CASA_2013 © Copyright, The Joint Commission Essentials of Joint Commission Accreditation for Surgery Centers September 12, 2013 Presented by: Dana McGrath, RN, MSN, CASC Pam Roark, RN, MA, MSN

CASA_2013 © Copyright, The Joint Commission 2  Purpose of Accreditation  How do I get started? –Pricing & Resources –Application & Survey Activity Guide  What does a survey look like? –Onsite Survey & Surveyors –After the Survey & Most Common Findings  Customer Resources  Your Questions! Agenda

CASA_2013 © Copyright, The Joint Commission 3  Why Accreditation –Meet CMS requirements or gain initial Medicare certification –Continually enhance safety and quality of care –Reinforce risk management efforts –Validate quality of care; engage staff & patients –Possible discounts on liability insurance Purpose of Accreditation Define the difference between office-based surgery suites and ASCs.

CASA_2013 © Copyright, The Joint Commission 4 Effective “We clearly see that patient care has improved since we achieved Joint Commission accreditation.” Faris Zureikat, M.B.A., CASC Administrator North Texas Surgery Center Effective “We clearly see that patient care has improved since we achieved Joint Commission accreditation.” Faris Zureikat, M.B.A., CASC Administrator North Texas Surgery Center Voice of the Customer Responsive “I was pleasantly surprised by the quick call-backs, gracious service, and expedited process The Joint Commission provided. Alex Rothschild, MS, CMPE Administrator Garden State Surgical Center, LLC Responsive “I was pleasantly surprised by the quick call-backs, gracious service, and expedited process The Joint Commission provided. Alex Rothschild, MS, CMPE Administrator Garden State Surgical Center, LLC Focused “Joint Commission has really re-focused their standards and surveyors… Their goals are our goals: to provide a safe environment for patients.” Kitty Bouchard, RN Clinical Director Towne Centre Surgery Center, LLC Focused “Joint Commission has really re-focused their standards and surveyors… Their goals are our goals: to provide a safe environment for patients.” Kitty Bouchard, RN Clinical Director Towne Centre Surgery Center, LLC Supportive “There are so many great ways to get the answers we need. Our account executive is always available by phone and the standards team gives great support.” Debbie Cooner Director of Quality and Compliance Outpatient Services East, Ltd. Supportive “There are so many great ways to get the answers we need. Our account executive is always available by phone and the standards team gives great support.” Debbie Cooner Director of Quality and Compliance Outpatient Services East, Ltd. What sets The Joint Commission apart from other accreditors?

CASA_2013 © Copyright, The Joint Commission 5 How Do I Get Started?  Fee Estimate – only accreditor with transparent pricing – posted on Joint Commission website: surgery_centers.aspx surgery_centers.aspx –Based on patient volume –Approx. cost typical surgery center = $10,880 –Fees spread over 3-year accreditation cycle How can I determine the cost of accreditation for my ASC?

CASA_2013 © Copyright, The Joint Commission 6 How Do I Get Started?  Web site: –Accreditation overview and pricing –Request standards/application –Blog (5-part Q & A series)  Joint Commission Resources (JCR) store.jcrinc.com store.jcrinc.com –Purchase surgery center standards –Webinars/Educational seminars  Standards Interpretation Group –FAQ’s, Online Form to Submit ?’s –Call , Option 6 Questions about: Anesthesia; Disinfection; Medication Safety; Disposal of Medications; etc.

CASA_2013 © Copyright, The Joint Commission 7 How Do I Get Started?  Dedicated Customer Service Resources –Ambulatory-specific Account Executives  Application: –Web-based ‘extranet’ platform –Data submitted drives survey length –YOU designate survey ready date Are there special requirements for deemed status?

CASA_2013 © Copyright, The Joint Commission 8 How Do I Get Started?  Survey Activity Guide –Document List or “Ready-to-Go List” – helps your organization and survey team –Organization chart –Description of committee structures –Environment of care plans and annual evaluations –IC Plan and goals –List of services provided/ locations –List of contracted services  Customer Value Assessment – advance insight to surveyor of what are your performance improvement needs? H ow soon can a survey be scheduled?

CASA_2013 © Copyright, The Joint Commission 9 What Does an Onsite Survey Look Like?  Patient and Customer-Centric –Observation of and discussion with patient with permission –Minimal interruption  Educational and Informative –Shared observations –Leaders/managers/staff encouraged to participate  Surveyors –Clinical & administrative professionals experienced in ambulatory arena –Collaborative and courteous

CASA_2013 © Copyright, The Joint Commission 10 What Does a Survey Look Like? After the Survey  Preliminary findings provided on-site  Post-survey steps, with prompt decision – under 10 days!  Resurvey 3 years  Interim support for continuous compliance

CASA_2013 © Copyright, The Joint Commission 11 Most Common Findings  Standards Compliance Issues for 2012 Yellow shading represents percentage of organizations that received Requirements for Improvement (RFIs) for that particular requirement. What are the most common findings?

CASA_2013 © Copyright, The Joint Commission 12 Resources for Customers  Joint Commission Connect TM (Extranet) –Targeted Solutions Tool TM - helps identify performance barriers & customized solutions regarding wrong- site surgery and other persistent issues –Perspectives - Joint Commission’s official monthly e-periodical –Leading Practice Library - real-life solutions from accredited organizations  QualityCheck –Lists accredited organizations –Used by consumers & payers –

CASA_2013 © Copyright, The Joint Commission 13 Your Questions!

CASA_2013 © Copyright, The Joint Commission 14 Next Steps!  Questions? Contact Darrell –Darrell Anderson Senior Specialist, Ambulatory Care The Joint Commission P: E:  Go to: –Register for free, 60-day trial of standards –Request the application –Review accreditation information