Transcript The Joint Commission - Light PP Presentation

Essentials of
Joint Commission Accreditation
for Surgery Centers
Presented by:
Dana McGrath, RN, MSN, CASC
Pam Roark, RN, MA, MSN
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© Copyright, The Joint Commission
September 12, 2013
Agenda
Purpose of Accreditation
How do I get started?
– Pricing & Resources
– Application & Survey Activity Guide
What does a survey look like?
– After the Survey & Most Common
Findings
Customer Resources
Your Questions!
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– Onsite Survey & Surveyors
Purpose of 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
www.jointcommission.org/liabilitylist
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Define the
difference
between office-based
surgery suites and
ASCs.
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Why Accreditation
Voice of the Customer
Responsive
“I was pleasantly surprised
by the quick call-backs,
gracious service, and
expedited process The Joint
Commission provided.
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
Focused
Supportive
“Joint Commission has
really re-focused their
standards and
surveyors… Their goals
are our goals: to provide a
safe environment for
patients.”
“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.”
Kitty Bouchard, RN
Clinical Director
Towne Centre Surgery Center,
LLC
What sets
The Joint
Commission
apart from
other
accreditors?
Debbie Cooner
Director of Quality and Compliance
Outpatient Services East, Ltd.
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Alex Rothschild, MS, CMPE
Administrator
Garden State Surgical Center, LLC
How Do I Get Started?
Fee Estimate – only accreditor with
transparent pricing – posted on Joint
Commission website:
–
–
–
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?
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www.jointcommission.org/accreditation/ahc_seeking_
surgery_centers.aspx
How Do I Get Started?
Web site:
www.jointcommission.org/ASC
– Accreditation overview and pricing
– Request standards/application
– Blog (5-part Q & A series)
store.jcrinc.com
– Purchase surgery center standards
– Webinars/Educational seminars
 Standards Interpretation
Group
www.jointcommission.org/standards
– FAQ’s, Online Form to Submit ?’s
– Call 630-792-5900, Option
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Questions about:
Anesthesia;
Disinfection;
Medication Safety; Disposal
of Medications; etc.
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© Copyright, The Joint Commission
Joint Commission Resources
(JCR)
How Do I Get Started?
Dedicated Customer
Service Resources
– Ambulatory-specific
Account Executives
– Web-based ‘extranet’
platform
– Data submitted drives
survey length
– YOU designate
survey ready date
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Are there
special
requirements for
deemed status?
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Application:
How Do I Get Started?
 Survey Activity Guide
– Document List or “Ready-to-Go List” – helps
your organization and survey team
 Customer Value
Assessment – advance
insight to surveyor of
what are your performance
improvement needs?
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How soon
can a survey
be scheduled?
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– 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
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
– Clinical & administrative
professionals experienced in
ambulatory arena
– Collaborative and courteous
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 Surveyors
What Does a Survey Look Like?
 Preliminary findings
provided on-site
 Post-survey steps, with
prompt decision – under
10 days!
 Resurvey 3 years
 Interim support for
continuous compliance
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After the Survey
Most Common Findings
Yellow shading
represents
percentage of
organizations that
received
Requirements for
Improvement
(RFIs) for that
particular
requirement.
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 Standards Compliance Issues for 2012
What are the
most common
findings?
Resources for Customers
 Joint Commission Connect
(Extranet)
TM
TM
 QualityCheck
– Lists accredited organizations
– Used by consumers & payers
– www.qualitycheck.org
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– Targeted Solutions Tool - helps
identify performance barriers &
customized solutions regarding wrongsite surgery and other persistent issues
– Perspectives - Joint Commission’s
official monthly e-periodical
– Leading Practice Library - real-life
solutions from accredited organizations
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Your Questions!
Next Steps!
 Questions? Contact Darrell
– Darrell Anderson
Senior Specialist, Ambulatory Care
The Joint Commission
P: 630.792.5292
E: [email protected]
– Register for free, 60-day trial of standards
– Request the application
– Review accreditation information
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 Go to: www.jointcommission.org/ASC