George Mills, director of engineering at The Joint Commission (TJC), delivered a two-part message at AAMI 2016.
First, the nation’s largest accreditation organization for hospitals is taking steps to streamline its survey process with a new emphasis on qualifying the risk associated with deficiencies. At the same time, the pressure is on hospital-based healthcare technology management (HTM) professionals to think critically and document their practices and procedures.
“You know how to do your jobs, and you do your jobs well,” Mills said at the AAMI 2016 Conference & Expo.
While Mills was quick to praise the work of HTM professionals, he also made it clear that TJC was expecting these departments to rise to the challenges within the fast-changing and complex world of modern health care.
For example, effective Jan. 1, 2017, HTM departments must have documentation on hand for specific devices at the time of a survey. Current practice allows for follow-up documentation.
“If we ask for it, and you don’t have it – you don’t have it,” Mills said. “I’m going to write you a finding.”
However, Mills emphasized that TJC was offering a solution, namely a checklist – which was expected to be available on TJC’s website on July 1 – that would help HTM departments keep track of this documentation.
The change, which is part of a broader initiative called Project REFRESH, took effect June 6 for psychiatric hospitals that use TJC accreditation. It kicks in at the start of next year for all other accreditation and certification programs.
For Mills, meeting TJC standards is not so much about ticking boxes as it is consistently applying critical thinking skills and tools, such as risk assessments, to meet the specific challenges faced within individual health care delivery organizations – and keeping detailed records of these processes.
Mills also “strongly encouraged” the group to start dashboarding, as it helps keep compliance “front and center” and can be leveraged to “get a seat at the table” for important discussions about things such as technology acquisitions.
Additionally, Mills explained the details of Project REFRESH. The acronym summarizes the changes as the following:
- Real-time information gathering between surveyors and the Standards Interpretation Group during surveys
- Enhanced survey accuracy
- Fewer standards
- Revised criticality models for standards
- Easier and less complex decision process
- Streamlined post-survey process
- Higher consistency in interpretation of standards
The move toward simplification includes a paring down of TJC’s code. According to Mills, 131 elements of performance (EP) have been deleted as a result of REFRESH projects, with additional deletions pending. These edits will help streamline the manual but won’t diminish any elements of performance linked to Centers for Medicare & Medicaid Services’ requirements or reimbursement, Mills assured the audience.
Starting Jan. 1, 2017, surveyors at most health care delivery organizations will classify their findings based on the new “SAFER matrix.” This model takes into consideration the context and environment of the finding, and maps it based on the likelihood of harm to a patient, visitor, or staff and how widespread the issue is (limited, pattern, or widespread).
The SAFER matrix will replace the current scoring methodology, which means:
- The elimination of direct and indirect EP designations.
- Consolidation of all Evidence of Standards Compliance submissions into one timeframe: 60 days.
- No more “measures of success.”
- No more “opportunities for improvement.”
- No more A or C categories.
“We really want to focus on patient safety rather than risk to patients,” Mills explained. It also will help health care delivery organization leaders prioritize corrective actions.
Mills’s presentation was recorded and will be available to attendees through AAMI University. Those unable to attend the AAMI 2016 Conference & Expo will have the opportunity to purchase the recording through the AAMI Store later in the year.