JCAHO Evaluation Timeliness Standard

susan macias

Sometime ago there was discussion about a JCAHO requirement that 90+% of evals fall into the timeliness range. Can anyone verify the percentage for me, and cite a source? Thanks.

davidh

JCAHO standards for hospitals are as follows:
HR.5 The hospital assesses each staff member's ability to meet the performance expectations stated in his or her job description including competency assessments of individuals that clearly address the ages of the patients served and the success with which employees produce the results expected from clinical interventions.

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Every employee must be evaluated based on the employer's own system. The hospital will be graded on their adherance to their own standards (as long as they are within the JCAHO parameters).

The scoring grid goes as follows:
Score 1 = 100% compliance
Score 2 = 95% to 99%
Score 3 = 90% to 94%
Score 4 = 80% to 89%
Score 5 = Less than 80% Compliance

A score of 3,4,or 5 gets a Type I Recommendation with follow up in 6 months to see if improved (NOT GOOD!). A score of 2 gets a Supplemental Recommendation with improvement expected at next survey (NOT GOOD either because surveys are no longer every three years - i.e., unannounced).

For example, If you're measuring timeliness of evaluations, set your standards where you can score 100%, i.e. all are turned in within 3 months of due date.

susan macias

David - thanks a lot. That clarifies things for me.

barry

Does anyone know the shortest period of time that we can be in compliance for the Joints to accept - 6 months, 1 year?

davidh

Joint Commission on Accreditation Healthcare Organizations (JCAHO) lets the employer define their own (within reason)timeliness standards. The key is to make sure you follow or beat your own criteria. When they last visited our hospital, I believe the HR interviewer stated that evals completed within 3months of the due date seemed reasonable. Have a system, follow your policy/procedure and document the results.

If the JCAHO interviewer sees evals completed 100% - within a year of due date, they could give you a good score, but you lose the war when they spend time looking for something else to dig up.

Do the right thing and complete evals on time. Obviously eemployee morale is improved when their evals are completed when due, not 3, 6, or 12 months late.

barry

David . . . My question is what is the shortest period of time that we can be in the 5% range to avoid a Type I. We will be below 5% for about 3 quarters when the JCAHO survey team arrives. Prior to this we were so awful that for the year our average (for the year) will be above the 5% threshold. Will they accept 2 or 3 quarters of below 5%?

davidh

The JCAHO evaluator may take several paths to score you. First, if you have a good clean system to track and report, they'll score from that, or what you report to them.
Since you must have changed some processes to improve timeliness, that can be presented as a positive. i.e., your scores are improved because of some effort to improve processes. That is really what they are looking for. Not so much a hard fast score, but outcomes from process/performace improvement. I have been in similar circumstances before and leveled with them and they tried to work with me to get as good a score as possible. They could just develop a timeliness score from the ~ ten or so employee files that they ask to review! If you're doing better now, report that and they will take the most recent score (i.e., the quarter your currently in when they arrive).
I hope this helps, and good luck.