Each fall, ASHRM reaches out to its membership for volunteers to participate in various ASHRM-sponsored committees and task forces. As a volunteer-based organization, ASHRM appreciates members’ contributions of talent.

In an effort to make more efficient use of members’ time, ASHRM leadership is modifying the way in which volunteers will be recruited and utilized. One significant change is in reframing the “Call for Volunteers” as a “Call for Participation” in ASHRM activities.

In Q & A format, here is how the Call for Participation will work in 2004.

Q. How will the opportunities be organized?

A. Beginning in 2004, ASHRM participation opportunities will be organized around subject matters relevant to the management of risk in health care. Therefore, subject matter experts (that’s you!) are being sought who can contribute expertise in a variety of professional development and advocacy areas. These activities are largely project-based in that members will come together as a working group to complete a specific task.

Q. What happens when the task has been completed?

A. Once the task is accomplished, the group will be disbanded.

Q. How many activities may members participate in?

A. Members are welcome to indicate as many areas of subject matter expertise as they possess. Members could be called upon by ASHRM staff to participate in one or more activities during the year, and are free to decline a call if they feel they may be unable to commit to seeing the task through to its completion.

In addition to some standing committees, work groups to be called “SWOT Teams” will convene.

Q. What’s a SWOT Team?

A. Specific Work Opportunity Tactical Teams are project-based groups. Each group is focused on patient safety, risk financing/claims management, enterprise risk management (everything that is neither patient safety, risk financing or claims) or membership services activities. These activities may include:

* Risk management topic identification (for programs and publications);

* Faculty identification and program objective development;

* Content development (for publications such as Pearls, Monographs, the Journal of Healthcare Risk Management);

* Issue development (for legislative or regulatory issues).

In 2004, SWOT Team members will be selected to support the development and delivery of the following (not inclusive):

Audio Conferences

Health Care Risk Management Week program

Journal Editorial Review Board

Patient Safety Leadership Fellowship Scholarship

Pearls

Monographs

Legislative Advocacy

Regulatory Advocacy

Special Topic Programs.

Q. Will there be any standing committees?

A. As in the past, several ASHRM standing committees will be convened. They are:

Annual Conference Planning Committee: Primary tasks are planning and supporting the 2004 annual conference. Responsibilities include keynote and faculty selection, program development, and support of conference attendees. The committee will have one face-to-face meeting and conference calls (as needed) to plan the ASHRM Annual Conference to be held Oct. 17-20, 2004, in Orlando.

Bylaws Committee: Primary task is to conduct a review of ASHRM bylaws and recommend changes if needed to ensure bylaws match with current practice and direction of ASHRM.

Ethics Committee: Primary task is to review all nominee applications for ASHRM office to ensure against a conflict of interest. If necessary, the committee will refine the code of professional responsibility for ASHRM and, should the need arise, review allegations of breaches of the code of professional responsibility.

Finance Committee: The president appoints members, including one at-large member of ASHRM (as per the bylaws), to this committee.

Nominating Committee (elected): Members are elected by ASHRM membership. Primary task is to review the nominations for ASHRM elected positions and prepare a slate of candidates for the ballot.

Q. How can I answer the Call for Participation?

A. Please complete the ASHRM 2004 Call for Participation form. There are several ways to access the form:

* Check the issue of the Journal of Healthcare Risk Management (Vol. 23, No. 3) that was mailed to members in October.

ASHRM is working with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to address discoverability issues raised by JCAHO’s impending accreditation process.

“Shared Visions – New Pathways,” the new accreditation process to be implemented next January, emphasizes continual compliance with accreditation standards. A key part of this process is the requirement that a JCAHO-accredited organization complete a Periodic Performance Review (PPR) at the mid-portion (18 months) of the triennial survey cycle.

Organizations approaching the mid-portion of their accreditation cycle as of Jan. 1 will be required to complete the PPR, which JCAHO will make available through restricted Web site access at the end of October or beginning of November.

The Periodic Performance Review requires each accredited organization to assess itself against all applicable JCAHO standards, develop a plan of action to address areas of non-compliance, and identify measures of success to demonstrate that the identified problem areas have been resolved when the organization undergoes its complete on-site survey 18 months later. All information developed through this process is to be shared with JCAHO.

Since JCAHO’s announcement of the PPR process this spring, ASHRM, the American Hospital Association and several state hospital associations have identified several significant legal and risk management concerns that could adversely affect accredited hospitals.

Legal issues of concern were brought to JCAHO Sept. 3 in a meeting at JCAHO headquarters. Representing ASHRM were President-Elect Jeff Driver, Board member Marta, Past-President Fay Rozovsky, member Christine Clark, and ASHRM staff members Elizabeth Summy and Pamela Para.

Their legal issues were:

“Waiver” of protection. There could be loss of state peer review or other protection incurred by disclosure of the PPR results to JCAHO.

Limited/no protection. In several states, due to routine and systematic nature of the assessment, the PPR is not protected by “peer review” statutes, regardless as to whether it is disclosed to JCAHO.

Access by regulatory oversight agencies. Where JCAHO is “deemed” by a state oversight agency and/or possibly a federal agency, a hospital could be required to submit the results of the PPR to the respective agency. Possible consequences of such a submission could be regulatory action taken by the oversight agency and/or disclosure of the PPR results to any individual requesting those results.

Over the past six months, ASHRM has worked with JCAHO to clarify the legal and risk management issues and to develop options to the existing PPR that would effectively address these issues.

To date, JCAHO has approved two options that a hospital can use if, on the advice of legal counsel, the hospital attests that it is unable to submit the standard PPR:

Option 1 – The organization completes the PPR, but DOES NOT submit the results, any plans of action, or measures of success to JCAHO; the organization attests to the fact that it has completed the PPR; measures of success are made available to the on-site surveyors at the time of the triennial survey.

Option 2 – One surveyor assesses compliance with the relevant JCAHO standards by conducting a fee-based, condensed on-site survey, approximately one-third the length of the typical triennial survey. Corrective action plans and measures of success will be completed and submitted to JCAHO by the organization for all areas where the organization is found to be in non-compliance.

To retain its JCAHO accreditation, an organization must utilize the standard PPR or one of these options. Unfortunately, neither of the approved options fully addresses the legal and risk management issues that have been raised. Discussions are continuing in an effort to develop solutions for these unresolved issues.

In the interim, since JCAHO will be making the PPR available to eligible organizations by the end of October/beginning of November, ASHRM suggests that the leaders of a JCAHO-accredited hospital and health system seeking re-accreditation, in coordination with their risk and quality managers, contact their state hospital association legal counsel or their own internal legal counsel to discuss the risks and benefits of completing the PPR or utilizing one of the available options.

Additionally, ASHRM has given JCAHO a number of suggested revisions to the PPR user’s manual.

With any further questions or concerns about the PPR process, ASHRM members may contact Elizabeth Summy, executive director of ASHRM, at (312) 422-3989, esummy@aha.org.

Two highly anticipated books arrive Nov. 1 when the latest editions of ASHRM’s Risk Management Handbook for Health Care Organizations and Certified Professional in Healthcare Risk Management Examination Study Guide make their debuts.

In its new 4^th edition, the Risk Management Handbook packs 1,400-plus pages with the most authoritative techniques and practices of today’s health care risk management professionals. Editor Roberta Carroll and her task force worked with 70 practicing risk managers, attorneys and insurance professionals to cover the enterprise-wide continuum of care and associated risk.

The result is an unmatched collection of current information, regulatory and legal updates, and assessment tools that will prove valuable to both new and seasoned risk management professionals.

While including insights on patient safety, risk financing, emergency preparedness and more, the big book’s focus is the concept of enterprise risk management (ERM), which encourages the evaluation of all risk exposures confronting an organization. ERM is introduced as the strategic way to help ensure the efficient delivery of safe and trusted health care.