What can you share with your governing body, medical staff, employees and other key audiences about your survey?
Remind your audiences that:
- Shared Visions-New Pathways® is an entirely new approach to evaluating quality and safety in your organization. It is truly an audit of the actual delivery of critical services and not a review of policies.
- Shared Visions–New Pathways shifts the view of accreditation – it's no longer a snapshot. It is a feature-length film, providing panoramic insight into your organization's daily operations and systems.
- This makes the process you've just undergone a true validation of the organization's continuous improvement efforts, rather than a snapshot resulting in scores.
- This emphasis on continuous improvement efforts carries over into sharing information about the results of the on-site survey.
- A final accreditation decision will be made after Joint Commission staff review and approve the health care organization's Evidence of Standards Compliance (ESC) and any identified Measures of Success (MOS) which are four-month audits of the success of the corrective actions, as appropriate. The Central Office review is completed within 30 days of receiving the ESC. If the health care organization successfully addresses all of its improvement requirements, the organization will be Accredited. This final decision will be posted on the Joint Commission's website, www.jointcommission.org, beginning in the third quarter of 2004. If some of the improvement requirements are not resolved, your organization will receive Provisional Accreditation.
- Upon receipt of the accreditation award, your health care organization may publicly disclose the survey decision and any findings.
With this process come new measures of achievement for your organization:
- Focus on successfully achieving accreditation, which is recognized nationally as the Gold Seal of Approval in health care.
- Focus on the fact that you have undergone a thorough on-site review and are committed to meeting rigorous national standards—continuously. The conclusion of the on-site survey is a validation of the work to continuously comply with standards in the weeks and months ahead.
- Emphasize your public commitment to continuous improvement and delivering safe, high-quality care.
- Stress how the ongoing compliance with Joint Commission standards results in sound management practices in the day-to-day delivery of quality and safe care. In fact, the Joint Commission survey serves as an independent audit of your organization's commitment to continuous quality improvement.
- Share information specific to your organization about what accreditation means by, for example, detailing your full compliance with particular areas of the accreditation process, such as challenging standards, or your level of compliance with the standards. For example, "Our hospital complies with all 250 hospital standards."
- Emphasize your compliance with National Patient Safety Goals.
- Demonstrate your successful performance by sharing your ORYX® data or National Quality Improvement Goals (for hospitals only). As more measures are approved and endorsed by the National Quality Forum (NQF), the Joint Commission will explore ways to incorporate that data into Quality Reports.
- Stress your focus on continuous standards compliance over the course of the three-year accreditation cycle (rather than once every three years) and point out the fact that efforts to maintain a constant state of survey readiness improve the safety and care of patients, residents and clients – the ultimate aim of accreditation.
- Compare systems issues identified during the Periodic Performance Review (PPR) process with the on-site survey findings, and emphasize the improvements made as a result of this ongoing work.
- If there are ESC and MOS requirements, you may want to share information about these improvement efforts. Leadership might, for example, compare this process to a financial audit by an accounting firm in which organizations have an opportunity to either present evidence contrary to the auditors' findings or accept the report and implement improvement strategies.
- Use specific examples of staff and physician involvement in the accreditation process and satisfaction with that involvement to demonstrate an MOS.
- Discuss how staff involvement was vital to the on-site survey because of the focus on patient care through the tracer methodology and observation of care.
- Emphasize how the accreditation survey is now tailored to your organization's unique characteristics and services.