as the future direction the organization will take with themodel. Finally, the conclusion will include some discussion of how the model can be applied at otherorganizations.

BACKGROUND

Children’s Healthcare of Atlanta like many other provider organizations voluntarily submits to a tri-ennial JCAHO survey for accreditation. A recently merged entity of two competing children’s health-care systems, both hospitals had received accreditation decisions of Accreditation withCommendation at their last triennial survey. Scottish Rite Children’s Hospital was surveyed inFebruary of 1998 immediately prior to the official merger. Egleston Children’s Hospital completedtheir triennial visit in November 1998 and in January of 1999 underwent a HCFA validation surveyconducted by the Georgia State Department of Human Resources. The HCFA survey was a moredetailed and traditionally focused survey than the JCAHO survey, but the hospital came through itwith no major findings.

Despite these outstanding results, there was a perception that survey preparation efforts were costly,resource intensive and stressful to the organization. This perception was particularly acute becausethe major task confronting the organization was not the survey, but the major effort of merging boththe structural and cultural aspects of two distinct organizations into one. The merger and the naturalanxiety and stress that it brought was understandably the focus of the leadership team. Survey prepa-ration had to be handled in addition to reapplying for positions, defining a new organizational struc-ture and creating a new culture.

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The survey came at the most inconvenient of times, and the resounding refrain throughout the organ-ization was why now? Of course, reality was that an accreditation survey would never be convenient.Especially in today’s healthcare industry, where the pace of change is forever bringing another trans-formation to the way we deliver healthcare there would never be a good time for a JCAHO visit.Whether it is the far reaching impact of reimbursement changes, some fierce competitor making amove or the increasingly informed consumer wanting a better value, there is always some imperativethat presents itself just when it is time for the next survey. Since the merger seemed to bring the situ-ation to the forefront, the moment was right for putting a system in place that would leave the organ-ization always prepared. Standard compliance could not continue to be an afterthought or a hugeproject that you pull out and work on every three years. It needed to become a fully integrated processthat would be part of the fabric of the organization.

The administration was very interested in finding a means of preserving the current high level ofcompliance with accreditation standards. An informal team consisting of the Vice President ofOperations at Children’s at Scottish Rite, the Vice President of Operations of Children’s at Egleston,an external consultant that had helped the organization with survey preparation and two internal qual-ity managers that played a significant role in the Egleston Survey decided to put together a model forcontinuous survey readiness.

APPROACH

How then do you get there? How do you convert your organization to a continuous accreditationmindset? It was decided that the keys to a successful model must focus on three criteria: accountabil-ity, collaboration, and communication. In addition, the design team felt strongly that the ideal modelwould be linked to everyday operations and supported by technology. A leadership and physiciansurvey was conducted to solicit feedback about the effectiveness of previous preparation efforts andideas for improvement.

To begin the team conducted a physician and leadership survey to determine the effectiveness of previ-ous survey efforts and solicit ideas for improvement. A summary of the results of this survey can befound in Figure 1. The chapter leader concept, departmental rounds and consults conducted by internalstaff, and the educational components used during the last surveys were all found to be effective. A cou-ple of important themes emerged from the survey. One was that some type of ongoing and plannedeffort that would keep the current high levels of standard compliance be put in place. The other themeemerging from the survey was that the educational efforts needed to be done over a longer period to easethe burden on the staff for learning new content and adjusting to process changes.

Based on the results of the questionnaire, their experience with past surveys and knowledge gleanedfrom sources such as the JCAHO Director Forum sponsored by Child Health Corporation of Americaand the JCAHO Watch List-Serv, the team put together a formal proposal of a continuous surveyreadiness model. The model they designed built on the things that helped both organizations achievesuccessful results in the past but also tried to take advantage of the changing culture. The proposalconsisted of a chapter profile for each functional area detailing elements within the chapter and the


Figure 1: JCAHO Preparation Effectiveness Survey

tasks associated with each (see Figure 2). In addition an outline of the ten components that could beput in place to integrate these activities into the daily operations of the new organization were pre-sented (Figure 3). The proposal was presented to the Senior Management team and accepted in early1999. The components of the model were put in place during 1999 and will continue to be improvedinto the year 2000. Each of the model components is described below.

1. Functional LeadersChildren’s first step in implementing a continuous survey readiness model was to breakdown theaccreditation standards into manageable units and to assign accountability for standard compliancewithin these units. For example, in the JCAHO Comprehensive Accreditation Manual for Hospitalsthe standards are grouped into Fifteen Functions. In each case, a separate chapter or function leaderwas assigned. Each leader assumed enterprise wide responsibility for the standards within their func-tion as outlined in the accreditation manual. In addition, an ORYX chapter leader was assigned to rec-ommend the selection of performance measures and oversee the submission of the data to theJCAHO. The ORYX chapter leader also coordinates the evaluation of the data and acts on area whereopportunities to improve the performance of these measures are noted.

2000 HIMSS Proceedings: Volume 4 Session 128 / 3

Figure 2: Continuous Survey Readiness Model

Figure 3: Continuous Survey Readiness Cycle

A clearly defined role description for the chapter leaders that was endorsed by Senior Managementwas key to this component. The role description developed at Children’s is included in Figure 4.Chapter leaders are responsible for keeping up to date on changes in standards, scoring guidelinesand intent statements and communicating these changes to rest of the organization. Where the organ-ization falls short in complying with a standard or group of standards, it is the chapter leader that isnow responsible for collaborating with their peers to develop a plan for regaining that compliance andseeing that it is implemented. Within larger functions, such as, “Care of the Patient,” leaders haveassigned sections of the standards to subchapter leaders. If subchapter leaders are utilized, however,the chapter leader remains ultimately responsible for the overall performance of the organization onthe standards within that chapter so that accountability remains focused.

As part of the implementation of this component Children’s arranged for the CEO to come to an oper-ational kick-off meeting to stress the importance of the chapter leader role. He also expressed his sup-port of the continuous readiness mindset that the chapter leaders would be pursuing for theorganization. Since the chapter leaders are not compensated directly for these additional responsibil-ities it is important to give them recognition whenever possible for their contribution.

2. Annual Chapter Assessments and UpdatesIn order to maintain focus on standard compliance Children’s developed a calendar for periodic chap-ter assessments as the next component for continuous survey readiness. Each chapter is fullyreviewed annually standard by standard by the chapter leaders. Evidence of compliance and a currentscore are recorded. Chapter leaders identify any areas of non-compliance and develop action plans toregain compliance in deficient areas. Chapters with identified deficiencies are then slated for report-ing at intervals that are more frequent until the deficiencies are resolved.

Originally planned for January of each year this process has been backed up to December for 1999and may be done even earlier for 2000 to allow for adequate planning for education, policy andprocess development as dictated by the assessments. January is usually the time that any new stan-dards become effective so plans for compliance need to be finalized in the fall of the preceding year.

These chapter reports are a regular item on the operational agendas of leadership meetings within theorganization. Previously a separate JCAHO Task Force met for this purpose. With the advent of theContinuous Survey Readiness model the task force was eliminated for several reasons. First, it wasjust one more meeting that all or part of the leadership team must attend. Secondly, having a separategroup caused fragmented communication or worse yet, duplication of effort. And finally, havingJCAHO compliance viewed as a separate effort supported the nonproductive notion that “we are justdoing this for JCAHO.”

The annual reporting calendar by chapter has been very helpful for keeping things on track and ensur-ing that everyday standard compliance is a way of doing business at Children’s. Certain chapter lead-ers were not department heads but meet monthly when chapter assessments are reviewed. Thesemeasures ensure that the necessary communication and collaboration is taking place. If a particularstandard is not in compliance, the entire leadership team is available to contribute to the action plan


Figure 4: Role of the JCAHO Chapter Leader

for eliminating the deficiency. Decisions can be made immediately and resources allocated as neededby the time the meeting is over unless a major budget exception is required. Knowing that they areslated to report to their peers until their standards are back in compliance keeps the chapter leadersaccountable.

3. JCAHO DatabaseA software application that supports the type of reporting described above is essential in keepingchapter assessments current and assisting chapter leaders to handle their responsibilities. Children’shad begun to address this need with an internally developed Access database; however, issues ofspeed, accessibility and functionality soon became apparent. The CSR team realized that a broadersolution was needed, one that could handle multiple users and begin to link JCAHO standards andevidence of Children’s compliance with the standards to daily operations.

Children’s found the expanded functionality with the HealthFlashTM application offered by EmergingSolutions, Inc. This Internet based project and document management tool offered a new communi-cation medium to the organization by allowing all the work related to a project to be accessible by allteam members at anytime with real-time updates of information. In addition, the Internet-based appli-cation has a built-in accreditation manager that can:

• house multiple standard sets from any type of accreditation agency

• flag standards that have deficiencies

• automate the chapter assessment and reporting process

• automate an executive summary report

• house and tag items by function and standard to a virtual document room whether it is a policy, aperformance improvement effort, a committee minute, indicator or an educational activity.

• link and manage projects and documents within the same database

• be accessible from any leader’s desktop

The application was purchased by Children’s in July of 1999 and implemented in the fall of 1999. Allchapter leaders and project managers have been trained on the application and are able to access itacross the enterprise with a web browser. Because it is a centralized database accessible via theInternet it can be accessed during a project team or operational meeting and used in the live setting.Anytime a project is moved forward the work that was done is immediately accessible to the teammembers. Built-in feedback and messaging within the application support the organization’s focus oncollaboration and accountability for the CSR model. An executive website that rolls up accreditation,project and indicator information in a summary format is automatically populated.

4. Annual Education PlanAnother important part of the continuous survey readiness model is the annual education plan.Targeting one or two functions to be highlighted each month in a staff education program is themethod for accomplishing this objective. A master calendar where January is always Patient andFamily Education month, for example, and June is always Safety and Infection Control Month hasbeen most effective. This approach lets staff know what to expect each month and enhances the plan-ning efforts of educators, chapter leaders and the leadership team.

Every effort has been made by Children’s to incorporate JCAHO related education into existing ven-ues since much of the content is integral to the everyday work that is performed in both patient careand support departments. For example chapter leaders may develop self-instructional models for thenew pain management standards that can be implemented by unit based educators. Alternatively, theymay take advantage of the monthly mandatory educational blitzes that are already in place and wellattended by staff to present a new policy that arose from their standards. Providing smaller regulareducational modules for staff instead of intensive efforts at the last minute has improved knowledgeassimilation by the staff.

Educational programs such as orientation, competency check-offs, in-services, self-instructionalmodules, policy reviews and collateral materials are developed to coincide with the highlighted func-tion of the month. A safety card with emergency procedures on it is now published annually and givenout to staff during Safety Month. A pocket handbook that was published for the staff in preparationfor the last triennial survey is now published annually and also given out at orientation.

As chapter leaders complete their annual review of the JCAHO standards and develop action plans toaddress deficiencies, consideration should be given to the education that will be needed by staff.These plans are then added to the annual education plan for the current year. Having an annual education plan enhances communication and collaboration within the organization in maintainingstandard compliance.


5. Annual Document Review and UpdateTo keep required JCAHO documents current and to focus accountability for maintaining documentsin a ready state, an annual review and update of required documents by function is performed by eachchapter leader at Children’s. The HealthFlash( application has an accreditation manager and virtualdocument room embedded in its project management software so documents and evidence of com-pliance flow easily into an electronic document room.

In this manner massive document preparation at the time of the next triennial survey will be avoided.Anytime a required document is revised or JCAHO mandates a new document the chapter leader caneasily link it to one or more standards and place it in a virtual holding bin organized by function andstandard. From the accreditation module in the application items to be placed in the virtual documentroom are selected and logged (see Figure 5). There is no indexing revisions necessary when a newdocument is developed and all documents are viewable via hyperlinks. This centralized database canbe accessed from any chapter leader’s desktop. Standards can be linked to projects, documents, indi-cators, policies, and any type of educational activity concurrently.

Children’s documents will always be available in a centralized database so they will be ready in caseof a random unannounced survey. Children’s can give the survey team access to the document roomfolders and they can view the required documents that have been placed there with no need for anypaper or manuals.

6. Committees, Task Forces, and Performance TeamsMaintaining a quality and medical staff structure to support excellence in performance of the 15important functions as outlined by JCAHO is another crucial element of the continuous survey readi-ness model in place at Children’s. A well-developed performance management plan provides theroadmap for an effective structure where performance assessment, measurement, and improvement ofkey processes are accomplished. These processes may be patient care processes, business processesor service delivery.

When revamping the system quality committee structure for the merged organization, each existingcommittee or group was reviewed to determine what contribution they made in the assessment andmeasurement of key processes within the organization. In this manner superfluous and redundantcommittees were eliminated. In addition, the Systems Quality Director made sure that each of the tenimportant processes or outcomes outlined under JCAHO standard PI 3.2 had a home within the com-mittee structure. The new streamlined structure that resulted is seen in Figure 6.


Figure 5: Document Room

Now each group has established what it measures, the data collection methodology it uses, the fre-quency of reporting and the accountable party for each process (see Figure 7). Children’s requiresthat a formal performance measurement plan be submitted to their quality oversight committee foreach key process. The purpose of these plans is to ensure that the data collection is useful, adequateand in accordance with the PI plan and to identify when the data needs to come before this committeeand eventually the system board. The indicators selected can be housed in the Internet -based projectand document application and linked to the appropriate standard. The graphs of the indicators areuploaded to the application and viewed via hyperlinks. They are also posted on the executive websitethat is part of the application so that the senior leadership can always informed on the organization’sperformance. In this manner, the desired communication and collaboration can take place.


Figure 6: Organizational Information Communication Process & Quality Committee Structure

Figure 7: Sample Performance Measurement Plan

7. Departmental Rounds and ConsultsTo keep frontline staff invested in a continuous accreditation model a method for conducting regulardepartmental rounds and consults has become an important component of the model. Joint roundswith the infection control officer, employee health coordinator and safety officer makes the requiredthe rounds more valuable.

In addition, regular consultative visits by chapter leaders that focus on identified deficiencies ornewly implemented improvement plans provide staff with a means for keeping up to date with thestandards. Ongoing consultations naturally keep staff prepared for their triennial unit visit by theJCAHO survey team. Open record reviews or spot checks are being done as well as quarterly closedmedical record reviews.

The development of an annual calendar that provides for at least one consultative visit to patient caredepartments is crucial. Chapter leaders as well as other members of the operational leadership teamcan share this responsibility. Involving department leadership and staff through these regular effortswill support ongoing quality instead of just something that is looked at every three years.

8. Forum ParticipationAnother important part of the model to help Children’s remain continually accredited is the network-ing opportunities in which they participate. One such opportunity is the Child Health Corporation ofAmerica’s JCAHO Director Forum. The group, which has over 35 member children’s hospitals, is agreat way to share ideas with peer organizations for JCAHO preparation and standard compliance.Survey results of the member hospitals are shared via quarterly conference calls. In addition eachyear the JCAHO Director of Accreditation Standards meets directly with this group to share newstandards and discuss pediatric specific concerns.

The second opportunity that Children’s has taken advantage of is a local networking group sponsoredby the Georgia Hospital Association. GHA contracts directly with the Joint Commission to offer aJCAHO-ORION project. These projects vary from state to state, but most offer some type of contin-uous accreditation support services provided by a regional representative from the JCAHO staff. Byparticipating in the effort Children’s has received low cost JCAHO sponsored educational offeringsand field representative visits to their facilities for consultation.

Many subscription-based on-line discussion groups exist where accreditation and preparation experi-ences are shared. The Systems Director for Accreditation at Children’s subscribes to a list-serv toremain current with the latest trends in Type I’s and JCAHO surveyor “hot buttons.” In addition, spe-cific questions can be posted to the list-serv for such things as sample policies, procedures and evensurveyor biographies.

Information from these networking and educational opportunities are brought back to the organiza-tion and shared with the chapter leaders. The information has proved invaluable in developing andmaintaining the annual compliance plans.

9. Accreditation Year PlanTo ensure that all required accreditation preparation activities such as application submittal, surveyagenda planning and final document preparation are completed no continuous accreditation modelwould be complete without a detailed accreditation year plan. To ensure that ample time for mocksurveys, mock unit visits, mock interview sessions is provided a twelve month detailed plan for thetriennial year has been developed at Children’s.

The chapter reports and action plans will be utilized to track any outstanding issues. Putting all ofthese activities into a GANTT chart has been very useful and will be reviewed and updated at the inte-grated leadership meetings during a survey year.

The implementation of the other building blocks of the CSR model will make the final months beforeChildren’s next triennial visit much easier to manage. Children’s has managed to integrate many ofthese activities into the everyday life of the organization.

RESULTS

There have been three major outcomes from the implementation of the Continuous Survey Readinessmodel at Children’s Healthcare of Atlanta. The first outcome albeit the least tangible has been a cul-tural shift in the organization from one of “we are just doing this for JCAHO” to “because we dothings right we are meeting accreditation standards.” The best evidence of this shift has been the com-mitment that has been demonstrated to the CSR model. Chapter assessments are completed, projectsand indicators have been linked to standards and the document room is being populated. The secondmajor outcome is the current scores of the JCAHO chapter assessments. At any given time in the past


over 95% of the 560 standards have a score of 1-2 with appropriate evidence of compliance logged.The third major outcome has been the savings to the organization in accreditation related expenses of$18,193 in 1999. Over the course of the next three years a conservative estimate of the savings isexpected to be an additional $190,057. Figure 8 details this information.

CONCLUSION

Children’s Healthcare of Atlanta made the choice to be continually ready for an accreditation survey.The 9-point plan has been put in place and will be improved upon over the coming year. One of thethings that will be put in place for the year 2000 is a plan to achieve JCAHO network accreditation.These standards and the HCFA standards will be added to the accreditation manager and a new doc-ument room will be built for each standard set.

The customs form module within the HealthFlash( Internet-based project and document tool will beused to develop a form used in conducting the department rounds and consultative visits. Data will beentered directly from the department and housed in the centralized database so that on-line reportswill be available real time. The system will also be used to house and update facility condition infor-mation, plans for improvement and to automatically generate work orders. Another improvement willbe to move the chapter assessment process to August of each year to allow more coordination with theorganization’s budget process and strategic planning efforts.

Many of the strategies used at Children’s to implement the CSR model can be applied at other health-care organizations. The chapter leader role is one that can be adapted for most organizations. Thisrole and the annual chapter assessments can be the foundation for building a CSR model. Once thechapter assessments are completed, a routine to present and follow the course of each deficiency canbe developed that fit with the current operational meeting structure. These responsibilities are builtinto the current leadership structure. Have chapter leaders work with the education department to for-mulate a master education plan that builds on current opportunities so that major costs are not added.A centralized project and document management database with the features described in this articlecan be invaluable in keeping things on track in terms of compliance and managing the large task ofdocument review. The advantages of an Internet application are accessibility, connectivity and real-time information being available to all levels of the organization. In addition, careful planning of thequality structure that fits your organizational needs, but supports performance assessment and meas-urement goes along way to always being prepared. Many successful quality structures have been


Figure 8: Continuous Survey Model Savings

described in the literature. Ongoing rounds and department visits are easy to implement with the helpof chapter leaders and always keep the staff in tune to survey readiness. Take advantage of organiza-tions such as state hospital associations and national professional organizations that offer forumgroups devoted to accreditation and compliance issues. Seek out these opportunities and ensure thatyour leadership staff participates.

Planning how a continuous accreditation model will look in your organization is crucial. Once youhave decided which of the building blocks described in this article will work in your particular organ-ization, it is wise to present your model as a formal proposal to the senior leadership team. Althoughit may be hard to get the attention of the senior executives when it comes to JCAHO standards, youcan usually find a champion that can get the message across to the rest of the team. Identify yourchampion and arrange a strategy session with him or her to determine the best methods for gainingsenior management support for a continuous accreditation mindset. Begin by associating the JCAHOstandards to some of the key initiatives of the organization. If their goals are related to quality andcost reduction, design your proposal to address these goals. Demonstrating in your proposal how yourgoals for continuous survey readiness include their goals for the organization will quickly gain theacceptance and support for your model.

AUTHOR BIOGRAPHIES

Amelia S. Black, R.N., M.S.N. is a Program Strategist at Emerging Solutions, Inc. She has held posi-tions in education, management and consulting in the healthcare industry. She holds a BSN from theUniversity of Delaware and a MSN from the University of Pennsylvania.

Charlene C. Roberts, R.N., M.S. is the Director for System Accreditation at Children’s Healthcareof Atlanta. She has over 25 years experience in the field of pediatric health care and administration.

ACKNOWLEDGEMENT

The authors would like to acknowledge Susan Bowen, Systems Director of Quality Management atChildren’s Healthcare of Atlanta for the development of the organization’s quality structure and per-formance measurement plan format. In addition, they would like to thank Anna Umphress, EditorialServices Manager at Children’s Healthcare of Atlanta for her time and expertise in reviewing thispaper.


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