Transcript Organization of the 2005 Accreditation Manual

The Survey Process in 2011
Typical Survey Activities in 2011 will Include:
 Communication to hospital by JC liaison with tentative
agenda, number of surveyors, survey days
 Extranet posting (by 7:30 AM local time)
 Survey arrival, ID verification
 Surveyors include a Physician, Nurse(s), Life Safety
Specialist; others may include an administrator and
specialty surveyors (lab, behavioral health, home health
care, ambulatory, etc.)
 Opening Conference (15 minutes)
 Organization Orientation (30 to 60 minutes)
 Preliminary Planning Session (1 hour)
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The Survey Process in 2011
Survey Activities (continued)
 On-Site Survey Activities (including tracers)
 Special Issue Resolution (end of day, 30 minutes)
 Daily Briefing (end of day, 30 minutes)
 Critical Survey Activities for the “Physical
Environment” (Life Safety Specialist - minimum of two
days, one additional day than in previous surveys,
effective 1/1/2011)
- Environment of Care
- Life Safety
- Emergency Management
 CEO Exit Briefing (15 minutes)
 Organization Exit Conference (30 minutes)
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The Survey Process in 2011
Post-Survey Activities
 Summary of Survey Findings Report (laptop computer
generated by end of survey)
 Official report posted on Connect site after the survey
 Central office review performed for situation decision
rules, CMS condition-level deficiency and “flagged”
issues
 Hospital submits ESC for all RFI’s (direct and indirect)
and applicable Measures of Success
 Clarifications can be submitted to the JC within 10
days of the final report Connect site posting
 Quality Report and Accreditation seal received
Reference: 2011 JC Accreditation Process Guide
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Revised Accreditation Categories for 2011
 Preliminary Accreditation: early survey policy
 Accredited: in compliance with all standards
 Accreditation with Follow-Up Survey: follow-up
survey required within 30 to 180 days (new for 2011)*
 Contingent Accreditation: follow-up survey within 30
days (new for 2011)*
 Preliminary Denial of Accreditation: immediate
threat or failure to resolve requirements
 Denial of Accreditation: Organization denied
accreditation; appeals exhausted
*Note: Provisional Accreditation category eliminated
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The Unannounced Survey Timeline
Unannounced Surveys will Occur:
 Between 30 and 36 months from the date of the
previous unannounced survey (changed for 2011)
Note: The chance of a survey is not equally distributed
from 30 to 36 months from the previous survey
 The timing of all surveys after the previous survey
may be based on Priority Focus Process (PFP) data and
other factors
 Surveys will probably occur between the 33 and 36
month anniversary date
 Prior to the survey (usually 6 weeks to 3 months), a
discussion with the JC liaison to discuss the surveyor
team members and agenda will occur
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The Unannounced Survey Challenge
Surveys Can Also Occur Due To:
 One year follow-up survey for newly
accredited organizations that provide high risk
or critical services
 Sentinel event follow-up
 Adverse media coverage of specific issue
 Complaint from the public
 Any other time that the JC decides it’s
appropriate!
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Meeting the Scoring Challenges
Understanding Survey
Scoring Decisions
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Scoring Decisions
 Few scoring changes in the in the EC, EM and LS
chapters have occurred for 2011
 “A” and “C” scores remain
 Four levels of scoring risk exist (surveyor discretion):
1. Immediate Threat to Health and Safety: results in
preliminary DOA until follow-up evidence of compliance
2. Situation Decision: results in preliminary DOA or CA
3. Direct Impact Requirements: immediate care
impact; must submit ESC within 45 days
4. Indirect Impact: no immediate risk; ESC
submission within 60 days
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Explanation of Scoring Levels
Immediate Threat to Health and Safety
1. Immediate Preliminary Denial of Accreditation
2. Action expected during survey
3. Upon resolution, status changes to Conditional
Accreditation based on follow-up survey
4. Triggered by unaddressed issues with:
- Fire alarm or extinguishing system
- Emergency power supply system
- Medical gas master panel
Note: Refer to EC News, November 2010 edition
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Explanation of Scoring Levels
“Situational” Decision Rule
1. Immediate Preliminary Denial of Accreditation
or Conditional Accreditation issued
2. ESC submission required within 45 days
3. Follow-up survey occurs to validate corrective
action
4. Examples include:
- Failure to implement interim life safety
measures
- Failure to meet PFI timelines on SOC
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Explanation of Scoring Levels
Direct Impact Requirements
1. If non-compliance is likely to have an impact on
patient safety or quality of care
2. ESC submission required within 45 days
3. A single Direct Impact “EP” results in the entire
standard being non-compliant
4. Examples include:
- Failure to perform risk assessments
- Improper disposal of hazardous medications
- Insufficient PM on life support equipment
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Explanation of Scoring Levels
Indirect Impact Requirements
1. Based on planning and care processes
2. If non-compliance is likely to have an increased
risk to patient safety or quality of care
3. ESC submission required within 60 days
4. Examples include:
- Incomplete management plan
- Non-compliance to smoking policy
- Insufficient fire drills performed or critiqued
- Insufficient disaster drills
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Joint Commission Scoring Decisions
Total Surveyor
“Person Days”
1-4
5-6
7-9
10-13
>13
*Non-Compliant
“Direct Impact”
7
8
9
11
13
•Meeting or exceeding the “Direct Impact”
number results in “outlier” status and SIG review
Note: May be revised or eliminated in 2011
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Joint Commission Scoring Decisions
“EC” Scoring Categories
Performance
Category
Immediate Threat
Number
Situation Decision
0
Direct Impact
41
Indirect Impact
98
0
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Joint Commission Scoring Decisions
“EM” Scoring Categories
Performance
Category
Immediate Threat
Number
Situation Decision
0
Direct Impact
3
Indirect Impact
111
0
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Joint Commission Scoring Decisions
“LS” Scoring Categories for Hospitals
Performance
Category
Immediate Threat
Number
Situation Decision
2
Direct Impact
21
Indirect Impact
98
0
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Joint Commission Scoring Decisions
“EC”, “EM” and “LS” Scoring Categories
Performance
Category
Immediate Threat
Number
Situation Decision
2
Direct Impact
65
Indirect Impact
307
0
Note: Minimal changes in scoring categories in 2011
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Joint Commission Standards Scoring
“A” Scores: High priority, One and Done!
Management Plan Scoring Sheet
Example: EC.01.01.01,
EP 1; Safety officer
appointment
You either have the letter or
you don’t – Compliant or
non-compliant, no partial
credit!
EC
Standard
01.01.01
1
2
3
4
5
6
7
8
Element of Performance
Minimizing Risks in EC
Safety leadership appointment
Intervention authority
Safety management plan
Security management plan
Hazardous materials plan
Fire safety management plan
Medical equipment plan
Utility management plan
Good News (sort of!) – This is only an
“indirect” impact requirement!
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Scoring Documents
Category Required?
A
A
A
A
A
A
A
A
D
D
D
D
D
D
Score
Rule
4
4
4
4
4
4
4
4
Joint Commission Standards Scoring
Fire Risks Scoring Sheet
“C” Scores: Three
strikes and you’re out!
Example: EC.02.03.05,
EP 15
Portable fire
extinguishers
Three missed monthly
checks (aggregated) is
an Indirect Impact
Citation
EC
Standard
02.03.01
1
2
4
9
10
02.03.03
1
2
3
4
5
02.03.05
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Element of Performance
Fire Risk Management
Proactive fire protection
Reduce fire risk from smoking
Unobstructed access to exits
Fire response plan
Staff response to fire
Fire Drills
Quarterly fire drills
Business occupancy drills
50% unannounced drills
Staff drill participation
Fire drill critique
Fire Component Tests
Supervisory devices
Tamper switches/ water flow
Duct/ heat/ doors/ smoke/ pull
Visual/ audible alarms
Off-site responders
Weekly fire pump test
Water tank level alarms
Water tank cold weather tests
Main drain tests
Fire department connections
Annual fire pump test
5-year standpipe test
Kitchen extinguishing systems
Gaseous extinguishing systems
Monthly extinguisher checks
Annual extinguisher PM
Occupant hose tests
Smoke/ fire damper tests
Air handling shutdown
Vertical/ horizontal fire doors
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Scoring Documents
Category Required?
C
A
A
A
A
Score
Rule
D
D
3
3
3
4
4
A
A
A
C
A
D
4
4
4
4
4
A
A
C
C
A
C
C
C
C
A
A
C
A
A
C
C
C
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
4
4
4
3
4
4
4
4
4
4
3
4
4
4
4
4
4
4
3
4
Joint Commission Scoring Decisions
Timeframe Test Interval Expectations
 Trienniel: 36 months +/- 45 days from the
previous test month
 Annual: 1 year +/- 30 days from the previous test
month
 Semiannual: 6 months +/- 20 days from the
previous test month
 Quarterly: 4 times per year, each quarter
 Monthly: within the calendar month
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Joint Commission Scoring Decisions
Timeframe Test Interval Expectations
 Weekly: Defined as Sunday 12:01 AM through
midnight Saturday
 Daily: once per day, beginning at 12:01 AM
 Other definitions take priority (example:
emergency generator testing)
Note 1: These will be default test interval expectations
unless the organization defines other acceptable intervals in
a policy that is approved by the safety committee
Note 2: Published in EC News, November 2010 edition
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Challenging Physical Environment
Standards
What were the most challenging
standards for hospitals during 2010?
 LS.02.01.20 – 50% (means of egress)
 LS.02.01.10 – 44% (fire compartmentation)
 EC.02.03.05 – 38% (fire device testing)
 LS.02.01.30 – 37% (smoke compartmentation)
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Challenging Environment of Care
Standards
What were the most challenging standards for
“critical access” hospitals during 2010?
 EC.02.03.05 – 47% (fire device testing)
 LS.02.01.10 – 44% (fire compartmentation)
 EC.02.05.07 – 40% (emergency power tests)
 LS.02.01.20 – 33% (means of egress)
 EC.02.06.01 – 27% (safe, functional environ.)
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The Top Sentinel Events for 2010
Description
Number
Unintended retention of object
Wrong-site surgery
Op/post-op complication
Delay in treatment
91
66
54
54
Suicide
Patient fall
Medication error
47
38
28
Perinatal death/ loss of function
23
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The Top Ten Health Technology Hazards - 2010
Flexible endoscope cross-contamination
Alarm hazards
Surgical fires
CT radiation dose
Retained devices, unretrieved fragments
Needlesticks/ sharps injuries
Computerized equipment problems
Surgical stapler hazards
Ferromagnetic objects in MRI area
Fiber optic light source burns
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“EC”-Related Patient Safety Goals
Ambulatory, Behavioral Health and Hospital Facilities
Goal #7: Reduce the risk of healthcare associated infections
Goal #9: Reduce the risk of patient harm resulting from falls
Goal #11: Reduce the risk of surgical fires - Eliminated in 2010
(sort of)
Goal #15: The organization identifies safety risks inherent in its
patient population (identify suicide risk – relates to patients being
treated for emotional and behavioral disorders) This applies to all
areas of the hospital where behavioral patients are treated – don’t
forget about the ED and outpatient areas! (refer to Sentinel Event
Alert #46)
Note: No new Patient Safety Goals for 2011
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Organizational Function Overview
 Human Resources (HR)
Staff training, competency and performance
 Leadership (LD)
Compliance, resources, patient safety, oversight of
contracts/ services
 Performance Improvement (PI)
Data collection, aggregation, analysis , action
 Information Management (IM)
Data collection, aggregation, security
 Infection Control (IC)
Measurement and reduction of infections
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Competition for the Joint Commission
 DNV (Det Norske Veritas) Healthcare has
received CMS “Deemed Status”
 Headquarters; Oslo, Norway; 9,000 employees,
300 offices, in 100 countries
 Approximately 150 accredited hospitals
 Integrates ISO 9001 standards with CMS
Conditions of Participation in annual survey
 Averages three surveyors, including Life Safety
 Focus on processes to manage patient safety
and quality practices
 Accredited or Not Accredited outcome
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Competition for the Joint Commission
 Health Facilities Accreditation Program (HFAP)
 Originally intended for Osteopathic Hospitals
 First program introduced in 1943; received
“Deemed Status” in the 1960’s
 Have accredited over 200 hospitals
 Requirements closely parallel the CMS
“Conditions of Participation”
 Accreditation levels include:
- Full Accreditation
- Interim Accreditation
- Denial of Accreditation
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The 2011 Survey Process
Questions?
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