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Accreditation Seminar — The Joint Commission

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1 Accreditation Seminar — The Joint Commission
Michael Kulczycki, MBA Executive Director, Ambulatory Care Accreditation Program The Joint Commission-

2 Session Overview Accreditation as a management tool
Patient safety issues Opportunities for improvement Other factors The Joint Commission-

3 Accreditation choices:
Primary reason = third party reimbursement All accreditors represented fill your need.

4 Accreditation choices: Designed for ASCs seeking: >>
Accreditation choices: Designed for ASCs seeking: >> added value from the accreditation process, >> partnership with an accreditor with consultative & collaborative resources, >> ability to use an accreditation process as a management tool, then……

5 The Joint Commission …your choice
Helping Health Care Organizations Help Patients

6 Joint Commission Background Not-for-profit organization
Accredits 15,000 total organizations Accrediting ambulatory since 1975 – ASCs = largest segment Awards Gold Seal of Approval™

7 Accreditation package
The Joint Commission offers multiple components which, taken together, form a comprehensive package. This package of services can be used as a management tool to enhance ASCs: quality of care and service, patient and staff safety, organization risk management, and continuous performance improvement.

8 Accreditation components include:
Continuous process, not “ramping up” Unannounced surveys Enhanced use of web-based tools Increased on-site survey focus on direct patient care

9 …..Accreditation components
Emphasis on an organization’s systems Annual self-assessment process (Periodic Performance Review) Ongoing improvement & tailoring of ambulatory standards.

10 Accreditation Manual: Ambulatory Care
Program specific statements of: standards, rationale, elements of performance (compliance criteria) National Patient Safety Goals Information about accreditation process Periodic updates

11 2007 Standards for ASCs On-site evaluation evaluates compliance with Standards & National Patient Safety Goals Standards organized in 10 chapters: RI Practice Ethics and Patient Rights (20) PC Provision of Care, Treatment, & Services (35) MM Medication Management (20) IC Prevention, & Control of Infection (9) PI Improving Organization Performance (6) LD Leadership (24) EC Management of the Environment of Care (24) HR Management of Human Resources (17) IM Management of Information (13) NPSGs 7 Goals plus Universal Protocol (8) The Joint Commission-

12 On-site Survey Process
Accommodates ASCs normal operational systems & schedules Few formal interviews More attention to actual individuals receiving care Use of pre-survey, focused information Tracer method allows customization: Settings / Services / Patients The Joint Commission-

13 Patient Tracer Method Process driven, initiated by priority focus areas (highlight 4-5 for ASCs) Customized to ASC services More focused on execution -- actual delivery of care / services Frontline staff…what do they do, and why do they do it that way The Joint Commission-

14 Patient Tracer (cont) Traces 3-4 patients through ASCs entire process
Use patient chart as “road map” As cases are examined, surveyor may identify performance issues in one or more steps of the process – or between processes Systems tracer includes dialogue on data / infection prevention / medications The Joint Commission-

15 Session Overview Accreditation as a management tool
Patient safety issues Opportunities for improvement Other factors

16 National Patient Safety Goals
Each year, a set of Goals is identified from topics published in Sentinel Event Alert & other sources Small number of specific requirements for Goals identified for survey following year Goals and their requirements published by mid-year Selection of Goals and requirements guided by panel of experts

17 2007 National Patient Safety Goals for surgery centers
Patient identification Communication among caregivers Medication safety Health care-associated infections Reconciliation of medications Surgical fires Patient involvement Universal Protocol for Preventing Wrong Site Surgery

18 Goal #13: Involvement of patients
New for 2007 Encourage the active involvement of patients and their families in the patient’s care as a patient safety strategy. Requirement #13.a. Define and communicate the means for patients to report concerns about safety and encourage them to do so.

19 2008 NPSG changes Medication Safety (3E)
Reduce the likelihood of patient harm associated with the use of anticoagulation therapy 2008 “expectations” for implementing 2009 implement compliance Medication Safety (3B: standardizing drug concentrations) retire, retain in medication standards

20 NPSG Compliance Data for 2003—2006 (Freestanding Ambulatory Care Surveys: % Non-compliance)
NPSG requirement 2003 2004 2005 2006 1a: Two identifiers 7.3% 8.0% 3.7% 6.9% 1b: Time out before surgery (UP) 6.0% 6.7% 13.9% 24.2% 2a: Read-back verbal orders 5.5% 7.6% 10.7% 9.2% 2b: Standardize abbreviations 19.6% 16.3% 17.9% 24.0% 2c: Improve timeliness of reporting --- 1.2% 8.3% 2e: Hand-off communications 2.5% 3a: Concentrated electrolytes 1.1% 1.7% 3b: Limit concentrations 1.5% 0.2% 0.0% 0.9% 3c: Manage look-alike/sound-alike drugs 3.5% 8.5% 3d: Label medications & solutions 4.1% 4a: Preoperative verification (UP) 2.3% 1.8% 4.5% 1.6% 4b: Surgical site marking (UP) 4.3% 4.0% 5.7% 7a: CDC hand hygiene guidelines 11.5% 7b: HC-associated infection & RCA 2.2% 8a: Medication reconciliation – list 1.0% 24.4% 8b: Medication reconciliation – reconcile 0.7% 25.8% 11a: Surgical fire 2.0%


22 Session Overview Accreditation as a management tool
Patient safety issues Opportunities for improvement Other factors

23 Standards for ASCs Source = Ambulatory Surgery Centers surveyed by Joint Commission during 2006 (n=170) Chapters with opportunities for improvement: Provision of Care Performance Improvement Environment of Care Human Resources National Patient Safety Goals Universal Protocol Source: THE JOINT COMMISSION PERSPECTIVES, February 2007, “Top Standards Compliance Issues for 2006” The Joint Commission-

24 ASC Opportunities for Improvement
Provision of Care.16.10: Organization establishes policies and procedures that define the context for using waived test results in patient care. (scored non-compliant on 28% of surveys) Lack of quantitative results in patient record accompanied by test-specific reference intervals appropriate to population served. 2. NPSG 8A: Accurately and completely reconcile medications across the continuum of care. (26% non-compliant) lack of process for obtaining and documenting a complete list of patient’s current medications upon entry into organization. 3. Performance Improvement.3.20: Organization selects a high-risk process to be analyzed annually to reduce risks to patients. (22% non-compliant)

25 …. ASC Improvement cont…..
4. NPSG 8B: Accurately and completely reconcile medications across the continuum of care. (20% non-compliant) lack of patient medication list being communicated to next provider when patient referred or transferred. 5. NPSG 2B: Improve the effectiveness of communication among caregivers. (17% non-compliant) lack of standardized list of abbreviations that are not to be used throughout the organization 6. UP 1: Organization fulfills the expectations set forth in Universal Protocol for Preventing Wrong Site Surgery, eg. implementation guidelines. (17% non-compliant) lack of preoperative verification process as described in Universal Protocol

26 …. ASC Improvement 7. Environment of Care.4.10: Organization addresses emergency management. (16% non-compliant) Lack of hazard vulnerability analysis 8. Human Resources Clinical privileges and appointments/reappointments are reviewed and revised at least every two years. (15% non-compliant) lack of defined process approved by leaders for ensuring competence of all practitioners permitted to practice independently

27 ASCs compared to all AHC – 2006
All AHC (n=430) Surgery Centers (n=170) Standard % PC.16.10 27% 28% PI.3.20 NPSG 8a 26% 22% MM.2.20 25% NPSG 8b 20% NPSG 2 17% UP 1 24% EC.4.10 16% HR.4.50 15% HR.4.10 These are color coded to show differences between subgroups (for some people it is easier to see patterns this way, for others it is more confusing). This is simply an alternative way of showing the same information provided on the previous slide. Again, percentages represent the proportion of surveys (n) where each particular standard was scored non-compliant (percentages are listed descending from most frequently scored non-compliant). The Joint Commission-

28 Session Overview Accreditation as a management tool
Patient safety issues Opportunities for improvement Other factors

29 Other factors State partnerships: Medicare option
Focused on establishing state recognition Staff available to partner with state/national associations Medicare option New “value” for accreditation Other partnerships Summary of advantages

30 Medicare “deemed status”
CMS awarded “deemed status” to Joint Commission & others Use accreditation survey to avoid duplicate state Medicare certification survey “Deemed status” option from Joint Commission: Always unannounced Covers nearly 30 additional CMS requirements “Early Survey Option” available The Joint Commission-

31 New driver for accreditation
Customers raised issue of insurance benefit of accreditation Validated linkage between liability insurers and accreditation Interviewed firms, eg. ASC underwriters, and polled liability industry 2007 launch website:

32 New accreditation driver: Liability recognition

33 Other factors on your choices
FASA / ASC involvement with The Joint Commission: Universal Protocol Standards development – Professional and Technical Advisory Committee for Ambulatory Customer Advisory Council Standards Improvement Initiative ( ) ASC performance measures ASC Quality Collaborative ( ) National Quality Forum

34 The Joint Commission Ambulatory Care Accreditation Program:
Accreditation timeframe – all evaluations produce a three-year accreditation decision, within 45 days of survey Accreditation Report – provided on-site Timely scheduling – ASCs identify “preferred”, scheduled initial survey for dates days from application Fully electronic process – application, post-survey steps, and all communication via secure, web Extranet Free phone/on-line access – answer your questions to aid understanding of standards or survey process

35 ….. The Joint Commission Ambulatory Care Accreditation Program:
Uses “Certified” Surveyors – who pass certification exam on standards and survey process Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working part-time for The Joint Commission. This means they survey organizations annually – serving as sources of consultative and educational ideas for your ASC Defined, Fixed Pricing – Fees are known before survey, include all costs, and billed over three-year period Name recognition -- Gold Seal of Approval™

36 Advantages Upon earning the Gold Seal of Approval™ your center:
Has access to a unique extranet site, Joint Commission Connect, for communications Has a single Account Representative, aiding: Updates to information All post-survey steps, conducted electronically Completion of annual self-assessment of compliance Survey process questions

37 Your choice > The Joint Commission ambulatory accreditation process: For those ASCs committed to quality & safety of care, Interested in an ongoing collaborative partnership in continuous performance improvement

38 What others say: “If you’re about to undergo your first accreditation survey, the message is the same….Accreditation bolsters processes, patient safety and ultimately the quality of your organization.” Outpatient Surgery Magazine, January Supplement, 2007

39 Resources --
Public site with updates, resource materials, frequently asked questions (FAQ’s), safety and quality initiatives. Extranet site for accreditation customers with organization-specific information, updates, and messages (Joint Commission Connect) -- affiliate providing education and publication resources

40 Free resources for ASCs
Video of patient tracer process in ambulatory setting AmbulatoryCare/ Accreditation_Process/ Standards sampler for ASCs AmbulatoryCare/

41 Your questions / Next steps?

42 Information
Ambulatory Care Accreditation

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