1. © Copyright, The Joint Commission Performance Improvement: Getting Started in Your ASC Dana Dunn RN, MBA, CNOR, CASC Certified Yellow Belt Field Representative, ACAS

2. Client name/ Presentation Name/ 12pt - 2 © Copyright, The Joint Commission Learning Objectives  Describe The Joint Commission program for Performance Improvement  Review ready resources to get started  Demonstrate the basic steps to improvement activities  Develop a Performance Improvement Plan

3. Client name/ Presentation Name/ 12pt - 3 © Copyright, The Joint Commission Resources  The Center for Transforming Healthcare –Robust Performance Improvement (RPI) –Targeted Solutions Tools (TST)  Joint Commission Resources –“Tools for Performance Measurement in Healthcare: A Quick Reference Guide 2 nd Ed. 2008” –“Root Cause Analysis in Health Care: Tools and Techniques 4 th Ed. 2010”

4. Client name/ Presentation Name/ 12pt - 4 © Copyright, The Joint Commission Warehouse of Data  Daily, weekly, monthly, annual data ex,: – Environment of Care –Infection Prevention –Medication Management –Information Management –Patient Satisfaction –Business efficiency –Incident/occurrence reports

5. Client name/ Presentation Name/ 12pt - 5 © Copyright, The Joint Commission Performance Improvement  Organization-wide  Ongoing  Data-Driven

6. Client name/ Presentation Name/ 12pt - 6 © Copyright, The Joint Commission Leadership  Using Data  Planning  Communicating  Changing Performance  Staffing

7. Client name/ Presentation Name/ 12pt - 7 © Copyright, The Joint Commission Performance Improvement Governance/ Leadership EC Plan: Safety/Security Hazardous M & W Fire Safety Equipment Utilities EM Plan: Disaster Prep IC Plan: HH SSI Flu Vaccine MM Plan: High Alert LASA Controlled Drugs IM Plan: Accuracy Timely Completion HIPAA EMR Contracts: Linen Housekeeping Pharmacy Biomed Pt. Input: Surveys Grievances Post op Calls Quality Indicators: Incidents Outcomes High Risk Sentinel Events Focused Studies Peer Review/HR: Competence Outcomes Staffing Ratio

8. Client name/ Presentation Name/ 12pt - 8 © Copyright, The Joint Commission Risk Assessment Set Goals Plan “Best” Strategies Implement Strategies Evaluate Re- Evaluate ( Document/ Report) Collect Data: Internal/External Analyze Prioritize Explain Why? Collect Surveillance Data Measurable Timeframe How will you achieve the goals? Basic Steps

9. Client name/ Presentation Name/ 12pt - 9 © Copyright, The Joint Commission Processes  Risk Assessment  Analysis  Prioritize  Determine Goal(s)  Strategies  Monitor Strategies- New data  Re-evaluate (Plan Evaluation

10. Client name/ Presentation Name/ 12pt - 10 © Copyright, The Joint Commission Risk Assessment Grid

11. Client name/ Presentation Name/ 12pt - 11 © Copyright, The Joint Commission Performance Improvement Plan  Position Statement -- Mission  Responsibility  Scope of Plan  Data Collection, Frequency, Analysis  Priorities  Goals  Strategies  Evaluation of Plan’s Effectiveness

12. Client name/ Presentation Name/ 12pt - 12 © Copyright, The Joint Commission Summary  Leadership –is ultimately accountable for the safety and quality of care provided. –uses organization-wide planning to establish structure and processes that focus on quality and safety. –prioritizes data collection and performance improvement activities. –evaluates the effectiveness of the planning.

13. Client name/ Presentation Name/ 12pt - 13 © Copyright, The Joint Commission More Resources  Ambulatory Surgery Center Association (ASCA)  Becker’s Clinical Quality & Infection Control  Institute for Healthcare Improvement (IHI)  Many more on the web

14. Client name/ Presentation Name/ 12pt - 14 © Copyright, The Joint Commission References  The Joint Commission: CAMAC, Comprehensive Accreditation Manual for Ambulatory Care  The Center for Transforming Healthcare: –Robust Performance Improvement –Targeted Solutions Tools  Joint Commission Resources

15. © Copyright, The Joint Commission Questions? Dana Dunn RN, MBA, CNOR, CASC VM: 630-792-6190 ddunn@jointcommission.org