Hospice accreditation: a useful tool for quality assurance.

Another survey! I can’t take anymore! That was my responsewhenI beganto considervoluntary accreditation by the Joint Commissionon Accreditationof HealthcareOrganizations(JCAHO) a coupleof yearsago. I thenattendeda JCAHO seminar whichhelpedmecalmdown.Thefocus was on quality careandthepresenters werebrightandreceptive. In manyways the philosophyand goalsof hospicealign with this objective. Yearsago,it becamecleartomany astheyevaluatedotherhealthcaresystems,thattheneedsoftheterminallyill werenotbeingmet.Sincetheirinception, hospice programs have demonstratedastrongcommitmento quality care.AccordingtoJCAHO,one of themajorobjectivesof accreditation is the advancementof this country’svoluntary effortsto evaluate and improve the quality of care providedby healthcareorganizations.”It is importantto keepin mind thatthe primary objectivesof JCAHO and hospiceprogramsareinagreement. Oncewedecidedto havethesurvey done,thenextstepwaspreparationand implementation. It ishelpful to setup a targetdatefor the survey.This motivates personnelto set up a planto accomplishthe tasksand implementthe changesmostlikely toberequiredonce anevaluationis completed.In ourparticular situation, the targetdatechangedtwice dueto changesin personnel and areorganizationwithin agencyin which the hospiceis based.Once the preparationis substantiallycomplete, the applicationshouldbefiled. The key to a successfulaccreditation surveyis theinclusionof thestaff andboardmembersin the process.At first, we gatheredtogetherinformally anddid afreeflowing overviewof the program.All disciplinesidentified the strengthsand weaknessesof the hospice.Wethenbrainstormedsomesolutions to the problem areasidentified. Our strengthswere emphasizedwith thegoalthattheybe maintainedor enhancedby any changeswe decidedto implement.This meetinghelped all personnelrealize their role and responsibility to makethe hospicethe bestit couldbe.It alsocreatedanatmospherethatmotivatedthe staff toward the accomplishment of ourgoals. A sub-committeewith representationfrom the staff and board workedtoward formalizingtheobjectives,goals,andtasksto improvethe program and satisfy accreditation standards. It is significantthatsatisfyingstandards wasnottheprimaryfocus of the initial meeting.Themainobjective wasto enrichthe programandthe qualityofcareprovided.ThesubCommittee then reviewedthe JCAHO Hospice StandardsManual and HospiceSelf-Assessment and Survey Guide; while evaluatingthe program and determiningwhattasksneededto be accomplished.The committee developedan outline of goalsandobjectives using the standardJCAHO framework,the informationfrom the informal staffmeetingandthe policy andproceduremanuals.Whenreviewing the policies andproceduresof the program,the committeealwaysasked thequestions: