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Process will direct surveyors to areas needing attention
Process aims to reduce unconscious surveyor bias
A primary goal of the "Shared Visions — New Pathways" survey process is to make the system meaningful instead of concentrating on rote recitations of standards or paperwork that seems to indicate compliance but may not.
To that end, the Joint Commission on Accreditation of Healthcare Organizations plans to use a priority focus process (PFP) that directs surveyors to the organization-specific, critical patient care processes and systems most useful for assessing compliance and quality of care.
The PFP guides the entire survey process by providing surveyors and Joint Commission central office staff with insight and information about your organization long before the survey. According to information provided by the Joint Commission, the PFP will be driven by an automated tool called the priority focus tool (PFT) that gathers pre-survey data from internal and external sources.
Those sources include the Joint Commission’s quality monitoring system, ORYX data, self-assessment information, accreditation history, and an organization’s own demographic and statistical information. The tool uses automated sets of rules to sort the data and turn them into valuable information that focuses the on-site survey on critical areas of focus.
In addition to making the survey process more relevant to each organization, the PFP also promises to virtually eliminate any unconscious surveyor bias or habit in the survey’s focus. Organizations with the same profile should have a consistent, predictable set of priority focus areas.
The Joint Commission offers the example of an organization with a large geriatric population and a high volume of medical admissions. The number of prescribed and dispensed medications is expected to be higher than that of an organization with mainly elective surgery populations, so medication-use issues would be critical. For the same facility, another focus area might be do-not-resuscitate orders and end-of-life care.
Critical focus areas are defined as processes or systems in a health care organization known to significantly affect patient safety and quality of care. If these processes fail, the Joint Commission says, there is a higher probability of negative outcomes.
These are the 14 areas of critical focus that the Joint Commission has identified and which the PFP can direct surveyors to investigate closely: patient assessment, communication, credentialing, equipment use, infection control, information management, medication use, organizational structure, staff orientation and training, rights and ethics, physical environment, quality improvement expertise and activity, safety engineering, and staffing.