Introduction to Joint Commission
on Accreditation of Health Care Organizations

This section describes the Joint Commission on Accreditation of Health Care Organization and its new process of surveying hospitals.

Overview

The Joint Commission’s new accreditation process focuses on systems critical to the safety and the quality of care, treatment, and services. It represents a shift from a focus on survey preparation to a focus on continuous operational improvement by encouraging hospitals to incorporate the standards as a guide for routine operations.
Under this new accreditation process, the survey is the on-site evaluation piece of a continuous process.
The new accreditation process encourages hospitals to continuously use the standards to achieve and maintain excellent operational systems. Initiatives like the Periodic Performance Review (PPR) and the sharing of Priority Focus Process (PFP) information will facilitate this.

Implementation and Time Line

The time line in the following Figure shows how components of the new accreditation process play out across a time continuum.
The graphic displays the three-year accreditation cycle in terms of how it is experienced by a hospital from full on-site survey in July 2002 to its next full on-site survey in July 2005.*
Key Milestones in the Time Line
Approximately 15 months after your last on-site survey, Joint Commission will electronically send PPR access, the output of the PFP and instructions to your hospital on how to proceed.
Your hospital has 3 months to complete its PPR, during which time staff will evaluate compliance with standards using elements of performance (EPs)
For standards identified as “not compliant,” your hospital will develop a plan of action with measures of success (MOS), if required. At the 18-month point in the accreditation cycle, you will submit via a secure extranet Web space your PPR containing plan(s) of action to Joint Commission.
Approximately 30 days after your plan of action has been submitted, Joint Commission staff will review plans of action over the telephone and indicate whether the corrective actions, MOS, and the time frames are acceptable. Your accreditation decision is not affected if you conduct a PPR.
Nine months before your next triennial on-site survey, your hospital will complete an electronic application for accreditation.
Two weeks before your survey, Joint Commission will provide the most current output of the PFP for your hospital.
The surveyor(s) scheduled to conduct your survey will also receive the PFP output for your hospital. This information will help the surveyor(s) develop a survey process that focuses on issues that are unique to your hospital.
Triennial on-site survey occurs. The surveyor(s) will visit various its/programs or services using tracer methodology.
During the survey, the surveyor(s) will also look for evidence that your plan of action from the PPR has been implemented.
After evaluating your hospital’s performance, the survey team will review the results of its individual findings.
Before the closing conference, the survey team will enter its findings into laptop computers, thus producing a report of survey findings.
After the report has been rendered, the team leader will meet with your hospital’s chief executive officer (CEO) to provide him or her with a copy of the report.
It is up to the CEO to decide whether the report will be distributed at the exit conference; however, the survey team will use the contents of the report during its exit conference.
Approximately 48 hours after your survey has taken place, Joint Commission will post your report of survey findings on a secure automated area of the extranet site that is password protected for each organization.
If the surveyor(s) find requirements for improvement in your hospital, you have 90 days (45 days beginning July 1, 2005) following the posting of your organization’s Accreditation Report on the Jayco extranet to submit an Evidence of Standards Compliance (ESC).
During the 90-day/45-day period, your hospital’s prior accreditation decision will remain in effect.
If, at the end of the 90-day/45-day period, your hospital successfully addresses its requirements for improvement, it will be moved to an accreditation decision of “Accredited.”
After the 90-day/45-day time frame, either the ESC report is received and approved or your hospital is moved to an accreditation decision of “Provisional Accreditation.”
Your Quality Report will be made available to the public on Joint Commission’s Quality Check®.

Revised Standards and Scoring Format

As part of the Joint Commission’s new accreditation process initiative (Shared Visions–New Pathways®), the Joint Commission conducted a major review of the standards.
During this process, all standards were reviewed and subsequently streamlined to enhance the focus on key quality and safety issues.
The revisions achieve the following:
– Reduce redundancy
– Improve the clarity of standards language
– Reduce the associated paperwork and documentation of compliance burden

Definitions: ESC & MOS

Evidence of Standards Compliance (ESC) A report submitted by a surveyed organization within 45 days (90 days between January 1, 2004 and June 30, 2005) of its survey, which details the action(s) that it took to bring itself into compliance with a standard or clarifies why the organization believes that was in compliance with the standard for which it received a requirement for improvement.
An ESC must address compliance at the element of performance (EP) level and include a measure of success (MOS)
Measure of success (MOS) A numerical or quantifiable measure usually related to an audit that determines if an action was effective and sustained due four months after Evidence of Standards Compliance (see definition) approval.

Revised Scoring

Scoring was also revised.
The revised framework provides for the scoring of the standards as compliant or not compliant.
The accreditation decision will be based on a simple count of the standards that are judged not compliant
The EPs for each standard will be scored on the following scale:
0 Insufficient compliance
1 Partial compliance
2 Satisfactory compliance
NA Not applicable
The determination as to whether a hospital is compliant with a given standard is based on the scoring of that standard’s EPs.
An EP is a specific performance expectation related to a standard that details the specific structures or processes that must be in place for a hospital to provide quality care, treatment, and services.
Two components are scored for each EP:
(1) compliance with the requirement itself and
(2) compliance with the track record* for that requirement.
Scoring has been simplified from past years , and track record achievements (which have always been part of the scoring) have been appropriately modified.
If during an on-site survey, your hospital has been found to be not compliant with one or more standards, you must submit an ESC for each standard that is not compliant.
The ESC must address compliance at the EP level; when an EP within a noncompliant standard requires an MOS, your hospital must demonstrate achievement with the MOS when completing the ESC.

Revised Accreditation Process

Pre-survey Activities
Periodic Performance Review
The Joint Commission’s new accreditation process is designed to shift the focus from survey preparation and passing the triennial exam to continuous standards compliance and operational improvement in the provision of safe, high quality care, treatment, and services.
One component of the accreditation process that supports this paradigm shift is the Periodic Performance Review (PPR), a compliance assessment at the midpoint of your hospital’s accreditation cycle.

Periodic Performance Review (PPR)

The PPR is an Accreditation Participation Requirement for ambulatory care, behavioral health care, home care, hospitals, and long term care organizations.
The PPR helps your hospital review applicable standards, assess compliance, develop and implement plans of action, and identify measures by which you will gauge your success in carrying out those plans.
By participating in the PPR, your hospital will be better able to incorporate Joint Commission standards into routine operations, which in turn will help to ensure the provision of safe, high-quality care on an ongoing basis.
Beginning January 1, 2005, your hospital will have continuous access to the PPR tool through the password-protected “Jayco”™ extranet site.
At the 15-month point of the accreditation cycle, your hospital will be notified that it must submit to the Joint Commission no later than the 18-month point of your accreditation cycle your selection and completion of the full PPR, option 1, option 2, or option 3. Table 1 outlines some of the activities in each of these options.

Plans of Action

A plan of action is a detailed description of how a hospital plans to bring into compliance any standard identified as “not compliant” in the PPR (plans of action are not required for standards where some EPs are marked “partial compliance” but where the standard does not meet the level of “not compliant”).
The plan of action should include the planned action to be taken and target dates.
If the EP has an MOS, you must also describe the MOS or how you plan to gauge your successful implementation of your plans of action.
The PPR will only affect an organization’s accreditation decision if the organization fails to participate in the PPR process, whether the full or one of the three options, or through the PPR process, an immediate threat to life situation* is identified.
If you need more information while completing your PPR, please contact your account representative.

Priority Focus Process

An important component of the Joint Commission’s accreditation process is the Priority Focus Process (PFP), which guides surveyors in planning and conducting your on-site survey.
The PFP uses an automated tool, which takes available data from a variety of sources—including electronic applications (e-Apps) for accreditation, previous survey findings, complaint data, ORYX core measure data (for hospitals only), and publicly available external data (such as MedPAR or OASIS)—and integrates them to identify clinical/service groups (CSGs) and priority focus areas (PFAs) for your hospital.
The PFP converts this data into information that focuses survey activities, increases consistency in the accreditation process, and customizes the accreditation process to make it specific to your hospital.
Surveyors will receive enhanced information and insight about a hospital before the on-site survey.
The PFP integrates various pre-survey data (listed below) on each hospital and recommends the PFAs (“priority focus areas” and “clinical/service groups”) for the on-site survey.
This information will guide tracer activities for more However, the PFP does not preclude any area from being surveyed.
From these sources, the PFP identifies PFAs for each hospital on which surveyors initially will focus during the initial part of the on-site survey.
Surveyors will use the PFP in the following ways:
– Two weeks before the triennial survey, the surveyor(s) assigned to your hospital will have access to your hospital’s PFP information via the surveyor extranet
– Surveyors will review the PFP information for hospital-specific PFAs as well as for hospital specific clinical/service groups
– As part of the planning process, surveyors will begin to assess and plan their tracer activities
– During the on-site survey, the surveyors will use the hospital’s active patient list to select tracer patients
The PFP will also be used for a hospital undergoing its initial survey.
The only difference with this type of hospital (versus a hospital that has already gone through a survey) is in the available data inputs that feed the PFP.
Hospitals undergoing initial survey will not have previous requirements for improvement (referred to as “type I recommendations” before January 1, 2004) or ORYX data available to feed into the PFP.
For initial surveys, Joint Commission will only be able to feed electronic application (e-App) data, external data (as applicable), and Office of Quality Monitoring (OQM) data into the PFP.
After these data are transformed to become the PFP information, the process for initial surveys is no different from any other type of survey. The data will be aggregated in the same manner to determine the PFAs and clinical/service groups for the hospital.
Priority focus areas (PFAs) are processes, systems, or structures in a health care organization that significantly impact safety and/or the quality of care provided.
The list of PFAs was developed from information provided by the Joint Commission’s Office of Quality Monitoring, expert literature, and expert opinions.
Joint Commission categorized the different processes, systems, and structures leading to improved health care in 14 PFAs.
The PFAs evolved from this process of identifying common patterns useful toward building positive health care outcomes and safe, quality health care.
The PFAs provide a consistent yet customized approach to providing an initial focus for the on-site survey process, and they may assist the health care organization at the time of its PPR.

Priority Focus Areas

Assessment and Care/Services
Communication
Credentialed Practitioners
Equipment Use
Infection Control
Information Management
Medication Management
Organizational Structure
Orientation & Training
Patient Safety
Physical Environment
Quality Improvement Expertise/Activities
Rights & Ethics
Staffing
Priority Focus Areas
Assessment and Care/Services
Assessment and Care/Services for patients comprise the execution of a series of processes including, as relevant:
– assessment;
– planning care,
– treatment, and/or services;
– provision of care;
– ongoing reassessment of care; and discharge planning,
– referral for continuing care, or discontinuation of services.
Assessment and Care/Services are fluid in nature to accommodate a patient’s needs while in a care setting.
While some elements of Assessment and Care/Services may occur only once, other aspects may be repeated or revisited as the patient’s needs or care delivery priorities change.
Successful implementation of improvements in Assessment and Care/Services rely on the full support of leadership.

Priority Focus Areas: Communication

Communication is the process by which information is exchanged between individuals, departments, or organizations.
Effective communication successfully permeates every aspect of a health care organization, from the provision of care to performance improvement, resulting in a marked improvement in the quality of care delivery and functioning.
Sub-processes of Communication include the following:
– Provider and/or staff-patient communication
– Patient and family education
– Staff communication and collaboration
– Information dissemination
– Multidisciplinary teamwork

Priority Focus Areas: Credentialed Practitioners

Credentialed Practitioners are health care professionals whose qualification to provide patient care services have been verified and assessed, resulting in the granting of clinical privileges. They typically are not employed staff at the health care organization.
The category varies from organization to organization and from state to state.
It includes licensed independent practitioners and, in some settings, nurse practitioners, advanced practice registered nurses, and physician assistants who are permitted to provide patient care services under the direction of a sponsoring physician.
Licensed independent practitioners are permitted by law and the health care organization to provide care and services without clinical supervision or direction within the scope of their license and consistent with individually granted clinical privileges.

Priority Focus Areas: Equipment Use

Equipment Use incorporates the selection, delivery, setup, and maintenance of equipment and supplies to meet patient and staff needs.
It generally includes movable equipment, as well as management of supplies that staff members use (for example, gloves, syringes).
(Equipment Use does not include fixed equipment such as built-in oxygen and gas lines and central air conditioning systems; this is included in the Physical Environment focus area.)
Equipment Use includes planning and selecting; maintaining, testing, and inspecting; educating and providing instructions; delivery and setup; and risk prevention related to equipment and/or supplies.
Sub-processes of Equipment Use include the following:
– Selection
– Maintenance strategies
– Periodic evaluation
– Orientation and training

Priority Focus Areas: Infection Control

Infection Control includes the surveillance/identification, prevention, and control of infections among patients, employees, physicians, and other licensed independent practitioners, contract service workers, volunteers, students, and visitors.
This is a system-wide, integrated process that is applied to all programs, services, and settings.
Sub-processes of Infection Control include the following:
- Surveillance/identification
- Prevention and control
- Reporting
- Measurement

Priority Focus Areas: Information Management

Information Management is the interdisciplinary field concerning the timely and accurate creation, collection, storage, retrieval, transmission, analysis, control, dissemination, and use of data or information, both within an organization and externally, as allowed by law and regulation.
In addition to written and verbal information, supporting information technology and information services are also included in Information Management.
Sub-processes of Information Management include the following:
– Planning
– Procurement
– Implementation
– Collection
– Recording
– Protection
– Aggregation
– Interpretation
– Storage and retrieval
– Data integrity
– Information dissemination

Priority Focus Areas: Medication Management

Medication Management encompasses the systems and processes an organization uses to provide medication to individuals served by the organization.
This is usually a multidisciplinary, coordinated effort of health care staff, implementing, evaluating, and constantly improving the processes of selecting, procuring, storing, ordering, transcribing, preparing, dispensing, administering (including self-administering), and monitoring the effects of medications throughout the patients’ continuum of care.
In addition, Medication Management involves educating patients and, as appropriate, their families, about the medication, its administration and use, and potential side effects.
Sub-processes of Medication Management include the following:
– Selection
– Procurement
– Storage
– Prescribing or ordering
– Preparing
– Dispensing
– Administration
– Monitoring

Priority Focus Areas: Organizational Structure

The Organizational Structure is the framework for an organization to carry out its vision and mission.
The implementation is accomplished through corporate bylaws and governing body policies, organization management, compliance, planning, integration and coordination, and performance improvement.
Included are the organization’s governance; business ethics, contracted organizations, and management requirements.
Sub-processes of Organizational Structure include the following:
– Management requirements
– Corporate by-laws and governing body plans
– Organization management
– Compliance
– Planning
– Business ethics
– Contracted services

Priority Focus Area: Orientation & Training

Orientation is the process of educating newly hired staff in health care organizations to organization-wide, departmental, and job-specific competencies before they provide patient care services.
“Newly hired staff” includes, but is not limited to, regular staff employees, contracted staff, agency (temporary) staff, float staff, volunteer staff, students, housekeeping, and maintenance staff.
Training refers to the development and implementation of programs that foster staff development and continued learning, address skill deficiencies, and thereby help to ensure staff retention.
More specifically, it entails providing opportunities for staff to develop enhanced skills related to revised processes that may have been addressed during orientation, new patient care techniques, or expanded job responsibilities. Whereas orientation is a one-time process, training is a continuous one.
Sub-processes of Orientation & Training include the following:
– Organization-wide orientation
– Departmental orientation
– Job-specific orientation
– Training and continuing or ongoing education

Priority Focus Areas: Patient Safety

Effective Patient Safety entails proactively identifying the potential and actual risks to safety, identifying the underlying cause(s) of the potential, and making the necessary improvements so risk is reduced.
It also entails establishing processes to respond to sentinel events, identifying cause through root cause analysis, and making necessary improvements.
This involves a systems-based approach that examines all activities within an organization that contribute to the maintenance and improvement of patient safety, such as performance improvement and risk management to ensure the activities work together, not independently, to improve care and safety.
The systems-based approach is driven by organization leadership, anchored in the organization’s mission, vision, and strategic plan, endorsed and actively supported by medical staff and nursing leadership, implemented by directors, integrated and coordinated throughout the organization’s staff, and continuously re-engineered using proven, proactive performance improvement modalities.
In addition, effective reduction of errors and other factors that contribute to unintended adverse outcomes in an organization requires an environment in which patients, their families, and organization staff and leaders can identify and manage actual and potential risks to safety.
Sub-processes of Patient Safety include the following:
– Planning and designing services
– Directing services
– Integrating and coordinating services
– Error reduction and prevention
– The use of Sentinel Event Alerts
– Joint Commission’s National Patient Safety Goals
– Clinical practice guidelines
– Active patient involvement in their care

Priority Focus Areas: Physical Environment

The Physical Environment refers to safe, accessible, functional, supportive, and effective Physical Environment for patients, staff members, workers, and other individuals, by managing physical design; construction and redesign; maintenance and testing; planning and improvement; and risk prevention, defined in terms of utilities, fire protection, security, privacy, storage, and hazardous materials and waste.
The Physical Environment may include the home in the case of home care and foster care.
Sub-processes of Physical Environment include the following:
– Physical design
– Construction and redesign
– Maintenance and testing
– Planning and improvement
– Risk prevention

Priority Focus Areas: Quality Improvement Expertise/Activities

Quality Improvement identifies the collaborative and interdisciplinary approach to the continuous study and improvement of the processes of providing health care services to meet the needs of consumers and others.
Quality Improvement depends on understanding and revising processes on the basis of data and knowledge about the processes themselves.
Quality Improvement involves identifying, measuring, implementing, monitoring, analyzing, planning, and maintaining processes to ensure they function effectively.
Examples of Quality Improvement Activities include:
– designing a new service,
– flowcharting a clinical process,
– collecting and analyzing data about performance measures or patient outcomes,
– comparing the organization’s performance to that of other organizations,
– selecting areas for priority attention, and experimenting with new ways of carrying out a function.
Sub-processes of Quality Improvement Expertise/Activities include the following:
– Identifying issues and establishing priorities
– Developing measures
– Collecting data to evaluate status on outcomes, processes, or structures
– Analyzing and interpreting data
– Making and implementing recommendations
– Monitoring and sustaining performance improvement

Priority Focus Areas: Rights & Ethics

Rights & Ethics include patient rights and organizational ethics as they pertain to patient care.
Rights & Ethics addresses issues such as patient privacy, confidentiality and protection of health information, advance directives (as appropriate), organ procurement, use of restraints, informed consent for various procedures, and the right to participate in care decisions.
Sub-processes of Rights & Ethics include the following:
– Patient rights
– Organizational ethics pertaining to patient care
– Organizational responsibility
– Consideration of patient
– Care sensitivity
– Informing patients and/or family

Priority Focus Areas: Staffing

Effective Staffing entails providing the optimal number of competent personnel with the appropriate skill mix to meet the needs of a health care organization’s patients based on that organization’s mission, values, and vision.
As such, it involves defining competencies and expectations for all staff (the competency of licensed independent practitioners and medical staff are addressed in the Credentialed Practitioners priority focus area for all accreditation programs);
Staffing includes assessing those defined competencies and allocating human resources necessary for patient safety and improved patient outcomes.
Sub-processes of Staffing include the following:
– Competency
– Skill mix
– Number of staff

Clinical/Service Groups

Clinical/service groups (CSGs) categorize patients and/or services into distinct populations for which data can be collected.
The Joint Commission created the list of CSGs based on data gathered from e-Apps from each accreditation program and on publicly available data from external sources.
The list then underwent a thorough review to make sure that all categories were actually representative of populations served or services provided by the organizations surveyed by theindividual accreditation programs.
Joint Commission surveyors use a hospital’s CSGs combined with other hospital-specific data to get a better understanding of the hospital’s systems and the patients it serves. Tracer patients are selected according to CSGs.
Clinical/Service Groups for Hospitals
● Cardiac surgery
● Cardiology*
● Dentistry
● Dermatology
● Endocrinology
● Gastroenterology
● General medicine
● General surgery
● Gynecology
● Hematology
● HIV infection
● Neonatology*
● Nephrology
● Neurology
● Neurosurgery
● Normal newborns
● Obstetrics*
● Oncology
● Ophthalmology
● Orthopedic
● Otolaryngology
● Pediatrics*
● Psychiatry
● Pulmonary*
● Rehabilitation
● Rheumatology
● Substance abuse
● Thoracic surgery
● Trauma
● Urology
● Vascular surgery
● Other

On-Site Survey Activities: Survey Agenda

The on-site survey process shifts the focus from survey preparation and scores to continuous operational improvement in support of safe, high-quality care, treatment, and services.
The survey agenda will include the following elements (in no particular order)
Opening Conference And Orientation To The Organization.
The opening session will be an opportunity for introductions and for an orientation to the structure and content of the survey.
At this time, your hospital will briefly explain its structures, mission, vision, and relationship with the community.

Surveyor Planning Session

During this session, the surveyor(s) will review data and information about the hospital, including plans of action generated from the PPR, and plan the survey agenda.
The surveyor(s) will also select initial tracer patients.
Leadership Session.
Surveyors will discuss the following with leaders:
- Information gathering and baseline assessment of leadership-level, system issues—system standards, management oversight and direction, and other leadership responsibilities
- Leadership’s approach to the PPR and methods used to address areas needing improvement
- Ongoing initiatives to improve delivery of health care Safety program and National Patient Safety Goals
- Oversight by trustees or board

Individual Tracer Activity.

During the tracer activity, the surveyor will do the following:
- Follow the course of a type of care, treatment, and service provided to the patient by the hospital
- Assess the interrelationships among disciplines and departments (where applicable) and the important functions in the care, treatment, and services provided
- Evaluate the performance of processes relevant to the care, treatment, and service needs of the patient, with particular focus on the integration and coordination of distinct but related processes
- Identify vulnerabilities in the care processes

Special Issue Resolution.

This session provides an opportunity for surveyors to follow up on potential findings that could not be resolved in other survey activities.
Daily Briefing
During the daily briefing, the surveyor will do the following:
- Facilitate leadership’s understanding of the survey process and the findings that contribute to the accreditation decision
- Report on findings from the previous day’s survey activities
- Emphasize patterns or trends of significant concern that could lead to noncompliance determinations
- Highlight any positive findings or exemplary performance
- Allow the hospital to provide information that may have been missed during the previous survey day
- Review the agenda for the survey day ahead and make any necessary adjustments based on hospital needs or the need for more intensive assessment of an issue

Competence Assessment Process

This process will help the hospital and the surveyor to do the following:
- Identify the competence-assessment, process-related strengths and vulnerabilities of staff and, as applicable, licensed independent practitioners
- Begin the assessment or determine the degree of compliance with relevant standards
- Identify human resources issues requiring further exploration

Medical Staff Credentialing and Privileging.

This activity will help the hospital and the surveyor to identify specific issues related to the following:
- Evaluation of the process the hospital uses to collect relevant data for decisions for appointment
- Evaluation of consistent implementation of the credentialing and privileging process
- Evaluation of processes for the granting and the appropriate delineation of privileges
- Determination that practitioners practice within the limited scope of delineated privileges
- Link results of peer review and focused monitoring to the credentialing and privileging process
- Identify vulnerabilities in the credentialing, privileging, and appointment process

Environment of Care Session

This session will help the hospital and the surveyor do the following:
- Identify vulnerabilities and strengths in their processes
- Begin to identify or determine the action(s) necessary to address any identified vulnerabilities
- Begin the assessment or determine the hospital’s actual degree of compliance with relevant standards
- Identify EC processes requiring further evaluation of implementation
- Identify issues requiring further exploration

System Tracer Sessions

System tracers are interactive sessions with surveyors and hospital staff that explore the performance of important patient-related functions that cross the hospital.
Surveyors and hospital staff will address critical risk points and provide education during the system tracer sessions.
The following are the system tracers:
Medication Management
Infection Control
Data Use

CEO Exit Briefing and Organization Exit Conference.

During this conference, the surveyor(s) will do the following:
- – Report the outcome of the survey and present the Accreditation Report if desired by the CEO or administrator
- – Review the issues of standards compliance that have been identified during the survey
- – Allow the hospital a final on-site opportunity to question the survey findings or provide additional material regarding standards compliance
- – Gain agreement between the surveyor(s) and the hospital regarding the survey findings, when possible
- – Review required follow-up actions, as applicable

Life Safety Code® (LSC) Building Tour

This session will help the organization and surveyor do the following:

Identify areas of concern in the organization’s processes for designing buildings to LSC requirements
Identify areas of concern in the organization’s processes for maintaining buildings to LSC requirements
Identify areas of concern in the organization’s processes for identifying and resolving LSC problems
Determine the organization’s degree of compliance with relevant LSC requirements
Identify or determine the action(s) necessary to address any identified LSC problems

Surveyor Team Meeting

On surveys being conducted by more than one surveyor, scheduled team meetings provide an opportunity for surveyors to share information and observations, plan for upcoming survey activities, and plan for communication and coordination with the organization.
Surveyor Report Preparation. The surveyor(s) will use this time to compile, analyze, and organize the data he or she has collected throughout the survey into a report reflecting the organization’s compliance with standards.

Tracer Methodology: Individual Tracer Activity

The tracer methodology is the cornerstone of the new survey process.
The individual tracer activity is an evaluation method conducted during an on-site survey designed to “trace” the care experiences that a patient had while at the hospital.
The tracer methodology is a way to analyze a hospital’s systems of providing care, treatment, and services using actual patients as the framework for assessing standards compliance.
Surveyors will use the following general criteria to select initial individual tracers:
- – Patients in top CSGs and PFAs for that organization
- – Patients who cross programs, for example, long term care residents who present at a hospital or some care patients received from a hospital in complex organizations
- – Patients related to system tracer topics such as infection control or medication management
- – Patients receiving complex services, such as surgery or treatment in an intensive care unit*
The typical patients selected for initial tracer activity will be those identified in the hospital’s PFP information as listed in the CSGs.
Based on identified PFAs and CSGs, the surveyor will identify patient tracers and follow specific patients through the hospital’s processes.
A surveyor will not only examine the individual components of a system but will also evaluate how the components of a system interact with each other. n other words, a surveyor will look at the care, treatment, and services provided by each department/unit/program and service, as well as how departments/units/programs and services work together
Surveyors may start where the patient is currently located. They then can move to where the patient first entered the organization’s systems, an area of care provided to the patient that may be a priority for that organization, or to any areas in which the patient received care, treatment, and services.
Along the way, surveyors will speak with health care staff members who actually provided the care to that tracer patient—or, if that staff member is not available, will speak with another staff member who provides the same type of care.
Based on the surveyor’s findings, he or she may select similar patients to trace.
The tracer methodology permits surveyors to “pull the threads” if there is a reason to believe that an issue needs further exploration.

System Tracer Activity

System tracers differ from individual tracers in that during individual tracers, the surveyor follows a specific patient through his or her course of care, evaluating all aspects of care. System tracers follow the flow of one specific system or process across the organization.
During the system tracer sessions, surveyors evaluate the system/process including, the integration of related processes, and the coordination and communication among disciplines and departments in those processes.
A system tracer includes an interactive session (involving a surveyor and relevant staff members).
Points of discussion in the interactive session include the following:
- The flow of the process across your hospital, including identification and management of risk points, integration of key activities, and communication among staff/units involved in the process
- Strengths in the process and possible actions to be taken in areas needing improvement
- Issues requiring further exploration in other survey activities
- A baseline assessment of standards compliance
- Education by the surveyor, as appropriate
The three topics evaluated with system tracers are:

Data Use The data use system tracer focuses on how your hospital collects, analyzes, interprets, and uses data to improve patient safety and care.

Infection Control The infection control system tracer explores your hospital’s infection control processes. The goals of this session are to assess your hospital’s compliance with the relevant infection control standards, identify infection control issues that require further exploration, and determine actions that may be necessary to address any identified risks and improve patient safety.

Medication Management The medication management system tracer explores your hospital’s medication management processes, while focusing on sub-processes and potential risk points (such as hand-off points). This tracer activity helps the surveyors evaluate the continuity of medication management from procurement of medications through the monitoring of their effects on patients

The Role of Staff in Tracer Methodology

To help the surveyor or survey team in the tracer methodology, staff will be instructed to provide the surveyor or survey team with a list of active patients including the patients’ names, current locations in the hospital, and diagnoses, as appropriate. Surveyors may request assistance from hospital staff for selection of appropriate tracer patients.
As surveyors move around a hospital, they will ask to speak with the staff members who have been involved in the tracer patient’s care, treatment, and services. If those staff members are not available, they will ask to speak to another staff member who would perform the same function(s) as the member who has cared for or is caring for the tracer patient.
Although it is preferable to speak with the direct caregiver, it is not mandatory because the questions that will be asked are questions that any caregiver should be able to answer in providing care to the patient being traced.

The Accreditation Decision Process

The goal of the new accreditation decision and reporting approach is to move hospitals away from focusing on achieving high scores to achieving and maintaining safe, high-quality systems of care, treatment, and services. During the decision process, there will be no numerical scores, and thus no scores will be disclosed to the organizations or to the public.
The lack of scores will facilitate shifting the focus from passing the exam to continuous operational improvement.
Changes to the new accreditation decision process
Scoring of EPs will be on the following scale:
– satisfactory compliance (2),
– partial compliance (1),
– insufficient compliance (0), or
– not applicable (NA)
Standards will be identified as compliant or not compliant
Type I recommendations will be replaced with “Requirements for Improvement”
The surveyor will leave an Accreditation Report of findings on site
The Accreditation Report will be posted on the hospital’s secure, password-protected extranet Web site space approximately 48 hours after survey
If the surveyor(s) find requirements for improvement, there is a 90-day window to submit an ESC report.
Beginning July 1, 2005, the ESC will be due within 45 calendar days of the Accreditation Report being posted on the Jayco extranet.

New Accreditation Decision Categories: Accredited

The organization is in compliance with all standards at the time of the on-site survey or has successfully addressed all requirements for improvement in an ESC within 90 days following the survey (45 days beginning July 1, 2005)
Provisional Accreditation—The organization fails to successfully address all requirements for improvement in an ESC within 90 days following the survey (45 days beginning July 1, 2005)
Conditional Accreditation
The organization is not in substantial compliance with the standards, as usually evidenced by a count of the number of standards identified as not compliant at the time of survey which is between two and three standard deviations above the mean number of noncompliant standards for organizations in that accreditation program.
The organization must remedy identified problem areas through preparation and submission of ESC and subsequently undergo an on-site, follow-up survey.

Preliminary Denial of Accreditation

There is justification to deny accreditation to the organization as usually evidenced by a count of the number of noncompliant standards at the time of survey which is at least three standard deviations above the mean number of standards identified as not compliant for organizations in that accreditation program.
The decision is subject to appeal prior to the determination to deny accreditation; the appeal process may also result in a decision other than Denial of Accreditation.

Denial of Accreditation
The organization has been denied accreditation. All review and appeal opportunities have been exhausted.
Preliminary Accreditation
The organization demonstrates compliance with selected standards in the first of two surveys conducted under the Early Survey Policy Option 1.

Accreditation Decision

A final decision letter will be posted to the hospital’s secure, password protected Web site when its ESC has been reviewed and an accreditation decision has been rendered.

A Quality Report will then be posted on Quality Check® on the Joint Commission’s Web site.

Recently Asked Questions

Ask a question and we will answer it within the next 48 hours. If you have no questions, please review the answer to the questions asked by others:

Question: Resuscitation services for JACHO 9.30 do you do this by teaching classes like CPR/ACLS/PALS and are competencies required??? Answer: I am sorry but the faculty member who has been responsible for answering these questions will not be available till next summer. We appologize for the delay but this is one area where we do not have access to our faculty member through out the year.

Question: What is the basic difference between the JCAHO survey process and the AAAHC survey process of an ambulatory healthcare entity, and which one is performing more surveys? Answer: The basic difference is that JCAHO is not limited to ambulatory care centers. Its accreditiaon services are extended to the following organizations • Ambulatory Care • Assisted Living • Behavioral Health Care • Critical Access Hospitals • Home Care • Hospitals • Laboratory Services • Long Term Care • Networks • Office-Based Surgery AAAHC is more focused on ambulatory surgical centers. Regarding the number of surveys conducted, I'd expect the JCAHO to conduct more surveys especially that in many instances the ambulatory surgical centers belong to hospitals that require JCHAO ascription.

Question: Am I correct in assuming that CSG's are the equivalent of Diagnosic related groups (DRG's)? Answer: No they are different

Suggestions for Improvement

You can add your suggestions or read below suggestions made by others:

Suggestion: This is yet another excellent lecture on JCAHO. It is well put together, organized, and easy to follow. I wish the lecture has a depiction of a real world example of a JCAHO survey of a healthcare organization.

Suggestion: Another very imformative lecture, however, I am not "connected" to the website; my questions are the only ones showing up and are not answered. This is obviously a technical problem. I'm rating the lecture 4 instead of 5 stars not based on lecture content but on this continuing problem. I would like to benefit from my fellow students questions/comments and that isn't happening.

Additional Reading Materials

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Introduction to Joint Commission on Accreditation of Health Care Organizations