© copyright, the joint commission accreditation seminar — the joint commission michael kulczycki,...

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Accreditation Accreditation Seminar — Seminar — The The Joint CommissionJoint CommissionMichael Kulczycki, MBA

Executive Director, Ambulatory Care Accreditation Program

WASCA 2007 Seminar 2

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Session Overview

Accreditation as a management tool

Patient safety issues

Opportunities for improvement

Other factors


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Accreditation choices:

Primary reason = third party reimbursement

All accreditors represented fill your need.


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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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The Joint Commission …your choice

Helping Health Care Organizations Help Patients


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Joint Commission

Background– 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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Accreditation package

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:– quality of care and service, – patient and staff safety, – organization risk management, and – continuous performance improvement.


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Accreditation components include:

Continuous process, not “ramping up”

Unannounced surveys

Enhanced use of web-based tools

Increased on-site survey focus on direct patient care


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…..Accreditation components

Emphasis on an organization’s systems

Annual self-assessment process (Periodic Performance Review)

Ongoing improvement & tailoring of ambulatory standards.


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Accreditation Manual:Ambulatory Care

Program specific statements of:– standards,– rationale, – elements of performance

(compliance criteria) National Patient Safety

Goals Information about

accreditation processPeriodic updates


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2007 Standards for ASCsOn-site evaluation evaluates compliance with

Standards & National Patient Safety GoalsStandards organized in 10 chapters:

– RI Practice Ethics and Patient Rights (20) – PC Provision of Care, Treatment, & Services (35)– MM Medication Management (20)– IC Prevention, & Control of Infection (9)– PI Improving Organization Performance (6)– LD Leadership (24)– EC Management of the Environment of Care (24)– HR Management of Human Resources (17)– IM Management of Information (13)– NPSGs 7 Goals plus Universal Protocol (8)


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On-site Survey Process

Accommodates ASCs normal operational systems & schedules

Few formal interviews– More attention to actual individuals

receiving care

Use of pre-survey, focused information

Tracer method allows customization: – Settings / Services / Patients


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Patient Tracer Method

Process driven, initiated by priority focus areas (highlight 4-5 for ASCs)

Customized to ASC servicesMore focused on execution -- actual

delivery of care / servicesFrontline staff…what do they do, and

why do they do it that way


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Patient Tracer (cont)

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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Session Overview




Other factors


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National Patient Safety Goals

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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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

11. Surgical fires

13. Patient involvement Universal Protocol for Preventing

Wrong Site Surgery


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Goal #13: Involvement of patients

Encourage the active involvement of patients and their families in the patient’s care as a patient safety strategy.

Requirement #13.a.

Define and communicate the means for patients to report concerns about safety and encourage them to do so.

New for 2007


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2008 NPSG changes

Medication Safety (3E)– Reduce the likelihood of patient harm

associated with the use of anticoagulation therapy–2008 “expectations” for implementing–2009 implement compliance

Medication Safety (3B: standardizing drug concentrations) – retire, retain in medication standards


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NPSG Compliance Data for 2003—2006(Freestanding Ambulatory Care Surveys: % Non-compliance)

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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Session Overview




Other factors


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Standards for ASCs

Source = Ambulatory Surgery Centers surveyed by Joint Commission during 2006 (n=170)

Chapters with opportunities for improvement:– 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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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)

• Lack of quantitative results in patient record accompanied by test-specific reference intervals appropriate to population served.

2. NPSG 8A: Accurately and completely reconcile medications across the continuum of care. (26% non-compliant)

• lack of process for obtaining and documenting a complete list of patient’s current medications upon entry into organization.

3. 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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…. 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)• lack of defined process approved by leaders for ensuring

competence of all practitioners permitted to practice independently


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ASCs compared to all AHC – 2006

All AHC(n=430)

Surgery Centers(n=170)

Standard % 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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Session Overview




Other factors


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Other factors

State partnerships:– Focused on establishing state recognition – Staff available to partner with

state/national associationsMedicare optionNew “value” for accreditationOther partnershipsSummary of advantages


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Medicare “deemed status”

CMS awarded “deemed status” to Joint Commission & others

Use accreditation survey to avoid duplicate state Medicare certification survey

“Deemed status” option from Joint Commission:

– Always unannounced – Covers nearly 30 additional CMS requirements– “Early Survey Option” available


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New driver for accreditation

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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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 performance measures– ASC Quality Collaborative ( www.ascquality.org )– National Quality Forum

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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

Timely scheduling – ASCs identify “preferred”, scheduled initial survey for dates 45-90 days from application

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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….. The Joint Commission

Ambulatory Care Accreditation Program:

Uses “Certified” Surveyors – who pass certification exam on standards and survey process

Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working part-time 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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Advantages

Upon earning the Gold Seal of Approval™ your center:Upon earning the Gold Seal of Approval™ your center:

Has access to a unique extranet site, Has access to a unique extranet site, Joint Commission Connect, Joint Commission Connect, for communicationsfor communicationsHas a single Account Representative, aiding:Has a single Account Representative, aiding:

Updates to informationUpdates to informationAll post-survey steps, conducted electronicallyAll post-survey steps, conducted electronicallyCompletion of annual self-assessment of complianceCompletion of annual self-assessment of complianceSurvey process questionsSurvey process questions


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Your choice >

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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What others say:

“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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Resources

www.jointcommission.org -- – 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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Free resources for ASCs

Video of patient tracer process in ambulatory setting– www.jointcommission.org/AccreditationPrograms/

AmbulatoryCare/ Accreditation_Process/

Standards sampler for ASCs– www.jointcommission.org/AccreditationPrograms/

AmbulatoryCare/


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Information

www.jointcommission.orgwww.jointcommission.org/HTBAC/AHCAmbulatory Care Accreditation

– 630.792.5286– [email protected]

© copyright, the joint commission accreditation seminar — the joint commission michael kulczycki,...

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