JCAHO: Nursing Practice Standards

1. JCAHO: Nursing Practice Standards Presented By: Nathan Buchinger Emily Dutmers Melanie Underwood Gerald Vorhies

2. What is JCAHO? • JCAHO stands for Joint Commission on Accreditation of Healthcare Organizations. It is now more commonly referred to as The Joint Commission or TJC. • This is an independent organization that remains non-profit, and is responsible for the accreditation and certification of more than 19,000 health care organizations and programs in the United States (TJC, 2011). • This accreditation is recognized across the U.S. as being a sign of commitment to the highest quality care for patients. This goal is met by the health care organizations dedication to meeting a detailed list of performance and practice standards required by JCAHO. • According to JCAHO (2011) their mission is: “To continuously improve health care for the public, in collaboration of other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (TJC).

3. Who created JCAHO and why? • The idea for JCAHO began with a proposition in the year 1910, by a physician named Ernest Codman. He wanted to be able to track patients to determine whether treatment by the hospital was effective or not. If it wasn’t effective he wanted to know what could be done better, so a more favorable outcome could be achieved for the next patient. This was soon called the “end result” system. (TJC, 2011) • The American College of Surgeons (ACS) was founded in 1917. They developed a page of requirements that was referred to as the Minimum Standard for Hospitals. After completing on-site inspections of 692 hospitals, it was discovered that only 89 of them met the minimum standards. (TJC, 2011). • After the development of the first standards manual and an improved standard of care in many hospitals in the nation, the Joint Commission on Accreditation of Hospitals (JCAH) formed in 1951. The TJC at this time consisted of The American College of Physicians (ACP), the American Hospital Association (AHA), the Canadian Medical Association (CMA) and the ACS (TJC, 2011). The CMA left shortly afterwards to focus on a similar organization in Canada. • In 1953, accreditation of hospitals by JCAH officially began. In 1965, Congress passed a Social Security amendment indicating that JCAH accredited hospitals are in compliance with most Medicare Conditions of Participation for Hospitals. This means they are able to participate in Medicare and Medicaid programs (TJC, 2011).

4. JCAHO up to the present day • From the year 1951 up to 2011, there has been many additions and changes to JCAHO. Most importantly, they developed many, detailed practice standards manuals to evaluate and accredit not simply hospitals, but many healthcare organizations. Multiple certifications for programs were also developed over the years that focus on standards related to chronic diseases and conditions , such as chronic kidney disease and heart failure. All of these modifications resulted in the name change from JCAH to JCAHO in 1987 (TJC, 2011). • Policies for sentinel events were developed, as well as the publishing of various monographs that focus on safety and infection control related issues/topics. National safety experts have developed National Patient Safety Goals, which are re-evaluated each year by JCAHO, with new more relevant goals being established to improve patient safety (TJC, 2011). • The on-site survey team has also changed from being only physicians to include registered nurses, hospital administrators, ethicists, educators, labor representatives and life safety code specialists (TJC, 2011). • While many things have been modified, the overall purpose of JCAHO has not changed. JCAHO’s vision remains as follows (2011): “All people always experience the safest, highest quality, best-value health care across all settings” (TJC).

5. What is JCAHO’s accreditation process? • The accreditation process involves an on-site survey of the healthcare organization, which is unannounced. This survey determines whether the 250+ JCAHO standards are being met satisfactorily. After this initial survey, an accreditation decision is made, which can take from 2 weeks to 2 months afterwards. Once accredited, this award remains in place for 3 years (TJC, 2011). • The surveyor team visits the accredited facility a minimum of once every 39 months, which is again unannounced. During these surveys, the team is assessing whether standards of care are being complied with and if accreditation should be maintained. They may trace a patients experience in an organization, by speaking with the patient and medical staff involved in their care. Observation of doctors and nurses providing care and administering medications is routine. A patient’s medical records may be pulled and examine thoroughly as well (TJC, 2011). • It is important to point out that this process is continuous. It is maintained when all of the practice standards for JCAHO are put to use, not just when a survey is being performed. Every 3 months, information is sent to TJC to evaluate ongoing standards compliance in the treatment of certain conditions, such as MI or CVA. All of this information is made available to the public through qualitycheck.org (Munroe, 2007). • The cost of accreditation varies depending on the size and service complexity of the healthcare organization. The annual fee can be anywhere from $2,180 to $37,245 (TJC, 2011).

6. What is Joint Commission certification and how is it obtained? • You can choose to be certified by the Joint Commission in chronic diseases and conditions such as chronic kidney disease, heart failure, diabetes or asthma. A certification shows that you are knowledgeable and meet the Joint Commission requirements for that specialty (TJC, 2011). • Certification is obtained by proving proficiency in the particular requirements of that chronic condition. The certification standards help to organize the treatment in disease management programs. This in turn improves quality of patient care by providing consistent care and reducing the risk of error (TJC, 2011). • Certification by JCAHO is now increasing eligibility for insurance reimbursement and participation in managed care plans (TJC, 2011). • The Joint Commissions “Gold Seal of Approval” is a sign of commitment to quality health care and excellence.

7. So how does JCAHO define whether or not a hospital or other healthcare organization is safe, of good quality, and deserves their accreditation? • It's simple. They use their own specific set of criteria known as “Standards” that apply to different parts of the organization. These standards are short, simple sentences that usually begin with, “The organization will, does, or prohibits...” These idealistic statements and their rationale are what JCAHO surveyors use to judge whether or not an organization is in compliance and deserves their continued accreditation and certification. • JCAHO standards are compiled under separate headings pertaining to different areas of the healthcare organization's delivery of care. There are many headings, including Emergency Management, Information Management, Management of Human Resources, Infection Prevention and Control, Environment of Care, Performance Improvement, Leadership, Rights of Individuals, and many more. • The full manual of standards, with their rationale and specific evaluation criteria is extensive. The following slides give examples of the standards that apply to only two areas of healthcare delivery.

8. Example 1: Environment of Care “The goal of [these standards] is to promote a safe, functional, and supportive environment within the organization so that quality and safety are preserved. The environment of care is made up of three basic elements: • The building or space, including how it is arranged and special features that protect individuals served, visitors, and staff • Equipment used to support care, treatment, or services or to safely operate the building or space • People, including those who work within the organization, individuals served ,and anyone else who enters the environment, all of whom have a role in minimizing risks” (JCAHO, 2011, chapter 54).

9. Specific Standards of Environment of Care The organization • plans activities that minimize risks in the environment of care. • manages safety and security risks. • prohibits smoking except in specific circumstances. • manages risks related to hazardous materials. • manages fire risks. • conducts fire drills. • manages risks associated with its utility systems. • has a reliable emergency electrical power source. • establishes and maintains a safe, functional environment. These axiomatic statements each have more specific “Elements of Performance” that JCAHO surveyors use to grade whether the organization in fact complies with these standards. For instance, under fire drills, JCAHO specifically states that drills must be done at least once per quarter, half of these being unannounced. This standard is either met or not met, and the offending organization must develop a plan of correction and demonstrate future compliance (TJC, 2011).

10. Example 2: Infection Control “Health care organizations have varied levels of infection risk because of the variety of settings in which care, treatment, and services are provided. The design and scope of infection prevention and control activities are based on the risks that the organization faces for the spread of infections in the places where it provides care, treatment, and services” (JCAHO, 2011, chapter 52) Specific Standards for Infection Control: The organization • Identifies the individual(s) responsible for managing infection prevention and control. • Identifies risks for acquiring and spreading infections. • Has leaders that allocate needed resources for infection prevention and control activities. • Sets goals to minimize the possibility of spreading infections. • Has, implements, and evaluates an infection prevention and control plan. • Prepares to respond to an increased number of infectious individuals. • Reduces the risk of infections associated with medical supplies and devices. These also have more specific “Elements of Performance” that spell out what a hospital must do to meet these standards. 

11. How are standards developed? • Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. • Standards for the Joint Commission are developed as a result of input from various health care professionals, providers, subject matter experts and consumers. Government agencies are also involved which includes Medicare and Medicaid Services and their employers. They receive information from scientific studies and expert consensus ,which is then approved by the Board of Commissioners. • New standards are only added if they directly relate to patient safety or quality of care, and have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured. (“Joint Commission,” 2011, para. 2) Where can these standards be found? • Because the Joint Commission is a private organization that provides oversight to healthcare organizations, and not a government agency owned by the public, it's policies and standards are not available free to the public. One must purchase the manual directly from JCAHO or find someone who has purchased the online “E-dition” of the manual, such as their local healthcare organization accredited by the Joint Commission. As the presenter can verify by experience, simply using Google to find the specific standards will yield little results.

12. What are National Patient Safety Goals in relation to JCAHO? • The National Patient Safety Goals (NPSGs) have become a critical method by which the Joint Commission promotes and enforces major changes in patient safety in thousands of participating health care organizations around the world. The criteria used for determining the value of these goals and required revisions to them, are based on the merit of their impact, cost, and effectiveness (TJC, 2010). • The National Patient Safety Goals (NPSGs) are designed to stimulate health care organizations' improvement activities for several of the most challenging patient safety issues (Joint Commission Resources Inc., 2012). • The goals are reviewed and published each year and are an essential component of The Joint Commission's overall efforts to improve health care (Joint Commission Resources Inc., 2012).

13. How does JCAHO influence my nursing practice? By: Emily Dutmers • In my current practice area of critical care, JCAHO practice standards influence my nursing practice by guiding nearly every aspect of the care I provide to patients. To list a few, this includes infection control, safety, communication, environment, pain management, documentation and following proper protocols/policies for procedures and treatments. • With almost 50% of JCAHO standards being related to safety, they are likewise a large part of providing quality care on my unit (Munroe, 2007). This includes implementing the five rights, 3 checks system for medication administration, validating patient identity by using 2 identifiers before giving and by proper labeling of drugs. This also includes using the proper method of communicating with physicians to receive verbal orders , by repeating back the order given to assure that it is correct. • JCAHO lays out the importance of accurate and thorough documentation, as well as using a “time out” before procedures. Following correct protocol for changing central lines, IV tubing and dressings all have the ability to prevent infections. Utilizing tools and checklists for fall risks or precautions (contact, airborne, droplet), and implementing them are also policies put in place by JCAHO that are used every day on the unit (Munroe, 2007). Additionally, the National Patient Safety Goals are available for all the medical staff to see on the unit, and are updated every year. This helps the nurses to understand where changes need to be made to improve certain areas of patient care. JCAHO also provides updates on new policies or ways to perform procedures, which assures that all medical professionals are doing them according to the correct standards. • By following the practice standards laid out by JCAHO, I am confident that the care I provide is the safest and highest quality it can possibly be for my patients.

14. How does JCAHO influences my nursing practice? By: Melanie K. Underwood • In my current practice area of Surgical Services, JCAHO practice standards impact my practice by focusing on the National Patient Safety Goals. Many of which are addressed in the surgical setting. • Beginning with patient identification by using at least two ways to identify a patient. Preventing wrong site surgery by marking the surgical site prior to the patient entering the operating room. Infection prevention which would include proper hand washing. Medication safety is also very important because patient’s home medications need to be reconciled properly. Additionally, medications given throughout the surgical department need to be labeled properly. These are just a few standards that are supported by JCAHO to help ensure patient safety.

15. How does JCAHO influence my nursing practice? By: Nathan Buchinger • Because I work in a critical care unit, nearly all of the National Patient Safety goals apply to me except the surgical services. Using two identifiers before doing anything with the patient, having another nurse verify blood products before administration, calling physicians or residents with critical lab results in a timely manner, and labeling all medications are all pertinent activities that are guidelines of JCAHO. • Infection Control is also a huge part of my job, and one that is influenced by JCAHO guidelines. For instance, wearing personal protective equipment when handling bodily fluids and following contact, droplet, or airborne precautions when appropriate, all help to decrease the spread of hospital acquired infections. Also, “scrubbing the hub” of central lines before injecting or flushing the lines is another patient safety goal that I adhere to on a nightly basis at work. • Overall, JCAHO's practice standards impact almost everything I do while at work.

16. References • Munroe, J. (2007). JCAHO partners with nurses for patient safety. Nursing Network. 9(1). 2-9. • The Joint Commission (TJC). Facts about Joint Commission accreditation standards. (2011). Retrieved from http://www.jointcommission.org/facts_about_joint_commission_accreditation_s • The Joint Commission (TJC). (2011). Hospital National Patient Safety Goals. Retrieved from http://www.jointcommission.org/assets/1/6/HAP_NPSG_6-10-11.pdf • The Joint Commission (TJC). (2011). History of the Joint Commission. Retrieved from http://www.jointcommission.org/assets/1/18/Joint_Commission_History_20111.PDF • Joint Commission Resources Inc. (2011). Retrieved from http://www.jcrinc.com/ • The Joint Commission (TJC). (2011). Benefits of Joint Commission certification. Retrieved from http://www.jointcommission.org/assets/1/18/Benefits_of_Certification_8_10.pdf • The Joint Commission (TJC). (2011). The Joint Commission E-dition. Retrieved from https://e-dition.jcrinc.com/Chapters.aspx?C=52