READINESS SURVEY AND IMPROVEMENT IN QUALITY

Readiness Survey and Improvement in Quality

Abstract

JCAHO AND CMS believes that a highly effective, centrally-administered, and well structured system for promoting quality of care and proactively addressing the risks inherent to provision of health care is critical to its mission. In 2004, JCAHO AND CMS reorganized the quality assurance function to better reflect the agency's commitment to strengthen its quality and safety agenda. As part of this reorganization, Quality Management was moved from a single bureau under the Chief Medical Officer to a Cabinet level office. This change was designed to ensure that quality issues remain at the forefront of JCAHO AND CMS executive discussions and decision making. The newly constituted Office of Quality Management (OQM) is designed to accomplish three goals:

To create a discrete quality management unit with a new level of functional independence, separate and distinct from the operational programs it is designed to oversee.

To reflect the importance of the quality management function and the expectation of a safe system of care as a baseline to all activities.

To foster an integration of all agency regulatory, standards compliance, performance improvement, and quality management activities under the quality management umbrella.

The newly formed Office of Quality Management is composed of two bureaus with complementary functions: the Bureau of Quality Improvement (formerly the Bureau of Quality Management) and the Bureau of Inspection and Certification.

Table of content

CHAPTER I- INTRODUCTION6

Mission of the Bureau of Quality Improvement (readiness survey)6

Nine 2005 readiness surveys have yet to take place.9

Mission of the Bureau of Inspection and Certification (BIC)9

Office of Quality Management Initiatives for 2005-200610

Improved Efficiency in the PAR Process14

Periodic Performance Review (PPR) Technical Assistance17

Focused Medical Record Review Process17

Internal Tracer Process17

JCAHO Standards Training18

Mock JCAHO Survey18

Environment of Care/Life Safety Code Reviews19

Off-Site Continuous Survey Readiness Support19

Always Ready for Every Patient21

Ensure accuracy23

Review definitions24

There must be a careful review of each definition accompanying the HCFA 672.24

Great opportunities24

Everyone's informed27

CHAPTER II- LITERATURE REVIEW29

Over view of the study29

Background29

Findings31

Overall Deficiencies Are Decreasing, but “Quality of Care” Deficiencies Are31

Increasing and Other Serious Deficiencies Persist at High Levels31

JCAHO and CMS with Chronic Quality of Care Problems Exist32

State Directors and Surveyors Express Reservations about Relying Exclusively on Oscar Data to Identify and Understand Problems in JCAHO and CMS33

Recommendation34

Agency Comments35

Background36

Medicare Requirements38

Enforcement Procedures39

Requirements Of Surveys40

Complaint Procedures43

Online Survey Certification And Reporting System (Oscar)43

Prior Studies46

CHAPTER III49

Methodology49

OSCAR Data49

Interviews51

CHAPTER IV52

Finding52

Overall deficiencies are decreasing, but “quality of care” deficiencies are increasing and other serious deficiencies persist at high levels52

General trends52

“Quality of care” deficiencies55

High deficiencies58

CHAPTER V62

Conclusion62

Snapshot in time66

Unclear definitions67

Recommendation69

References75



Chapter I- Introduction

Mission of the Bureau of Quality Improvement (readiness survey)

Readiness survey's mission is to provide technical assistance, support, tools and training for health providers in New York State to continuously improve the safety and quality of services by promoting ongoing compliance with nationally established standards of excellence and proactive clinical risk management. (Rosenbloom, 2006) While the clinical risk management program includes the identification and management of adverse events (incidents), it focuses primarily on utilization of a coordinated approach for identifying high risk processes and systems, reducing variation in the processes ...