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Librarian's Guide to a JCAHO Accreditation Survey

The purpose of this guide is to provide answers to questions that librarians might have about the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation process as it relates to libraries and information services.

To top of page What is JCAHO?

JCAHO is the national accrediting body for hospitals and other health care delivery organizations. Hospitals request to have JCAHO evaluate their facility and are charged a fee. Because accreditation is not automatically renewed, a full accreditation survey is required at least every three years.

After two years of preparation, in 2004, JCAHO began using a new accreditation process called "Shared Visions-New Pathways." Beginning in 2006, all regular accreditation surveys will be conducted on an unannounced basis. The transition to unannounced surveys will begin with pilot tests conducted in volunteer organizations during 2004 and 2005.

To top of page What is "Shared Visions--New Pathways?"

The "Shared Vision" is that health care organizations are dedicated to providing safe, high-quality care. JCAHO shares this vision, so it is providing an accreditation process to support a health care organization's quality and safety efforts.

"New Pathways" represents a new set of approaches or pathways to the accreditation process that will support the shared visions.

The 2004 Comprehensive Accreditation Manual for Hospitals (CAMH) reflects the changes in the process. This includes everything from the wording of the standards to their scoring as well as the methods of the pre- and onsite survey.

Each standard includes a rationale for the standard and elements of performance (EPs) that give clear expectations with little room for interpretation. The list of scored requirements is identical to what the surveyors use (no hidden information). To improve consistency in the survey process, JCAHO began a certification process for surveyors in 2002.

"Shared Visions--New Pathways" shifts the focus from survey preparation to continuous improvement of operational systems that directly affect the quality and safety of patient care. As described on the JCAHO Website, the elements of the new process are:

  • Substantial consolidation of the standards to reduce the paperwork and documentation burden of the accreditation process and increase its focus on patient safety and health care quality
  • A required mid-cycle, periodic performance review (PPR)
  • A focused on-site survey directed by the priority focus process (PFP)
  • On-site evaluation of compliance with standards relating to the care experience of actual patients
  • Revision of individual organization performance reports to provide performance information not portrayed in the current reports
  • Active engagement of physicians and other direct caregivers in the new accreditation process

To top of page How is the onsite survey agenda developed?

The onsite survey agenda is developed from the organization's mid-cycle PPR and the PFP.

For the PPR, the health care organization evaluates its own compliance with applicable standards and develops a plan of action for identified areas of non-compliance. Validation of corrections and other randomly selected PPR findings occurs during the triennial on-site survey.

The PFP process aggregates organization-specific information through an automated, rules-based tool. Input information includes ORYX core measure data, previous recommendations, demographic data related to clinical service groups and diagnostic-related groups, complaints, sentinel event information, and MedPar data.

Additionally, JCAHO identifies priority focus areas (PFAs) for each hospital based on a combination of the PFP, on which surveyors initially will focus during the initial part of the on-site survey, and on systems and processes that are relevant to patient safety and health care quality. For example, systems and process include such things as assessment and care, medication management, credentialing, equipment use, infection control, etc. Information management is one of the PFAs.

To top of page How does an organization conduct its mid-cycle periodic performance review (PPR)?

  • The organization's JCAHO team reviews the standards and identifies areas for improvement (15-18 months cycle).
  • The team creates a plan of action for each EP that they have marked as partial or insufficient compliance.
  • The team defines "measures of success," that is, improvement targets with audits. The surveyors will review the measures of success and decide if the targets were met.
  • The team will also conduct phone reviews with the Standards Interpretation Group.

To top of page How will the onsite survey be conducted?

There is a new agenda for the onsite survey:

  • Opening conference and orientation
  • Survey planning session
  • Individual tracer activity
  • System tracer activity (such as medication management, infection control, data use)
  • Proficiency testing validation and regulatory review (laboratory only)
  • Special issue resolution
  • Daily briefing
  • Competency assessment process
  • Medical staff credentialing and privileging
  • Environment of care session
  • Life safety code building tour
  • Leadership session
  • Chief executive officer exit briefing and organization exit conference

It is estimated that 50% to 60% of the survey time will be spent on tracer activities, where the surveyors look at how care is being delivered, rather than on policies. For the "tracer methodology," the surveyors will focus on what is important as identified through the organization's PFP. They will look at how the standards are executed as they follow selected patients through the health care organization. The surveyors will visit patient care settings and functional areas, guided by randomly chosen open records that relate to the PFP information. For example, if the PFP information includes a clinical service group for heart failure, the survey team will trace selected patients from the critical care unit to a medical floor and discharge and look at processes such as assessment and medication management. During the tracer, the surveyors will include all relevant standards.

Videos describing the new process are available on the JCAHO site. JCAHO regards the tracer methodology as a way to provide education to the organization staff and leaders.

To top of page What is the scoring process?

Under the new decision process, each standard is judged either "compliant" or "not compliant" based on the scoring of the EPs. A standard will be "not compliant" if any of the EPs is scored 0 (insufficient compliance) or 35% or more of its EPs are scored 1 (partial compliance). If problems are identified, the surveyor will issue a "Requirement for Improvement" and the organization has 90 days to submit "Evidence of Standards Compliance" (changes to 45 days after July 1, 2005).

To top of page What elements of the "Management of Information" chapter are critical for effective management of knowledge-based information (KBI)?

The overview of the chapter discusses why management of information is an essential endeavor:

  • The goal of the information management function is to support decision making to improve patient outcomes…assure patient safety…improve performance.
  • A hospital's provision of care, treatment, and services is a complex endeavor that is highly dependent on information. This includes information about the science of care, treatment, and services.
  • Managing information is an active, planned activity.

To achieve a vision for effectively and continuously improving information management in health care organizations, the following are critical:

  • Ensuring timely and easy access to complete information throughout the organization.
  • Accessing and using external knowledge bases…to pursue opportunities for improvement
Standard IM.1.10 relates to information planning
  • The hospital plans and designs information management processes to meet internal and external information needs.

The rationale for this standard requires evidence of a planned approach that "identifies the hospital's information needs and supports its goals and objectives."

EPs for IM.1.10 state that "The hospital bases its information management processes on a thorough analysis of internal and external information needs." IM.1.10 outlines all of the components of needs analysis that should be used for knowledge-based informatoin (KBI) as well as the other standards.

Standard IM.4.10 addresses information-based decision making
  • The information management system provides information for use in decision making.

The rationale for this standard states that "Clinical and strategic decision making depends on information from multiple sources, including the patient record, knowledge-based information, comparative data/information, and aggregate data/information."

To top of page What standards, rationales, and elements of performance specifically relate to KBI?

The knowledge-based information standard is IM.5.10:

  • Knowledge-based information resources are readily available, current, and authoritative.

JCAHO defines knowledge-based information as "A collection of stored facts, models, and information that can be used for designing and redesigning processes and for problem solving. In the context of this manual, knowledge-based information is found in the clinical, scientific, and management literature."

The rationale for the standards delineates the purposes for ready access to KBI for all hospital practitioners and staff. These purposes include maintenance of competence, clinical and management decision making, patient and family information, performance improvement and patient safety, and educational and research needs.

The standard is expanded by the EP, which must be addressed in the PPR. There are four EPs, and the scoring range for the EPs are 0, 1, 2, and NA:

  1. Library services are provided by cooperative or contracted arrangements with other institutions, if not available on-site.
  2. The hospital provides access to information resources needed by staff in print, electronic, Internet, audio, and/or other appropriate form.
  3. Knowledge-based resources are available at all times to clinical or service staff, through electronic means, after-hours access to an in-house collection, or other methods.
  4. The hospital has a plan to provide for access to information during times when electronic systems are unavailable.

To top of page How will the KBI standards be addressed in the PPR and onsite survey?

The librarian should be an active participant on any management of information planning committee or task force in the hospital. When the PPR is done, the librarian should be involved in responding to the EPs that address KBI throughout the standards. The librarian should point out how "library services," which are specifically mandated in EP#1, are most effectively and efficiently addressed by an onsite, professionally managed library. The librarian is also the one who can select where and when certain contractual arrangements can be effective. For example, some consortia agreements are only made between libraries; the librarian can point out to administration how this serves the information requirements of the hospital.

Since publication of the 2004 CAMH, there have been discussions in the hospital library community regarding EP#4, "The hospital has a plan to provide for access to information during times when electronic systems are unavailable." The hospital must have backup systems for access to all types of information, including KBI. The librarian can point out the most effective methods for assuring KBI access when electronic systems are unavailable. An up-to-date, organized print collection for basic clinical and drug information, providing redundancy in case of extended downtime, is the most basic way to address this requirement.

Because the survey team will address all of the standards in some fashion, a hospital staff member may be asked how to get clinical information if the computers are down. KBI may be addressed this way as well. The surveyors will look at how the standards are executed as they follow selected patients through the health care organization or as they do system tracer activities.

To top of page Where else does JCAHO address KBI needs?

Throughout the 2004 CAMH, the importance of the literature for evidence-based decision making is clearly stated:

  • The "Sentinel Event" chapter states that to be credible, a root cause analysis must include consideration of any relevant literature.

  • Standard MM.8.10: The hospital evaluates its medication management system.
    "The hospital routinely evaluates the literature for new technologies or successful practices that have been demonstrated to enhance safety in other organizations to determine if it can improve its own medication management system."

  • Standard IC.1.10: The hospital uses a coordinated process to reduce the risks of nosocomial infections in patients and health care workers. EP#1 states,"The hospital's infection control process is based on sound epidemiologic principles and evidence-based information on reducing nosocomial infection."

  • Standard IC.4.10: The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, staff, and those who come into the hospital. Strategies for risk reduction includes the statement that "The strategies are consistent with current scientific knowledge, accepted practice guidelines" (EP#2).

  • Standard PI.2.10: Data are systematically aggregated and analyzed. EP#4 states, "Data are analyzed and compared internally over time and externally with other sources of information when available." Examples of external sources of information include recent scientific, clinical, and management literature.

  • Standard LD.4.20: New or modified services or processes are designed well. EP#4 states that one of the design elements is "Current knowledge when available and relevant (for example, practice guidelines…information from relevant literature)."

  • The "Nursing" chapter overview states, "The nurse executive also ensures the quality of nursing standards of patient care, treatment, and services and practice by incorporating current nursing research finding, nationally recognized professional standards, and other literature into the policies and procedures governing the provision of nursing care, treatment, and services."

Thus, IM.5.10 is not the only place in the CAMH that addresses the importance of KBI in the organization. And, "survey time" is not the only time for the librarian to note these requirements. Throughout the year, as the librarian provides services that address these standards, the librarian should point out the contribution of professional library services to these activities.

To top of page How do the MLA "Standards for Hospital Libraries" relate to the JCAHO standards?

The MLA standards were written to complement and further define the JCAHO standards. For example, the JCAHO standards state that information management should be based on the assessed needs of the users. The MLA standards provide a suggested framework from which a needs-assessment process can be developed. In addition to complementing JCAHO standards, the MLA standards are a useful tool in working with hospital administration and with other accrediting bodies.

The abstract of the MLA standards states, "The standards define the role of the medical librarian and the links between knowledge-based information and other functions such as patient care, patient education, performance improvement, and education. In addition, the standards address the development and implementation of the knowledge-based information needs assessment and plans, the promotion and publicity of the knowledge-based information services, and the physical space and staffing requirements." The MLA "Standards for Hospital Libraries" is a living document that will be added to as the health care environment changes and new challenges present themselves.

To top of page Credits

This overview of the 2004 JCAHO accreditation process is intended to provide some highlights of "Shared Visions--New Pathways" that may be most useful to hospital librarians. The JCAHO Website (available at either www.jcaho.org or www.jcaho.com) provides additional information on the survey process and other critical activities such as the national patient safety goals that will affect all health care organizations. As MLA members gain experience with the new process, changes and additions to this overview will be made. Members are encouraged to contact the MLA member liaison to JCAHO with their ideas and comments.

Thanks to Jeannine Cyr Gluck, AHIP, and Susan Schweinsberg Long, AHIP, for their input.

Margaret Bandy, AHIP
MLA member liaison to JCAHO, 2003-2005
April 2004
Thanks to Rittenhouse for their sponsorship of MLA's website.

Thanks to Elsevier's Procedures Consult for their sponsorship of the MLA website.

Thanks to American Psychiatric Publishing for their sponsorship of the MLA website!