1. CASA 2014 Accreditation 4-1-1 Essentials of Joint Commission Accreditation Pamela Roark Field Representative, Ambulatory Care Program The Joint Commission

2. The Joint Commission’s Mission To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

3. Agenda Purpose of Accreditation Standards Applicability Grid for ASCs Deemed Status Survey Standards Changes for ASCs 2014 The most challenging standards for ASCs Burning Questions…..Q&A

4. Purpose of Accreditation Continually enhance safety and quality of care Reinforce risk management efforts Validate quality of care; engage staff and patients Meet CMS requirements or gain initial Medicare certification Possible discounts on liability insurance

5. The Joint Commission Ambulatory Surgery Center (ASC) Accreditation Accrediting U.S. healthcare services since 1951… Ambulatory centers, including ASCs, since 1975. Joint Commission accreditation helps you demonstrate practice safety, patient safety, quality of care Increases practice efficiency, reduces risk Joint Commission Gold Seal of Approval™ enhances your competitive edge

6. The Joint Commission Ambulatory Surgery Center (ASC) Accreditation Scheduling & customer service from exclusive Ambulatory team Fully electronic format – from application to post-survey steps Defined, fixed pricing – include all costs, billed over three-years Currently accredit over 600 ASC practices in the U.S.

7. Ambulatory Care Applicability Grid

8. CMS “Deemed” Status

9. Additional Requirements “Deemed Status” Organizations Unannounced survey Life Safety Code applicable CFC Conditions for Coverage Minimum number records/files reviewed – Closed Medical Records – All hospital transfers for past 12 months – Credentials and Privileging Files Infection prevention and control audit

10. Standards Changes for “Deemed Status” New EPs developed to fully align with CfCs (Changes effective August 25, 2014) – Leadership (LD.01.03.01 EP 22) – Leadership (LD.04.01.07 EP 10) – Leadership (LD.04.01.01 EP 19) – Leadership (LD.04.04.01 EP 26) – Performance Improvement (PI.03.01.01 EP 12)

11. Changes for Ambulatory Care Single observation C Elements of Performance included in new section of Report under “Opportunities for Improvement” Open, accepted Plan for Improvements (PFIs) from SOC included in new section of Report Additional action for Life Safety Code equivalencies

12. Most Challenging Standards for First Half 2014…..

14. Available Accreditation Resources Perspectives The Source EC News Perspectives on Patient Safety Journal of Quality and Safety Leading Practice Library Jointcommission.org CAMAC Manuals Survey Activity Guide (SAG) Standards Interpretation Group (SIG) Sentinel Event Alerts Standards BoosterPaks

16. Joint Commission Center for Transforming Healthcare Targeted Solutions Tools (TST) and Projects relevant to ASCs – Hand Hygiene – Hand-off Communications – Wrong Site Surgery – Surgical Site Infections – Safety Culture – Preventing Falls With Injury

18. Burning Questions??

19. For More Information Michael Kulczycki, Executive Director, 630.792.5290 / mkulczycki@jointcommission.orgmkulczycki@jointcommission.org Mike Dye, Senior Associate director, 630.792.5259 / mdye@jointcommission.orgmdye@jointcommission.org (Initial point-of-contact for all incoming inquiries) Jacqueline Franklin, Coordinator, 630.792.5286 / jfranklin2@jointcommission.orgjfranklin2@jointcommission.org