May 2001
Volume 65 |
Number 5
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| How
to Prepare for a Joint Commission Survey |
Jerry A. Cohen, M.D.
Beverly K. Philip, M.D.
Committee on Quality Management and Departmental Administration
Passing a survey of the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) requires a good understanding
of JCAHO's standards that apply to the institution and/or department
under review. Below is a review of relevant standards, annotated
by us in italics. The standard numbers given are from the Comprehensive
Accreditation Manual for Hospitals (JCAHO, January 1, 2001 update).
Assessment of Patients (PE)
PE.1.8.1 Any patient for whom moderate or deep sedation or
anesthesia is contemplated receives a presedation or preanesthesia
assessment (see also, Care of Patients section). This
must be done or approved by a licensed independent practitioner
(LIP). This practitioner need not have privileges to administer
anesthesia or sedation.
PE.1.8.2 Before anesthesia, the patient is determined to be
an appropriate candidate for anesthesia. The language in
this section addresses not only the need to evaluate the patient
before sedation or anesthesia, but also to make sure that the
techniques contemplated are appropriate for the patient’s medical
status and that the patient’s preoperative state has been optimized,
taking into account the degree of urgency of the procedure.
PE.1.7.3 The patient is re-evaluated immediately before anesthesia
induction. This assessment is done immediately before induction
of anesthesia. It documents the patient’s baseline status, creating
a benchmark against which changes may be measured. The intent
is to make sure that when patients are seen in advance, and perhaps
given sedatives, antibiotics, beta blockers, treatment for hypertension,
diabetes, etc., that they are re-evaluated immediately before
induction. Although anesthesiologists routinely re-evaluate patients
before induction by reviewing the preoperative evaluation, evaluating
the electrocardiogram, blood pressure and pulse, this must be
explicitly documented. Attempts to simply refer the surveyor to
the vital signs recorded in the brief period before induction
have not been successful. Compliance can be simple and unobtrusive.
In one of our institutions, a statement that appears in very small
print under the anesthesiologist’s signature says ,I have reviewed
preoperative evaluation and VS immediately before induction and
concur with plan. More robust wording might include, I have re-evaluated
the patient immediately before induction and find that the patient
is still fit for the planned anesthetic and procedure.
PE.1.8.4 The patient's postoperative status is assessed on
admission to and discharge from the postanesthesia recovery area.
Care of Patients (TX)
Standards for Moderate and Deep Sedation and Anesthesia
This section now includes standards for sedation. In previous
editions of the Comprehensive Accreditation Manual for Hospitals
(CAMH), sedation was brought under the standards for anesthesia
principally in a footnote. Now, it is explicitly placed in the
body of the text. Sedation and anesthesia now occupy a common
continuum of drug-induced neurological depression (“minimal anxiolysis,
moderate sedation/analgesia, deep sedation/analgesia, anesthesia).
The older oxymoronic term “conscious sedation has been replaced
by the term moderate sedation/analgesia. The wording used by JCAHO
in addressing the sedation-anesthesia continuum, monitoring, requirements
for rescue from a deeper level of sedation than intended and the
capabilities of the individuals involved in providing sedation
is derived from the work of ASA members, including the Committee
on Quality Management and Departmental Administration.
TX.2. Moderate or deep sedation and anesthesia are provided
by qualified individuals. In order to qualify, individuals
must have specific training in standards for giving sedative and
anesthetic drugs, monitoring their effect and rescuing from deeper
levels of sedation than those intended. Appropriate equipment
and trained individuals are available to deliver and monitor sedation
and anesthesia as well as recovery of the patient. The level of
care is specifically no less for sedation than for anesthesia,
although the qualifications are different. A quality improvement
mechanism must exist for tracking, analyzing and improving the
outcome of patients receiving moderate and deep sedation.
TX.2.1 A presedation or preanesthesia assessment is performed
for each patient before beginning moderate or deep sedation and
before anesthesia induction. Hospitals providing obstetrical
or emergency operative services can provide anesthesia services
within approximately 30 minutes after anesthesia is deemed necessary.
The preanesthesia or presedation evaluation of the patient
must include historical data and sufficient information to plan,
administer and monitor sedation and anesthesia.
TX.2.1.1 Each patient's moderate or deep sedation and anesthesia
care is planned. Because sedation and anesthesia carry
potential risks, an anesthesia plan is developed based on the
patients’ assessed needs and is communicated among care providers.
Policies, guidelines and medical records are examples of compliance.
TX.2.2 Sedation and anesthesia options and risks are discussed
with the patient and family prior to administration. Examples
include discussion of anesthesia, blood transfusion options, risks
and the documentation of informed consent.
TX.2.3 Each patient's physiological status is monitored during
sedation or anesthesia administration. The level of monitoring
depends on the acuity of illness and presumes that the patient
may lose consciousness when only sedation is attempted. Rescue
depends on prompt recognition by means of systematic monitoring
of cardiac and respiratory depression. Continuous monitoring of
heart rate and oxygenation and continual monitoring of ventilation
and blood pressure are documented during the entire period of
care.
TX.2.4 The patient's postprocedure status is assessed on admission
to and before discharge from the postsedation or postanesthesia
recovery area.
TX.2.4.1 Patients are discharged from the postsedation or
postanesthesia recovery area and the organization by a qualified
LIP or according to criteria approved by the medical staff.
TX.3.5 Preparation and dispensing of medication(s) is appropriately
controlled. It primarily pertains to dispensing and labeling
of medications by a pharmacy. Specific reference to the appropriate
labeling (see TX.4.1, 1994 AMH) has been omitted. An LIP with
appropriate clinical privileges may prepare and administer medications.
All medications must be labeled in a consistent, standard manner.
JCAHO does not define what is standard, but at minimum it should
include the name of the medication and its concentration. It is
likely that JCAHO and its surveyors will continue to examine for
proper labeling and restriction to access of drugs, regardless
of who controls them, especially because the Health Care Financing
Administration's conditions of participation (CFR 482.25) require
that drugs and biologicals must be kept in a locked storage area.
Although JCAHO no longer states that medication carts must be
locked, they expect that drugs should be secured from tampering,
should be safe from patient-to-patient cross-contamination and
should be properly labeled. If the operating room cannot be accessed
by unauthorized individuals, as in the case of automatic locks
or portals under continuous observation, locking of carts is not
essential. In a 1996 Medication and Security alert, JCAHO said:
The area of greatest concern appears to be for medications that
have been prepared for use by an anesthesiologist or certified
registered nurse anesthetist (CRNA). These drugs are placed on
the anesthesia cart in the operating room while the anesthesiologist
or CRNA goes to the holding area to get the patient and bring
him or her back to the operating room. Some believe that these
drugs are unsecured because they are not locked or constantly
attended.
Those drugs are secure in that they are not readily available
to anyone other than operating room personnel. In the absence
of evidence to the contrary —that is, there have been no instances
of drug abuse, misuse, or diversion— this practice is considered
to be safe and the drugs are considered secure.
TX.3.5.5 Emergency medications are consistently available,
controlled and secure in the pharmacy and patient care areas.
Applies to emergency drug carts.
Improving Organizational Performance
PI.4 Data are systematically aggregated and analyzed on an
ongoing basis. The performance improvement section has
been extensively reorganized. It no longer explicitly requires
that “Adverse events or patterns of adverse events during anesthesia
are intensively assessed (PI.4.5.2, CAMH, 1998). The standards
emphasize the competent use of mechanisms to systematically gather
data on a continuous basis, aggregate it so that the frequency
and distribution of problems is clear, use statistically valid
means to evaluate and present conclusions, place findings in context
over time by trending and comparison with external benchmarks
and ultimately making improvements to enhance performance. Great
emphasis is placed on the detection and elimination of the root
causes of undesirable performance, outcomes and sentinel events.
Of note, JCAHO's use of the term sentinel event is quite different
than that used by engineers, i.e., a previously unknown defect
or set of circumstances under which a system will fail. JCAHO
identifies as a sentinel event any unanticipated death or permanent
loss of function that is not consistent with the patient's disease
process.
Over time, JCAHO has been adopting performance improvement
standards that have strategic value to health care organizations.
Although JCAHO has not directly addressed the strategic benefits
of performance improvement, application of these concepts should
lead to the exposure and correction of problems that hurt patients
and frustrate medical staff. Ultimately, improved outcome and
logistics should lead to better, more economical care that links
quality management and resource management.
PI.4.1 Appropriate statistical techniques are used to analyze
and display data.
PI.4.2 The organization compares its performance over time
and with other sources of information. Various CQI tools
apply, including means to display comparative data such as run
charts, control charts and other graphic tools. The assessment
of data involves determining current levels of performance, how
stable it is over time, how it compares to external benchmarks,
identifying areas that can be improved, prioritizing improvement
opportunities and developing strategies to make improvement where
indicated. Emphasis is placed on identifying best practices and
developing practices that can be proven to produce the best possible
results.
PI.4.3 Undesirable patterns or trends in performance and sentinel
events are intensively analyzed. JCAHO considers major
adverse events associated with anesthesia to be sentinel events.
Presumably these events result in permanent damage or death. They
may also include a variety of adverse outcomes, and failures in
using processes, such as transfusion reactions, medication errors,
performance levels that vary from the expected, lack of adherence
to appropriate practices and logistical problems.
PI.4.4. The organization identifies changes that will lead
to improved performance and reduce sentinel events. Trending
and analysis of data lead to improvements that are monitored and
sustainable. The risk of sentinel events is reduced. Emphasis
is placed on the reduction of sentinel events. Here again, it
is necessary to accept JCAHO’s concept of “sentinel event to understand
its intent. While an engineer might argue that a sentinel event
is a hidden system failure that cannot be known before it occurs,
and thereafter appears obvious, JCAHO uses the term to denote
a catastrophic outcome.
The Survey Process Key Points
The survey proceeds from a review of documented performance and
improvement to a review with the executive leadership, then to
a series of hospital site visits and concludes with a review of
problems with specialty groups and a final wrap-up. We have abstracted
the core of this process from the Comprehensive Accreditation
Manual for Hospitals, pages AC 16-19.
Survey Team – Consists of at least one physician,
one nurse and one hospital administrator (for hospitals with more
than 75 beds).
Opening Conference – Surveyors and hospital
staff discuss the hospital’s approach to quality improvement and
may use this as an opportunity to discuss specific performance
improvement projects.
Documentation Review – Bylaws, rules and regulations,
performance improvement data and reports are all reviewed. The
departmental QA/QI activities will be reviewed here instead of
with the chair, as was done in the past. It is important to provide
a clear picture of how the department assesses and controls quality,
including examples of problems, sentinel events, improvement strategies
and policies that have been adopted for the surveyors to evaluate
in order to avoid a more intense review later in the survey process.
Leadership Interviews – Addresses the collaboration
of leaders in the performance improvement process. This session
is designed to make sure that problems are routinely brought to
the attention of leadership and resolved as part of the overall
strategic planning of the hospital.
Visits to Patient Care Settings – These include
the operating room, anesthetizing locations and recovery areas.
All personnel are expected to be familiar with the performance
improvement activities relating to their area, the regulations
that apply (JCAHO and hospital) and how they meet those requirements.
Surveyors are especially sensitive to patient privacy, control
of medications, the preoperative process, re-evaluation of the
patient's status before induction, infection control and compliance
with the other regulations set forth above.
Function Interviews – With multidisciplinary
groups responsible for a particular function, e.g., medical records,
conscious sedation or CQI. Unresolved issues are likely to surface
here.
Leadership Exit Conference – Surveyors meet
with leadership to review and discuss findings, including any
potential accreditation issues and presentation of a preliminary
report.
ORYX – Adding Performance Measures
ORYX is the name of JCAHO's initiative to integrate performance
measures into the accreditation process. Its long-range goal is
to establish a data-driven, continuous survey and accreditation
process to complement the standards-based assessment. A standardized
set of performance measures will be identified for use in each
JCAHO accreditation program. The use of these core measures will
allow for benchmarking based on processes and actual outcomes
of patient care. Over time, meaningful performance measurement
data will likely be made available to the public. Currently, there
are performance measurement requirements for the hospital, long-term
care, network, laboratory, home care and behavioral health care
accreditation programs. The timetables for ORYX implementation
in ambulatory care organizations and long-term care pharmacies
have not yet been established.
Performance measurement systems were solicited by JCAHO and then
reviewed, and those meeting the criteria have been listed as acceptable
for accreditation. Each health care organization in participating
programs must select and enroll in an accepted measurement system;
a list of acceptable systems can be obtained from JCAHO at .
There is a chapter in each accreditation manual on the evaluation
and selection of performance measurement systems. The chapter
assists organizations in selecting the measurement system that
best meets local measurement. It provides advice and guidance
and profiles the first group of measurement systems meeting initial
screening criteria. The cost of ORYX will be assessed to the performance
measurement systems, and it is expected that “some of these costs
will be passed back to enrolling health care organizations.
ORYX data can trigger a response outside a regular triennial
survey if an organization fails to provide ORYX data for two consecutive
quarters. Organizations that fail to provide data for two consecutive
quarters may be issued a Type I recommendation for missing data.
This recommendation will be cleared when JCAHO has received a
single quarterly transmission of all required data. Continued
failure to send data would result in a second generation Type
I recommendation that could be cleared by the same mechanism.
Failure to clear the second generation Type I recommendation would
result in conditional accreditation.
More information about ORYX can be found at JCAHO's Web site
by selecting For Health Care Organizations and
Professionals and then ORYX/Performance Measurement on the green
navigation bar. The ORYX Information Line can be reached at (630)
792-5085, and questions can be submitted via e-mail to oryx@jcaho.org.
JCAHO also suggests that you call your usual contact for survey-
and accreditation-related questions in the Division of Accreditation
Operations.
Current ‘Hot’ Issues for Anesthesiologists
Based on feedback from recently surveyed departments, three controversial
issues surface repeatedly. The first of these concerns is the
standard requiring that the patient be re-evaluated immediately
before anesthesia induction [PE.1.7.3]. It is important to document
that this assessment has been performed. This documentation can
consist of a note or a check-box with a preprinted attestation
conforming to the above, located on the preanesthesia assessment
form or on the anesthesia record. Recording of vital signs at
a time before induction is not sufficient.
The second issue concerns the determination of secure storage
in the operating room. There is a common misconception that this
requires a locked cart. The Joint Commission continues to maintain
its long-standing position that drugs need not be locked to be
secured. (For more information on secure storage, see .) The standards do require that preparation and
dispensing of medications are “appropriately controlled [TX.3.5].
This point was addressed in an article by William L. Collins,
M.D., and Eugene P. Sinclair, M.D., in the August 1996 ASA NEWSLETTER,
available at www.asahq.org/
NEWSLETTERS/1996/08_96/Articles.html. The issue is also covered
in the November 1999 issue of The Inside Perspective, a JCAHO
publication.
The third issue concerns applicability of the anesthesia standards
to the provision of sedation care [reference: Introduction
to Anesthesia Care, TX.2]. This issue is not a factor specifically
in the review of anesthesiology departments but rather in the
review of the institution as a whole when sedation is provided
in other departments for conformity in the quality of care. The
anesthesiology department often needs to be involved in the development
of institution-wide, safe sedation policies and in teaching the
knowledge and skills required by such policies.
The reporting of sentinel events is another hot issue
that applies to institutions in general. The reporting of these
events by hospitals is now mandatory. One of the variations of
performance referred to in PI.4, above, is the sentinel event.
JCAHO defines a sentinel event as ... an unexpected occurrence
or variation involving death or serious physical and psychological
injury, or risk thereof. The event is called sentinel’ because
it sends a signal or sounds a warning that requires immediate
attention. JCAHO's definition, therefore, includes adverse events
that lead to an unanticipated death or permanent loss of function,
... is associated with significant deviation from the usual process(es)...or
has undermined, or has the potential for undermining the public's
confidence in the hospital.
In addition, the issue of restraint and seclusion has
become an area of great concern to JCAHO. Although they are principally
concerned with the rights and safety of psychiatric patients,
the standards apply to all patients who must be restrained. It
is expected that the environment of care will be modified to reduce
the need for restraint and that when needed its usage and limitations
are specified in the policies of the health care organization.
Standard 7.5 and its subcategories refer to restraint in the patient
for medical reasons, including those required in the perioperative
period. Restraint may be used based on need, and only while needed.
Its use and the reasons for use should be documented and should
conform to written policy. Restraint may be invoked by protocol
or, in the absence of protocol, by written order of an LIP. It
may be initiated by a registered nurse who has properly assessed
the need for restraint, but it must be confirmed by the written
or verbal order of an LIP within 12 hours. Orders for continued
restraint must be made by an LIP at least daily. He or she must
address the mechanism for monitoring the patient if there is any
variance from the written protocol. It is contemplated that patients
in the operating room and recovery room require restraint when
to do otherwise would cause injury, extubation, removal of parenteral
lines or injury because such patients are unconscious or at a
level of consciousness that precludes sufficient judgment to prevent
injury. It is expected that when restraint is no longer clinically
justified, it will be discontinued and that orders or protocols
are written to affect this outcome.
What to Do if You Disagree With the Surveyor
The best time to address points that may be unclear is after
your mock survey. You can either fax the Standards Interpretation
Group of the Joint Commission at (630) 792-5942 or e-mail its
director, Carol Patterson cpatterson@jcaho.org
to request written clarification before your actual survey occurs.
When shown to your surveyor, this may avert controversy. If your
institution disagrees with the interpretation made by the surveyor
at the time of the actual survey, we recommend that you do not
argue with the surveyor on site. Instead, address your concerns
as an appeal if you are cited for a deficiency in the controversial
area. Issues are then frequently resolved.
Hotline Information
ASA members who have specific questions that they would like
to address to ASA’s JCAHO representatives may do so by e-mailing
Karin Bierstein k.bierstein@
asawash.org or Ron Bruns r.bruns@asahq.org.
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