© Copyright, The Joint Commission Joint Commission Update National Credentialing Forum San Diego, California February 5, 2015 Paul Ziaya MD Field Director Accreditation and Certification Operations The Joint Commission

2 © Copyright, The Joint Commission Objectives 1.Briefly discuss the most commonly cited medical staff standards 2.Discuss OPPE as a performance improvement process 3.Introduce the Patient Safety Systems Chapter 4.Share Initiatives in Physician Engagement

3 © Copyright, The Joint Commission Most Often Cited Standards  MS Medical staff bylaws address self-governance and accountability to the governing body. –Relates to structure, function and activities of the organized medical staff  Most commonly EP 5 –The medical staff complies with the medical staff bylaws, rules and regulations, and policies.

4 © Copyright, The Joint Commission Most Often Cited Standards  MS Ongoing Professional Practice Evaluation –All elements of performance among the top 10 medical staff EP cited –Single most common related to lack of effective use of the data in decision making

5 © Copyright, The Joint Commission Most Often Cited Standards  MS Organized medical staff oversees the quality of patient care, treatment, and services –Medical staff oversight of radiology and nuclear medicine –Monitoring the quality of histories and physicals –Practicing in scope of privileges

6 © Copyright, The Joint Commission Most Often Cited Standards  MS – Focused Professional Practice Evaluation –Primarily lack of a process for all initially requested privileges

7 © Copyright, The Joint Commission OPPE: A Performance Improvement Process Selection of Metrics Accuracy in Measurement Departmental Review and Analysis Physicians Review Performance Reports Education, Simulation, Training, Coaching

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9 Opportunities  From performance monitoring to performance improvement  Resolving problem areas for each specialty or department –OR first start times –Improving specific documentation –Adherence to order sets and practice guidelines, as appropriate  Selected by the department/chair and approved by the MEC  Can be changed

10 © Copyright, The Joint Commission Challenges  Attribution  Selecting appropriate measures for the specialty  Triggers  Zero data is data  Physicians seeing the data  Frequency of assessment - < 12 months  Use of the data

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12 © Copyright, The Joint Commission New for 2015 Patient Safety Systems Chapter

13 © Copyright, The Joint Commission Overview  There are no new requirements  The chapter serves as a road map for hospital leaders to use existing requirements to improve patient safety.  The chapter is only included in the 2015 Comprehensive Accreditation Manual for Hospitals.

14 © Copyright, The Joint Commission The Chapter…  Describes the framework of an integrated patient safety system  Discusses how hospitals can develop into learning organizations  Describes how to evaluate status and progress  Focuses on prevention through proactive risk reduction activities  Identifies all standards and requirements that support a patient safety system

15 © Copyright, The Joint Commission Learning Organizations  People continuously learn, and thereby enhance their capabilities to create and innovate  Transparent, non-punitive approach to error reporting so that the organization can report to learn  Fair and just safety culture enriched by sharing lessons learned  Data driven improvement

16 © Copyright, The Joint Commission Role of Hospital Leaders  Promote learning  Motivate staff to uphold a fair and just safety culture  Provide a transparent environment in which patient safety events are honestly reported  Model professional behavior  Remove intimidating behavior that might inhibit a culture of safety  Provide the resources and training necessary to take on improvement initiatives

17 © Copyright, The Joint Commission Safety Culture  Valuing transparency, accountability and mutual respect  Safety as everyone’s first priority  Undermining behaviors not acceptable  Collective mindfulness –close calls mean improvements are needed  Reporting errors is valued  Learning from those reported errors

18 © Copyright, The Joint Commission Data Use and Analytics  Data use and reporting systems  Proactive risk reduction strategies  Statistical tools  Resources and references

19 © Copyright, The Joint Commission It is about Patient Safety Systems and Safety as a Core Competency

20 © Copyright, The Joint Commission The Joint Commission’s Physician Engagement Goal  Help physician leaders in our accredited organizations meet or preferably exceed their patient safety and performance improvement goals

21 © Copyright, The Joint Commission Aspiring Higher: Organizations will need to achieve optimal physician engagement Overall Physician Indifference Some Physicians Participate Some of the Time Optimal Physician Engagement Optimal Physician Engagement Searching for Stability Searching for Stability Building for Success Achieving Superior Performance Achieving Superior Performance Quality and Safety Continuum

22 © Copyright, The Joint Commission TJC Physician Engagement Strategies  CMO Academy  Physician Leader Forum  Physician Leader E Letter  Social Media  Fellowship Rotations at TJC  IHI CMO Mini Course

23 © Copyright, The Joint Commission Questions?

24 © Copyright, The Joint Commission  For Standards/NPSG question: – , Option 6 or – OnlineQuestionForm/ OnlineQuestionForm/  Paul Ziaya –

25 © Copyright, The Joint Commission The Joint Commission Disclaimer Statement  These slides are current as of February 3, The Joint Commission reserves the right to change the content of the information, as appropriate.  These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.  These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.