January 20, 2006

JCAHO survey: Outpatient practices get ready

As the hospital refines its preparations for the next survey from the Joint Commission of Accreditation of Healthcare Organizations (JCAHO), to take place some time in 2006, special focus recently has been on preparing the ambulatory care services.

In December, the hospital's JCAHO operations committee hosted a consultant who spent three days with practice managers and practice support staff discussing JCAHO preparations. Linda Faber, RN, PhD, of Joint Commission Resources, brought her expertise in accreditation readiness and compliance knowledge to further help practices prepare, focusing most of her efforts on the National Patient Safety Goals (NPSG) and the JCAHO's new tracer methodology.

The tracer methodology "traces" a patient's entire care experience. Unlike an inpatient tracer, which follows the patient's care experience from admission to discharge, the outpatient tracer will follow a patient from a primary care visit to referrals to specialists and sometimes to outpatient testing or procedures. "Tracers used in an outpatient setting can be complicated," says Stacey Houghton, the newly appointed director of the Practice Support Unit. "Many outpatients receive their care in several locations. They can receive their primary care at a practice on the main campus and then travel to a satellite location such as MGH Chelsea or Mass General West in Waltham for their ancillary testing. These tracers follow the patients to these multiple sites and are focused on coordination of care and communication with the patient."

In a three-hour presentation, Faber showed a video depicting tracers in outpatient settings and discussed several case studies about JCAHO tracers. She then conducted seven separate "mock" tracers in MGH outpatient settings such as the MGH Chelsea and Charlestown health centers, Internal Medicine Associates, Oncology and Pediatrics. During these tracers, Faber selected several outpatient medical records, evaluated the care documented in the records, visited the different areas where the selected outpatients were sent during their care and interviewed the staff who cared for those patients.

"She did a wonderful job in spending most of her time asking questions of the front-line staff and the direct caregivers, which is most likely what the JCAHO surveyor will be doing," says Maryanne Spicer, director of MGH Compliance and chair of the JCAHO operations committee.

During Faber's visit, a panel discussion was held on the NPSGs and how they affect the ambulatory care setting. MGH staff members were included on the panel. Liz Mort, MD, associate chief medical officer and director of the Decision Support Unit; Gregg Meyer, MD, medical director for the Massachusetts General Physicians Organization; and Christopher Coley, MD, of MGH Medicine, spoke about initiatives at the MGH to meet the NPSGs.

The outpatient practices will continue JCAHO preparations by conducting more mock tracers, holding monthly JCAHO forums and hosting workshops on various JCAHO-related topics. In addition, practice managers and Practice Support Unit staff will be conducting self-assessments to evaluate JCAHO compliance and readiness. For more information about the survey, visit www.massgeneral.org/jcaho.