Problem: My long-term care pharmacy is preparing for its first JCAHO accreditation survey. How can we help ensure a smooth, successful survey?

Solution: Those who've already been through the survey process say the keys to success are advance planning, careful preparation, and concerted involvement by the entire organization.

The first applicants have fared well under the Joint Commission on Accreditation of Healthcare Organizations' fledgling long-term care pharmacy accreditation program (30 surveys in the first four months and 30 favorable outcomes), but prospective accreditees still have many questions: What's the best way to go about preparing for the survey? How much staff time is required? What will it cost to get accredited? Is it worth the cost?

JCAHO official Darryl Rich addressed those and other accreditation issues in a panel presentation at ASCP's recent Annual Meeting in Nashville. More tips and insights were offered by other panelists whose pharmacies are among the first accredited-ASCP member Paul Herring of Vrable Healthcare Services, and Lori Luttmer, RN, of Cincinnati-based Skilled Care Pharmacy, both of whom described their pharmacy's experience as "very positive."

The initial long-term care pharmacy survey takes 16 hours over two days. If the pharmacy is also seeking accreditation of its home care and/or home infusion operations, however, the survey will take longer. "The home care survey involves some 400standards, as opposed to 150 in the long-term care manual, "Rich noted, "so the process is somewhat more involved. And the [compliance] expectations are higher because these patients aren't under the care of health professionals 24 hours a day."

Luttmer's survey experience bears this out, particularly with regard to care planning activities. "The surveyors will want to see a lot of in-house records to show that the pharmacy has a care plan package on each patient. They'll want to see specific care plans. They'll want to know the specific drugs a particular infusion patient is on. They'll want to know: Do you have a plan for how often to check lab values? What were you looking for in the way of patient improvement? Is the pharmacist connecting and coordinating with the nursing staff? Are you getting labs back and making appropriate recommendations based on those values?"

The duration of the survey also depends on the volume of patients served by your company. "If you're serving more than 150patients per year, the survey will go from three to four days, "Rich said. "If you're serving over 1,000 patients, it might go even longer."

First-time accreditation candidates are advised to submit an application to JCAHO six to 12 months before the target survey date. It takes three to four months from receipt of the application until the actual survey takes place, and JCAHO requires a four-month track record of demonstrated compliance with the standards. JCAHO will notify the pharmacy of the exact survey dates 30 to 60 days in advance, at which time the pharmacy must move ahead with public information requirements: posting notices in public areas, sending written announcements to all staff and client facilities, and notifying consumer advocacy groups and the general public.

When the surveyors arrive, there shouldn't be any surprises. "The manual has everything the pharmacy needs to prepare for the survey, "Rich stressed, referring to the Comprehensive Accreditation Manual for Long Term Care Pharmacies, furnished to all applicants. "You need to read the manual" in a studious, thoroughgoing manner, Rich emphasized. That may seem too obvious to bear mention, but Rich said that in his years with JCAHO he has been amazed at many organizations' woeful lack of preparation-"The shrink wrap was still on the manual when we arrived." Not surprisingly, he said, "Those organizations did not do well."

Applicants can keep abreast of any changes in scoring guidelines or standards interpretation in the still-evolving survey program by reading JCAHO's Perspectives newsletter, also routinely sent to every applicant.

Given the comprehensive scope of the JCAHO survey, "It's important to get a buy-in from everyone," Luttmer said. That means the consulting and dispensing staff, pharmacy technicians, billing personnel, all the way down to drivers and receptionists. All the panelists agreed that close interdisciplinary collaboration greatly facilitates the process of attaining and maintaining full compliance.

"We formed a JCAHO committee to marshal all preparation activities," Herring said. "We broke down the standards by department and assigned responsibility for various components to different staff members [and task forces]."Luttmer's pharmacy took a similar approach.

Rich and the others strongly urged applicants to conduct a comprehensive mock survey well before the actual survey; this allows plenty of time to identify shortcomings, develop and implement plans of corrective action, and ensure that all required documentation is present and readily available when the surveyors show up. The mock survey can be done by either internal or external personnel in accordance with the standards, scoring guidelines, aggregation rules, and decision rules from the JCAHO manual-the same tools surveyors will use.

Just before the survey takes place, an all-staff briefing is agood way to define expectations, make sure everyone knows whatto expect, and address any last-minute concerns.

While broad staff involvement and input is essential, JCAHO requests that the pharmacy choose one individual to coordinate all survey-related activities and serve as JCAHO's primary contact. This team leader should be knowledgeable in all aspects of the pharmacy's operations (the director of consulting or director of dispensing may be a good choice). However, Rich cautioned against relying too heavily on any one staff member. "Be prepared for turnover and the possibility of losing a key person, or you could be in trouble if that key person leaves."

Some pharmacies may be used to performing certain patient care and administrative functions without formal, written protocols. To satisfy JCAHO, these "unwritten" policies and procedures must be put in writing, and this is usually the most

challenging and time-consuming survey preparation task. Some pharmacies choose to write new P&Ps "from scratch." Others customize model documents from one or more reference books or software programs marketed for this purpose, but care must betaken to ensure that the modified P&P's presented to JCAHO reflect actual pharmacy practices.

"If your procedures say your staff is double-gloving for every repackaging process, and we don't see your person with two sets of gloves on, we're going to hold you responsible," Rich said.

In the first wave of long-term care surveys last year, some pharmacies whose activities include home care were surprised to learn that those operations were fair game for JCAHO scrutiny even though the pharmacy hadn't applied for home care accreditation. Rich reiterated JCAHO's policy: "We accredit everything you do for which we have standards . . . all the services you represent to the public. If you say you provide it and you market it, we're going to look at it." That includes services performed on the pharmacy's behalf by outside contractors (for example, nurses hired to help with I.V. starts or train staff) as well as services performed by "functionally and organizationally related" entities, he emphasized.

Once accreditation is achieved, the next survey will be in three years-with a few important exceptions. A random 5% sample of accredited pharmacies are subject to unannounced surveys 18 months after the initial survey, and JCAHO may at any time conduct an unscheduled, unannounced survey "for cause" (i.e., a specific complaint or media report relating to the quality of care provided by the pharmacy).

Herring shared a couple of survey tips: "If your survey isscheduled to begin on Tuesday, the JCAHO team will come into townon Monday night. Possibly that night they're going to test youremergency call system." Herring also hinted that there mightbe an advantage in going through the survey process now ratherthan later: "Gray areas" in the standards that are nowopen to compromise and negotiation-he mentioned drug recall policiesand drug packaging requirements-"may get more locked in"as time goes by.

Rich emphasized that JCAHO is interested in working with all applicants to achieve a good survey outcome. The JCAHO headquarters staff stands ready to handle any inquiries about interpretation of standards(630-792-5900) or accreditation operations such as applications, scheduling, the survey process, or survey reports (630-792-5754).In addition, JCAHO offers a variety of survey preparation resources, including seminars, manuals and other publications, even a speaker's bureau (call customer service at 630-792-5800). A new survey process guide will be available this month, with other manuals planned for the near future. Above all, Luttmer advised, "Talk to colleagues who've been through the survey process. They can tell you exactly what to expect."

Rich and the other panelists agreed that pharmacies with especially large or complex operations may want to consider hiring an outside consultant with special expertise in JCAHO accreditation issues.

So, how much time and expense is involved in getting a pharmacy accredited? "That depends on where you are going in," Rich said. "If you're only in compliance with a few of the150 standards, you've got a lot of work. But if you're in compliance with 140, you can probably 'tweak' what you need to get done within a month or two." Luttmer said the owner of her company estimatedthe total cost at more than $100,000, taking into account not only fees paid to JCAHO, but also the investment in staff time and resources. But Skilled Care is confident that the investment will pay off in increased staff competency, overall quality improvement, increased marketability and respect from payers, and identification of new cost-saving strategies. "Going through the survey process has made us a better company," she said. "It's a win-win situation."

David K. Buerger
Associate Editor