Transcript The Joint Commission - Light PP Presentation

Michael Kulczycki, MBA
Executive Director,
Ambulatory Care
Accreditation Program
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Accreditation
Seminar —
The Joint
Commission
Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
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Other factors
Accreditation choices:
All accreditors represented
fill your need.
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Primary reason = third party
reimbursement
Accreditation choices:
Designed for ASCs seeking:
added value from the
accreditation process,
>> partnership with an accreditor
with consultative & collaborative
resources,
>> ability to use an accreditation
process as a management tool,
then……
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>>
Helping Health Care Organizations Help Patients
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The Joint Commission …your choice
Joint Commission
– Not-for-profit organization
– Accredits 15,000 total
organizations
– Accrediting ambulatory
since 1975 – ASCs = largest
segment
– Awards Gold Seal of
Approval™
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Background
Accreditation package
–
–
–
–
quality of care and service,
patient and staff safety,
organization risk management, and
continuous performance improvement.
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The Joint Commission offers multiple
components which, taken together, form a
comprehensive package.
This package of services can be used as a
management tool to enhance ASCs:
Accreditation components include:
Continuous process, not “ramping up”
Unannounced surveys
Enhanced use of web-based tools
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Increased on-site survey focus on
direct patient care
Emphasis on an
organization’s systems
Annual self-assessment
process (Periodic
Performance Review)
Ongoing improvement &
tailoring of ambulatory
standards.
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…..Accreditation components
Accreditation Manual:
Ambulatory Care
Program specific
statements of:
National Patient Safety
Goals
Information about
accreditation process
Periodic updates
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– standards,
– rationale,
– elements of performance
(compliance criteria)
2007 Standards for ASCs
–
–
–
–
–
–
–
–
–
–
RI
PC
MM
IC
PI
LD
EC
HR
IM
NPSGs
Practice Ethics and Patient Rights (20)
Provision of Care, Treatment, & Services (35)
Medication Management (20)
Prevention, & Control of Infection (9)
Improving Organization Performance (6)
Leadership (24)
Management of the Environment of Care (24)
Management of Human Resources (17)
Management of Information (13)
7 Goals plus Universal Protocol (8)
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On-site evaluation evaluates compliance with
Standards & National Patient Safety Goals
Standards organized in 10 chapters:
On-site Survey Process
Accommodates ASCs normal
operational systems & schedules
Few formal interviews
Use of pre-survey, focused
information
Tracer method allows customization:
– Settings / Services / Patients
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– More attention to actual individuals
receiving care
Process driven, initiated by priority
focus areas (highlight 4-5 for ASCs)
Customized to ASC services
More focused on execution -- actual
delivery of care / services
Frontline staff…what do they do, and
why do they do it that way
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Patient Tracer Method
Traces 3-4 patients through ASCs entire
process
Use patient chart as “road map”
As cases are examined, surveyor may
identify performance issues in one or
more steps of the process – or between
processes
Systems tracer includes dialogue on
data / infection prevention / medications
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Patient Tracer (cont)
Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
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Other factors
Each year, a set of Goals is identified from
topics published in Sentinel Event Alert &
other sources
Small number of specific requirements for
Goals identified for survey following year
Goals and their requirements published
by mid-year
Selection of Goals and requirements
guided by panel of experts
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National Patient Safety Goals
2007 National Patient Safety
Goals for surgery centers
1. Patient identification
2. Communication among caregivers
3. Medication safety
7. Health care-associated infections
8. Reconciliation of medications
13. Patient involvement
 Universal Protocol for Preventing
Wrong Site Surgery
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11. Surgical fires
Goal #13: Involvement of
patients
New for 2007
Encourage the active involvement of patients
and their families in the patient’s care as a
patient safety strategy.
Define and communicate the means for patients
to report concerns about safety and encourage
them to do so.
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Requirement #13.a.
2008 NPSG changes
Medication Safety (3E)
Medication Safety (3B: standardizing
drug concentrations)
– retire, retain in medication standards
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– Reduce the likelihood of patient harm
associated with the use of anticoagulation
therapy
–2008 “expectations” for implementing
–2009 implement compliance
NPSG Compliance Data for 2003—2006
NPSG requirement
2003
2004
2005
2006
1a: Two identifiers
7.3%
8.0%
3.7%
6.9%
1b: Time out before surgery (UP)
6.0%
6.7%
13.9%
24.2%
2a: Read-back verbal orders
5.5%
7.6%
10.7%
9.2%
2b: Standardize abbreviations
19.6%
16.3%
17.9%
24.0%
2c: Improve timeliness of reporting
---
---
1.2%
8.3%
2e: Hand-off communications
---
---
---
2.5%
3a: Concentrated electrolytes
2.5%
1.1%
1.7%
---
3b: Limit concentrations
1.5%
0.2%
0.0%
0.9%
3c: Manage look-alike/sound-alike drugs
---
---
3.5%
8.5%
3d: Label medications & solutions
---
---
---
4.1%
4a: Preoperative verification (UP)
2.3%
1.8%
4.5%
1.6%
4b: Surgical site marking (UP)
4.3%
4.0%
5.7%
7.6%
7a: CDC hand hygiene guidelines
---
1.8%
6.9%
11.5%
7b: HC-associated infection & RCA
---
0.0%
2.2%
0.0%
8a: Medication reconciliation – list
---
---
1.0%
24.4%
8b: Medication reconciliation – reconcile
---
---
0.7%
25.8%
11a: Surgical fire
---
---
2.0%
1.2%
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(Freestanding Ambulatory Care Surveys: % Non-compliance)
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Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
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Other factors
Standards for ASCs
–
–
–
–
–
–
Provision of Care
Performance Improvement
Environment of Care
Human Resources
National Patient Safety Goals
Universal Protocol
Source: THE JOINT COMMISSION PERSPECTIVES, February 2007,
“Top Standards Compliance Issues for 2006”
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Source = Ambulatory Surgery Centers surveyed
by Joint Commission during 2006 (n=170)
Chapters with opportunities for improvement:
ASC Opportunities for Improvement
1.
Provision of Care.16.10: Organization establishes policies
and procedures that define the context for using waived test
results in patient care. (scored non-compliant on 28% of
surveys)
•
NPSG 8A: Accurately and completely reconcile medications
across the continuum of care. (26% non-compliant)
•
3.
lack of process for obtaining and documenting a complete list
of patient’s current medications upon entry into organization.
Performance Improvement.3.20: Organization selects
a high-risk process to be analyzed annually
to reduce risks to patients. (22% non-compliant)
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2.
Lack of quantitative results in patient record accompanied
by test-specific reference intervals appropriate to population served.
…. ASC Improvement cont…..
4. NPSG 8B: Accurately and completely reconcile medications
across the continuum of care. (20% non-compliant)
•
lack of patient medication list being communicated to next provider
when patient referred or transferred.
5. NPSG 2B: Improve the effectiveness of communication
among caregivers. (17% non-compliant)
lack of standardized list of abbreviations that are not to be used
throughout the organization
6. UP 1: Organization fulfills the expectations set forth in
Universal Protocol for Preventing Wrong Site Surgery,
eg. implementation guidelines. (17% non-compliant)
•
lack of preoperative verification process as described in Universal Protocol
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•
…. ASC Improvement
7. Environment of Care.4.10: Organization addresses
emergency management. (16% non-compliant)
• Lack of hazard vulnerability analysis
8. Human Resources.4.50 Clinical privileges and
appointments/reappointments are reviewed and revised
at least every two years. (15% non-compliant)
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• lack of defined process approved by leaders for ensuring
competence of all practitioners permitted to practice independently
ASCs compared to all AHC – 2006
Surgery Centers
(n=430)
(n=170)
%
Standard
%
PC.16.10
27%
PC.16.10
28%
PI.3.20
27%
NPSG 8a
26%
NPSG 8a
26%
PI.3.20
22%
MM.2.20
25%
NPSG 8b
20%
NPSG 8b
25%
NPSG 2
17%
UP 1
24%
UP 1
17%
NPSG 2
24%
EC.4.10
16%
EC.4.10
17%
HR.4.50
15%
HR.4.10
16%
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Standard
All AHC
Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
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Other factors
Other factors
State partnerships:
Medicare option
New “value” for accreditation
Other partnerships
Summary of advantages
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– Focused on establishing state recognition
– Staff available to partner with
state/national associations
Medicare “deemed status”
– Always unannounced
– Covers nearly 30 additional CMS requirements
– “Early Survey Option” available
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CMS awarded “deemed status” to Joint
Commission & others
Use accreditation survey to avoid duplicate
state Medicare certification survey
 “Deemed status” option from Joint
Commission:
Customers raised issue of insurance
benefit of accreditation
Validated linkage between liability
insurers and accreditation
Interviewed firms, eg. ASC underwriters,
and polled liability industry
2007 launch website:
www.jointcommission.org/BusinessCommunity/liability_insurers.htm
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New driver for accreditation
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New accreditation driver: Liability
recognition
Other factors on your choices
FASA / ASC involvement with
The Joint Commission:
– Universal Protocol
– Standards development – Professional and Technical
Advisory Committee for Ambulatory
– Customer Advisory Council
– Standards Improvement Initiative
( www.jointcommission.org/Standards/SII/ )
– ASC Quality Collaborative ( www.ascquality.org )
– National Quality Forum
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ASC performance measures
The Joint Commission
Ambulatory Care Accreditation Program:
Accreditation timeframe – all evaluations produce a
three-year accreditation decision, within 45 days of survey
Accreditation Report – provided on-site
Fully electronic process – application, post-survey steps,
and all communication via secure, web Extranet
Free phone/on-line access – answer your questions to
aid understanding of standards or survey process
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Timely scheduling – ASCs identify “preferred”, scheduled
initial survey for dates 45-90 days from application
….. The Joint Commission
Ambulatory Care Accreditation Program:
Uses “Employee” Surveyors – ambulatory professionals
both employed in ambulatory settings AND working parttime for The Joint Commission. This means they survey
30-100+ organizations annually – serving as sources of
consultative and educational ideas for your ASC
Defined, Fixed Pricing – Fees are known before survey,
include all costs, and billed over three-year period
Name recognition -- Gold Seal of Approval™
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 Uses “Certified” Surveyors – who pass certification exam
on standards and survey process
Advantages
Has access to a unique extranet site,
Joint Commission Connect, for communications
Has a single Account Representative, aiding:
Updates to information
All post-survey steps, conducted electronically
Completion of annual self-assessment of compliance
Survey process questions
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Upon earning the Gold Seal of Approval™ your center:
The Joint Commission ambulatory
accreditation process:
For those ASCs committed to quality &
safety of care,
Interested in an ongoing collaborative
partnership in continuous performance
improvement
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Your choice >
“If you’re about to undergo your first
accreditation survey, the message is
the same….Accreditation bolsters
processes, patient safety and ultimately
the quality of your organization.”
– Outpatient Surgery Magazine, January Supplement, 2007
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What others say:
Resources
– Public site with updates, resource
materials, frequently asked questions
(FAQ’s), safety and quality initiatives.
– Extranet site for accreditation
customers with organization-specific
information, updates, and messages
(Joint Commission Connect)
www.jcrinc.com -- affiliate providing
education and publication resources
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www.jointcommission.org --
Free resources for ASCs
Video of patient tracer process
in ambulatory setting
– www.jointcommission.org/AccreditationPrograms/
AmbulatoryCare/ Accreditation_Process/
– www.jointcommission.org/AccreditationPrograms/
AmbulatoryCare/
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Standards sampler for ASCs
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Your questions / Next steps?
Information
www.jointcommission.org
www.jointcommission.org/HTBAC/AHC
Ambulatory Care Accreditation
WASCA 2007 Seminar 42
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– 630.792.5286
– [email protected]