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Physicians Be Prepared /JCAHO Q&A.pdf

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TRACING REALITY

by: LAWRENCE M. SHUER

The upcoming April 13 to 16 visit from JCAHO surveyors will be the last such scheduled visit for which Stanford Hospital and Clinics can formally prepare. In the future, we can expect surveyors to visit our institution unannounced to assess our compliance with JCAHO accreditation standards. There are other important changes.

To begin with, this year's survey and presumably those in the future will be structured far differently than before. The team will be making sure we "walk the walk," rather than just "talk the talk." This may sound glib and easier said than done, but the surveyors have a system which is likely to give them substantive information about what's happening at SHC - not just what should be happening.

Here's how it works: The surveyors will select patients and follow them through the course of their experience in the hospital and clinics. The team will observe directly how we function as a healthcare organization, including how well we follow our own policies and the policies and rules of state and federal agencies. This technique is called "tracer" methodology - we "walk," they watch, they analyze, then they talk.

Those of you who have been around a few years can immediately sense that "tracer" methodology marks a paradigm shift from past years, when surveyors were content just to interview administrative and medical staff leadership. This year the team will stop and question physicians, residents, interns, nurses and other staff in the halls to make sure we are doing what we say we are.

Another important change is that unlike in past years, when the JCAHO assigned a numerical score after each visit, the grading this year essentially will be pass-fail. We know we give good care, so let's demonstrate this to the surveyors. A pass-fail system enables both ourselves and the surveyors to stay focused on the big picture - "Are we doing a good job?" Since the answer is yes, we should feel some relief from anxiety.

Furthermore, in the recent past we placed most preparation duties on the shoulders of administrators and select medical staff. Today we all share the burden not to cram but to learn what is needed to improve the quality of care for our patients. We also need to tell the surveyors about what we are doing, but much of what we say should be similar or identical to what we tell our colleagues, students, patients and families about staying safe. We are not being asked to learn an irrelevant body of facts - we are simply being asked to understand and describe a system that will make us better practitioners.

Integrating good practice with regulatory requirements will help us prepare efficiently with less stress when visits in the future become unannounced. If what we need to do to practice effectively is the same as what we need to do to pass an inspection, we no longer need to "cram for the test."

The focus on professional excellence rather than test taking provides many of us who have practiced for a long time with a special obligation not only to look at our skills and practices, but to examine our attitudes as well. Improved practice requires open-mindedness. The belief, "I do it this way because that is the way I have always done it, so it must be okay" may sound ludicrous, but ask yourself: "How many times have I comforted myself with that notion?" Let's be open, even proactive, in finding and using changes in practice to improve care and make it safer.

The information and training tools you will see and receive prior to our upcoming survey are an opportunity to incorporate innovative ideas into your practice or at least provide a fresh look at your commitment to improve patient care.

To ensure that the medical staff and employees have the knowledge needed to practice effectively and comply with applicable regulations, the surveyors will be asking about National Patient Safety Goals, which serve as a valuable blueprint for planning quality care in our institution and hospitals nationally. Included in the goals are such specific, life-saving targets as eliminating wrong site surgeries. We have already implemented specific measures intended to meet this and other NPSG components. We have discussed these with you over recent months.

For a summary of NPSG, see: http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm

The surveyors will also be asking about performance improvement plans in your areas of practice, as well as hospital policies and procedures. We are familiar with these issues, but to make the survey successful, we need to articulate them. The information we're continuing to make available to you should help.

Practicing with national and hospital standards in mind will do far more than help us pass a survey. It will make us all better physicians. Easier said than done? Over the coming years, let's track this notion of patient-centered care. I wager care will improve. A safe bet? I think so.

(lshuer@stanford.edu)