Maintaining Accreditation: Meeting the Challenges of Compliance

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Maintaining Accreditation Meeting the
Challenges of Compliance

• AATOD 20th Anniversary National Conference
• October, 2004
• Mary Cesare-Murphy, PhD
• Executive Director, Behavioral Healthcare
  Accreditation
• Megan Marx, MPA
• Associate Director, OTP Accreditation Project
• Joint Commission on Accreditation of Health Care
  Organizations

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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.

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2004 CAMBH Chapters with Non-Compliant
Standards Chapter of Non-compliant
Standards RI (Ethics, Rights
Responsibilities) 17 LD (Leadership)
7 APR (Accreditation Participation
Requirements) 7 HR (Management of Human
Resources) 37 PI (Improving Organization
Performance) 11 IC (Infection Control)
2 MM (Medication Management) 11 IM
(Information Management) 14 EC (Environment
of Care) 5 PC (Provision of Care, Treatment
Services) 45
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2004 OTPs Most Challenging Standards
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2004 OTPs Most Challenging Standards cont.
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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

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Individual-Focused Functions RI (Rights
Responsibilities Ethics) PE (Assessment) TX
(Care) PF (Education) CC (Continuum) Organiza
tion 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)
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2002 2003 OTPs Most Challenging Standards
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2002 2003 OTPs Most Challenging Standards
con.t
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Comparison of overall trend(s) identification
of problem areas within OTPs

• Standards most frequently cited in OTPs
  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.

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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.

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Periodic Performance Review
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Periodic Performance Review (PPR)

• Facilitates a more continuous accreditation by
  incorporating an additional mid-cycle evaluation.
• Provides for educational opportunities

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Periodic Performance Review

• 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.

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Periodic Performance Review

• 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.

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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.

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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.

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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 101-500
• 70 cases for a population over 500

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Plan of Action

• For each standard evaluated as Not compliant
  the organization will
• Described the planned action for each element of
  performance (EP) marked as partial or not
  compliant
• Develop a measure of success

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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

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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

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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 organizations specific
  performance review or action plans

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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

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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

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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

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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

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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

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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?

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• 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.

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Using Data to Improve Program Performance

• Facts Data
• Data Combinations Measures
• Analyzed Measures Information
• Applied Information Improvement
• Improvement generates knowledge

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Using Data to Improve Program Performance

• Follow these steps to avoid common pitfalls in
  data collection
• Review the specific purpose of your outcomes
  focused improvement project determine what
  information, measures and data are necessary to
  achieve that purpose.
• Review the specific information you need, specify
  performance measures that will generate that
  information identify the data that compose
  these measures.

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Using Data to Improve Program Performance

• Define indicator data elements.
• Determine the sources for all needed data.
• Create your data collection instruments.
• 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.
• Document your data collection plan.
• Pilot test the data collection tool and analysis
  strategies.

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Using Data to Improve Program Performance

• The Three Ts
• TREND
• Data over time on indicators
• TARGET
• Range of performance of each one
• TOGETHER
• Look at indicators in combination
• Joint Commission Benchmark January 2003 pgs 1,7

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Using Data to Improve Program Performance

• Types of Measurement
• Administrative Measures Productivity
• Comparison Measures Benchmarking
• Process Measure Access, Satisfaction
• Functional Measures Improvement
• Fidelity Measures Following processes

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Using Data to Improve Program Performance

• 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.

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Using Data to Improve Program Performance

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

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Using Data to Improve Program Performance

• 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.

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• Construct a Likert Measure
• List the functional elements that are important
  in the persons 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

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Using Data to Improve Program Performance

• 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.

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Using Data to Improve Program Performance

• 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.

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• Readily Available Outcome Measures
• Beck Depression
• Beck Anxiety
• CAP Childrens Attention Problems, for
  Attention Deficit Hyperactivity Disorder (ADHD)
• Conners (for ADHD)
• Yale Brown Obsessive Compulsive
• Michigan Alcohol Screening Test (MAST, for
  addiction)

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Using Data to Improve Program Performance

• Selecting the Measures
• Organizational Context
• Matching measures to your needs
• Measure what reflects your vision and mission

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Using Data to Improve Program Performance

• Organizational Context
• Organizational culture committed to data based
  decision making
• Technical management systems interdependent
  well integrated
• Support by top levels of management

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Using Data to Improve Program Performance

• Measures and your Mission
• Quality
• How do you know people are improving or at least
  maintaining functional level?
• Coordinated
• How can you tell if people can get needed
  services?
• Responsive
• What is your access goal? What is your actual
  access rate? Difference?????

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Using Data to Improve Program Performance

• Matching Measures to your Needs
• For example, measure what
• Reflects your population base
• Will help you improve outcomes
• Will help you improve financial status

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Using Data to Improve Program Performance

• 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?

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• Measures You Can Use
• Data Based Decision Questions
• Measures related to organizational safety
• Environment of Care (e.g., test results)
• Infection Control Rates
• Required Lab Tests (e.g., medication specific)
• Measures related to quality of your meetings
• Agenda? Minutes? Time for each agenda item?
  Timely attendance?

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Using Data to Improve Program Performance

• 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

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Using Data to Improve Program Performance

• Implementing Measures
• Other considerations
• Board administrative support
• Staff training
• Measurement Champion
• Emphasizing the benefits of measurement

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Joint Commission on Accreditation of Health Care
Organizations

• Mary Cesare-Murphy, PhD
• Executive Director, Behavioral Healthcare
  Accreditation
• 630-792-5790
• mcesaremurphy_at_jcaho.org
• Megan Marx, MPA
• Associate Director, OTP Accreditation Project
• 720-348-0672
• mmarx_at_jcaho.org