JCAHO imposters identified in Connecticut

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is in charge of ensuring that quality standards are adhered to at healthcare facilities across the country.

But how do you know JCAHO is JCAHO?

Always ask for identification – they should have a JCAHO ID badge and a letter addressed to Hospital President and Chief Executive Officer Thomas P. Pipicelli, signed by a JCAHO executive, explaining who they are and the purpose of their visit.

If something doesn’t seem right, report it to your supervisor and the Security Department.

Just this week, the Connecticut Hospital Association (CHA) announced that a Connecticut hospital recently experienced a JCAHO imposter incident.

According to Carrie Brady, Vice President, Quality and Performance Reporting for CHA, several staff members from an unidentified hospital noticed three individuals in business dress (2 women and 1 male) sitting in a hospital lounge writing on clip boards and displaying an identification badge from the Joint Commission.

Staff was surprised to see the Joint Commission in the hospital and asked if they could be of assistance. After their offer was declined, staff went to report JCAHO's presence to the unit manager.

Staff returned with the unit manager a few minutes later but the three individuals had left the lounge. Security was notified and the hospital went into lock down. Shortly thereafter, the fire alarm was pulled, which automatically opens selected egress doors.

Security searched the hospital, but the imposters were not found. Please notify your immediate supervisor immediately if you experience any incident with apparent JCAHO imposters. They should then report the incident to JCAHO and CHA.

At Backus Hospital, JCAHO is scheduled to visit sometime after Jan. 1. Anyone with questions about the upcoming JCAHO visit, or suggestions to improve patient safety at Backus, should call Mary Bylone, RN, Assistant Vice President of Patient Care Services and Patient Safety Officer, at ext. 2771, or Joe Hughes, Director of Quality Improvement, at ext. 2345.

Going in Circles? Sometimes it helps

“Life comes at you fast” is the slogan for the latest ad campaign for Nationwide Insurance. It might just as well be the motto for beleaguered hospital caregivers everywhere.

New National Patient Safety Goals. A new nationwide survey of the patient experience. Hospital quaolity report cards. It’s all here. It’s all an important part of hospital life. And it’s coming at us fast.

In an presentation to the Backus Board of Trustees this past Monday, Peter Shea, MD Backus Medical Director, began by making a critical point: These aren’t separate,
disconnected items. In fact, they are all part and parcel of the same thing.

It makes sense, when you put the patient at the center.

Let’s take just one example -- but an important one. No one would deny that medications are an important part of the patient experience, that preventing drug-dispensing errors is a key safety measure, and that the timely dispensing of life-saving meds to patients who present with heart attack symptoms is a quality metric. It would be easy to compartmentalize this into three separate “things to do”:

• Patient Safety Goal number 8-B from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
• Quality Measures number 1 through 5 as collected by the government and reported on the "Hospital Compare” website
• Patient experience questions number 15 through 17 of the new HCAHPS survey, which begins Sunday, Oct. 1.

It’s better, said Dr. Shea, to consider this as one important area of patient-centered care that’s measured in three different ways. “Put the patient at the center, and the circle goes around,” he said. “Good quality promotes a culture of safety that leads to patients who always have a good experience. It’s simply good healthcare.”

An HCAHPS Overview

THE SURVEY

Q: What is HCAHPS?
A: HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems. In the summer of 2002, the Centers for Medicare and Medicaid Services (CMS) asked the Agency for Healthcare Research and Quality (AHRQ) to develop an instrument to measure patient perceptions of care. This measurement would be used to publicly report hospital performance (quality of care as perceived by patients). The goal of this public reporting instrument, as stated by CMS, is to provide consumers with information that might be helpful in choosing a hospital. CMS has also stated that it should complement rather than compete with quality improvement instruments already being used by hospitals. Although the survey has changed significantly since 2002, its purpose remains the same.

Q: What is the HCAHPS questionnaire like?
A: Here is an overview of the survey:
• The instrument asks patients to rate the frequency of events during their care (never, sometimes, usually, always).
• The survey is organized under the following headings:
-- Your Care from Nurses,
-- Your Care from Doctors,
-- Your Experiences in the Hospital,
-- When You Left the Hospital,
-- Overall Rating of the Hospital,
-- About You.

• The survey questions will be reported in the following domains:
-- Communication with Doctors
-- Communication with Nurses
-- Responsiveness of Hospital Staff
-- Pain Control
-- Communication about Medicines
-- Cleanliness and Quiet of the Physical Environment
-- Discharge Information

• The survey instrument can be used either as a stand alone survey or embedded into an existing patient survey with the core HCAHPS questions at the beginning of the survey. The hospital can decide how many questions to add.

• Initially, the survey will only be available in English and Spanish.

Q: I have heard that reimbursement will be tied to HCAHPS. Is that true?
A: There have been discussions recently that indicate there could be a link between reimbursement and participation in HCAHPS. Nancy Foster of AHA indicated in an interview in AHA News (Jan. 23, 2006) that at some point, payment will be tied to HCAHPS participation.

HCAHPS TIMELINE

Q: What is the "Dry Run?"
A: Before the national implementation of HCAHPS, hospitals who will participate in the HCAHPS initiative are required to go through a Dry Run. Backus Hospital participated in the dry run during the second quarter of calendar year 2006.

Q: Will the Dry Run data be publicly reported?
A: Dry Run data will not be publicly reported. The data will be submitted to CMS for quality checks and to ensure that all processes are running smoothly before participating in national implementation. Data from national implementation will not be publicly reported until late 2007 (after nine months of data).

SAMPLING

Q: What patients are eligible to receive an HCAHPS survey?
A: The survey is designed for all (not just Medicare) adult patients discharged from general acute care hospitals after an overnight stay. Patients to be excluded include: patients who are under 18, those who died while in the hospital, and those who had either psychiatric or rehabilitative services. Other allowable exclusions would include those required to comply with any state legislation.

Q: Should patients who are discharged to another facility be mailed a survey at their home or at the other institution?
A: Vendors should attempt to contact all discharged patients at the home
address/telephone number provided in the hospital’s administrative record.

Q: Can we sample once a year to fulfill the HCAHPS requirement?
A: No. In order to have your data publicly reported, you must have data for every month. Most hospitals will sample on an ongoing basis each month.

Q: How often should a patient receive a survey?
A: A patient should receive a survey for every inpatient stay. The only allowable exclusion is for a patient who has multiple stays in one calendar month.

Q: How many completed surveys do we need to have our data publicly reported?
A: A minimum of 300 completed surveys must be received over the course of 12 months. For the initial collection period during national implementation, you need 300 returns in a nine-month period so that public reporting can take place after 10 months of data collection. This means that on average, 35 completed surveys should be collected during each of the first nine months.

SURVEY ADMINISTRATION—MODE AND TIMING

Q: What methodologies are allowed for HCAHPS?
A: The survey can be administered via any of the following: two-wave mail survey, five-attempt phone survey, combined mail/phone survey, or Active Interactive Voice Response (Active IVR). Backus Hospital, like most hospitals, has decided to perform a two-wave mail survey.

Q: When should the survey be sent to the patient and when does it need to be
returned?
A: Surveys must be distributed between 48 hours and six weeks post discharge to be included. Data collection must close six weeks following the start of data collection for each respondent.

REPORTING

Q: What will the data look like when they are publicly reported on the Hospital Compare Web site?
A: Report formats are currently being tested with consumers. It is anticipated that bar graphs will be used to note hospital performance. For composites and global items, the percent of responses in the top box (i.e., percent Always, 10, Yes, etc.) will be displayed.
The entire distribution of responses may be also displayed. Consumers will have the ability to drill down for more information. Data will likely be reported in a fashion similar to clinical data on the Hospital Compare Web site: www.hospitalcompare.hhs.gov.

Q: Will there be peer groups or adjustments for hospital characteristics (e.g., size)?
A: Reports will provide a national and state norm. There will not be peer group comparisons or other adjustments on the Hospital Compare Web site.

Q: I have heard discussions of patient-mix adjustment. What is that?
A: Patient-mix adjustment is a calculation to adjust a hospital’s results, based on patient and hospital demographics, to reflect what one would expect from a “typical” patient population. The intent of patient-mix adjustments is to make data comparable across different settings. The formula for patient-mix adjustment is currently being developed by CMS. CMS will apply patient-mix adjustments to a hospital’s data before it is publicly reported.