CRITICAL ACCESS HOSPITAL ACCREDITATION

1. CRITICAL ACCESS HOSPITAL ACCREDITATION Fall 2002 Teleconference Presentation

2. JCAHO Contacts • Kurt Patton, Executive Director, Accreditation Operations (630)792-5810; kpatton@jcaho.org • Meg Gravesmill, Accreditation Operations (630) 792-5813; mgravesmill@jcaho.org • Laura Smith, Standards Development, (630) 792-5098; lsmith@jcaho.org

3. JCAHO contacts • Darlene Christiansen, Survey Process, (630) 792-5273; dchristiansen@jcaho.org • Phavinee Thongkhong-Park, Survey Process, (630) 792-5984; ppark@jcaho.org • Mark Schario, Surveyor Management, (630) 792-5706; mshario@jcaho.org • Frank Zibrat, ORYX (630) 792-5992; fzibrat@jcaho.org

4. PRESENTATION OVERVIEW • Conceptual framework for the standards • Standards development process • Findings from test surveys • Structure of the Accreditation Manual for CAH • COP linkages • Swing bed requirements • Scoring CAH standards and the survey report • Capping of supplemental standards • Conversion from HAP to CAH • CAH performance measurement (ORYX) requirements

5. CAH STANDARDS DEVELOPMENT • Reviewed Medicare Conditions of Participation (COPS) to identify provider requirements • Field observations and surveys at CAH’s • Identified HAP standards and LTC standards that crosswalk to COPS • Created first draft and conducted test surveys and field review.

6. CAH ACCREDITATION • Observations at CAH’s indicate that the level of complexity and scope of services are more than might be envisioned by the conditions alone. • Challenge was to design a standards manual and survey process that adequately evaluates the services, yet is still reasonable in depth of preparation and cost.

7. CAH ACCREDITATION • Visits to 4 CAH’s for information gathering • Development of a standards crosswalk • Draft of a survey process built off small and rural JCAHO model • Plan for a process that is less than a 2X2 • Extension surveys at accredited CAH’s • Testing at 6 CAH’s, accredited and nonaccredited, in 5 states.

8. CONGRUENCE WITH CONDITIONS OF PARTICIPATION • JCAHO Hospital survey process designed to assess compliance with standards in the CAMH. • JCAHO LTC survey process designed to assess compliance with standards in the CAMLTC • Both CAMH and CALTC standards can be cross walked to Medicare COPS. • CAH conditions combine features of CAMH and CAMLTC.

9. EXAMPLE OF A STANDARDS CROSSWALK • 485.608 (a) Compliance with state law and regulation • MA.2 & MA.2.1 • 485.608 (b) • MA.2 & MA.2.1 • 485.608 (c) • MA.2 & MA.2.1 • 485.608 (d) • HR.2

10. COPS/STANDARDS CROSS WALK • 485.608 Condition of participation: Compliance with Federal, State, and local laws and regulations. • The CAH and its staff are in compliance with applicable Federal, State, and local laws and regulations. • (a) Standard: Compliance with Federal laws and regulations. The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. • (b) Standard: Compliance with State and local laws and regulations. All patient care services are furnished in accordance with applicable State and local laws and regulations. • (c) Standard: Licensure of CAH. The CAH is licensed in accordance with applicable Federal, State, and local laws and regulations.

11. COPS/STANDARDS CROSS WALK • MA.2 The chief executive officer provides for the hospital’s compliance with applicable law and regulation and • MA.2.1 The chief executive officer reviews and promptly responds to reports and recommendations from planning, regulatory, and inspecting agencies, as outlined by the governing body. • Intent of MA.2 and MA.2.1 • The hospital's chief executive officer provides for • • the hospital's compliance with applicable law and regulation and • • filing applicable legal documents and copies of the hospital's state licensure or certification. • The chief executive officer is responsible for implementing governing body policies. The governing body defines the chief executive officer's responsibility for acting on reports or recommendations from planning, regulatory, and inspecting agencies.

12. CAH STANDARDS DEVELOPMENT • Field review critical of the extensive supplemental expectations • Developed “parent” standard and “offspring” concept, e.g. TX.1, TX.1.1, TX.1.1.1, TX.2 • Added most parent level standard not already identified through COPS

13. CAH STANDARDS DEVELOPMENT • Circulated redraft to consultants and email contacts who had inquired about accreditation • Presented to and approved by JCAHO leadership • Presented to and approved by JCAHO Board Committees October 2001

14. CAH STANDARDS and the ACCREDITATION MANUAL • Chapters and performance areas identical to hospital manual – standards are different • Policies, Sentinel events and APRs except ORYX are identical • Patient Focused Functions: • Rights and Organizational ethics (RI) • Assessment of Patients (PE) • Care of Patients (TX) • Education (PF) • Continuum of care (CC)

15. CAH STANDARDS and the ACCREDITATION MANUAL • Organization Focused Functions: • Improving Organization Performance (PI) • Leadership (LD) • Management of the Environment (EC) • Management of Human Resources (HR) • Management of Information (IM) • Surveillance, Prevention and Control of Infection (IC)

16. CAH STANDARDS and the ACCREDITATION MANUAL • Structures with Functions: • Governance (GO) • Management (MA) • Medical Staff (MS) • Nursing (NR) • Glossary

17. CAH STANDARDS and the ACCREDITATION MANUAL Major Differences • Fewer standards per functional area • Standards focus on COPS and major care principles, less on prescriptive “how to” mandates • Supplemental (not linked to a COP) standards are capped at 3 • APR for performance measurement does not require enrollment in a performance measurement system

18. CAH STANDARDS and the ACCREDITATION MANUAL • Major Differences – hard bound manual, not designed to update 4 x year • Most, but not all patient safety standards from HAP were included • New staffing effectiveness standards from HAP were not included • Pharmacist review of medication orders before the first dose is dispensed is not included • New Patient Safety Goals do become effective January 1, 2003

19. CAH STANDARDS FORMAT • Some standards are reviewed in all areas of the CAH. • Some standards are only reviewed in the designated swing bed area • Some standards have an expanded intent statement incorporating Medicare COP language • Some standards link completely to a Medicare COP • Some standards are JCAHO only and have no link to Medicare COP’s – called supplemental standards

20. EXAMPLE OF A SUPPLEMENTAL STANDARD • PE.1 Each patients physical, psychological, and social status are assessed. • Not linked to a Medicare COP • Capped at a 3 • Evaluate in all patient care areas • Type 1 recommendation will not adversely effect deeming or conversion

21. CAH STANDARDS LINKED TO COPS AND FULLY MATCHED • PE.1.3 and PE.1.3.1 – The JCAHO standard as written in the hospital manual, and now the CAH manual fully meets the intent of the COP. No additional federal language needed to be added to the intent statement. • Linked to COP 485.635(b)(1)

22. CAH STANDARDS LINKED TO COPS WITH EXPANDED INTENT STATEMENT • PE.1.4 – PE.1.4.1.1 • However, some elements of the assessment of a patient must be performed and documented by all critical access hospitals and for all patients within 24 hours of admission, even on weekends and holidays. These elements are:………pulled into the manual directly from COP language

23. CAH STANDARDS EVALUATED ONLY ON SWING BEDS • PE.1.4.2 – Each resident’s initial assessment is completed within the timeframe specified by organization policy or by law and regulation, not to exceed 14 days. • Corresponds to COP 488.20(b)(4)I and iii)

24. CAH STANDARDS LINKED TO COPS ON SWING BED UNITS AND NOT ACUTE UNITS • RI.1.1.1 – Informed consent is obtained • Corresponds to COP (d) (2)

25. NEW CAH SURVEY TYPE • Conversion Survey – this will be scheduled when a hospital is authorized by the state Office of Rural Health to convert to CAH status. At the completion of the conversion survey JCAHO will notify CMS that the hospital has successfully passed the survey and may be designated a CAH.

26. CONVERSION SURVEYS • Most hospitals (almost 700) that were going to become a CAH have already gone through the conversion process. • The hospital seeking to convert must be authorized to convert by the State. • After the survey is completed, the hospital may obtain a new Medicare provider number as a CAH.

27. CONVERSION SURVEYS • At the conclusion of the survey a conversion will not be approved if there are any type 1 recommendations against a COP standard. • COP standards are marked in the accreditation manual and report. These standards can be scored a 5. • All non COP standards are capped at 3. • The surveyor must tell the CAH about any type 1’s in COP linked standards

28. CONVERSION SURVEYS • The CAH must immediately prepare a 1 month WPR to clear any type 1’s against a COP linked standard. • The surveyor must tell the organization which standards require an immediate response • The organization is not approved as a CAH until their clear the 1 month WPR

29. CONVERSION SURVEYS • At the time of the survey the CAH may not already have swing beds, as they may not be authorized to have swing beds until they are a CAH. • A track record of compliance cannot be evaluated for swing bed requirements in this case. • Federal requirements mandate a one year full follow up survey always be conducted after a conversion survey. • Resurvey due date is calculated off the first survey • Convert 2002, 1 year survey 2003, no survey 2004, resurvey 2005

30. CAH PRELIMINARY REPORT Critical access hospital accreditation does not have the usual laptop support at this time. A word based survey report form has been created.

31. CAH SURVEY REPORTS • Central office staff will prepare a final survey report and grid and mail it to the organization. • If this is a conversion survey, at the time of the exit conference, the surveyor will inform the organization of any type I recommendations. • If this is the first CAH accreditation survey, and the organization previously converted through a state survey, type 1’s do not block deemed status.

32. CONVERSION FROM HAP TO CAH • Currently accredited and become a CAH – notify the Joint Commission • When next due for survey we will use the CAH manual, not the CAMH • No extension survey needed given the scope of the CAMH survey • The CAH program will be an initial survey with a 4 month track record

33. MIDSTREAM SEMI -CONVERSIONS? • Some critical access hospitals have completed their conversion survey with the state while accredited by JCAHO as a hospital. • These CAH’s may be due for 1 year state follow-up survey • If due for JCAHO survey, JCAHO will schedule as a CAH and coordinate timing to substitute for 1 year state follow-up if possible.

34. ADDITIONAL CENTRAL OFFICE PROCESSES • JCAHO will send reports to CMS central, regional and state offices as needed • Central office will prepare the grid and score • Central office will tickler the 1 year follow-up if needed • Central office will coordinate with the state office of rural health

35. EARLY SURVEY OPTIONS • ESO1- 2 surveys, the first results in PROVISIONAL ACCREDITATION – Not deemed • Use ESO1 if very unfamiliar with JCAHO • ESO2 – 2 surveys, the first results in ACCREDITATION. No track record assessed on the first survey • Conversion survey must have a 1 year full follow-up • All surveys are assessed the fee

36. CAH ORYX REQUIREMENTS ORYX-related APR • Requires the use of a minimum of 6 performance measures per applicable accreditation program • NO REQUIREMENT to contract with a performance measurement system and transmit measure data to the Joint Commission • For initial survey • Provide surveyors with list of selected measures • No data collection/analysis required • For all subsequent surveys • Share evidence of data collection and analysis and any performance improvement activities that may have resulted with the surveyors at time of survey

37. CAH ORYX & CORE MEASURES REQUIREMENTS • A CAH may use core measures if applicable • Survey process for PI will include an assessment of the measure selection process, roles of leadership and medical staff, use of data to manage care, display of data and change activities

38. SUMMARY OF SURVEY FINDINGS • 55 organizations scheduled for survey through 12/31/02 • Majority of organizations were previously accredited by JCAHO. • 34 organizations have received their findings; average grid score was 95.

39. COMMON TYPE I RECOMMENDATIONS • HR.5* (staff meeting performance expectations in job description) • LD.1.3.2 (MS approves sources of patient care provided outside the CAH) • PE.1.2* (pain is assessed in all patients) • TX.3.3 (controlled prep and dispensing of medications) • IM.7.7*(medical record entry dated, author identified, and when necessary, authenticated.)

40. COMMON SUPPLEMENTAL RECOMMENDATIONS • IC.4 (CAH takes actions to prevent or reduce nosocomial infections) • EC.1.5.1 (Life safety code) • IM.7.7* (medical record entry dated, author identified, and when necessary, authenticated.) • HR.5* (staff meeting performance expectations in job description) • PE.1.2 *(pain is assessed in all patients)

41. QUESTIONS OR SUGGESTIONS FROM TODAY’S PARTICIPANTS