Download - The Joint Commission Leadership Preparation
The Joint Commission Leadership Preparation
May 17, 2010
Opening Conference
Opening Conference
Governing body, senior leaders, medical staff leadership
Approximately 15 minutes Introductions Agenda discussion with surveyors Priority Focus Process and System
Tracers described
Opening Conference
Discussion includes leadership’s responsibilities for planning, resource allocation, management, oversight, performance improvement, and support in carrying out our mission and strategic objectives
Orientation to our OrganizationSession
Orientation to our OrganizationSession
Occurs immediately after the Opening Conference
Interactive dialogue to learn about our organization to focus survey activities
Learn how we are governed and operated Leadership’s perception of our top Priority
Focus Areas and Clinical Service Groups Learn about our Performance Improvement
Process
Orientation to our OrganizationSession Topics
Mission, vision, goals and strategic initiatives
Organization structure Contract management process Health care error reduction Patient safety initiatives-Coumadin,
Falls, Restraints National Patient Safety Goals
Orientation to our OrganizationSession Topics
Community involvement Leadership’s role in emergency
management planning Cleaning, disinfection and sterilization Patient Flow Organ procurement and donation
Orientation to our OrganizationSession Topics
Priority Focus Area (PFA) and Clinical Service Groups (CSG) Leadership role in the top PFA and CSG Processes at the PFA level Leadership’s oversight
Orientation to our Organization Session Topics
Leadership’s role in Performance Improvement How leaders set expectations, plan,
assess, and measure initiatives to improve quality of services
Approach to safety and selection of proactive risk assessment topics, improvements and Board involvement
Provision of resources for Safety
Strategic Surveillance System
S3 is a suite of information tools with the first available tool being the Performance Risk Assessment (PRA) tool.
S3TM – PRA provides a series of risk assessment and comparative performance measure reports to help hospitals improve their care processes and prioritize the actions to take for improvement.
The data within the S3 - PRA tool is updated on a quarterly basis
Customized Survey Focus Areas
PFAs are processes, systems or structures in an organization that significantly impact the quality and safety of care.
Our PFAs are Assessment and Care, Performance Improvement expertise and activities, Staffing, Communication, Credentialed Practitioners, Infection Control and Patient Safety
Clinical Service Groups (CSGs)
CSGs are services of a hospital for which data are collected
Surveyors select units based on our CSGs
Our CSGs are: Surgery, Medicine, Cardiology and Gastroenterology
Leadership Session
Leadership Session
Occurs on 4th day at 12:30 pm Board members, Medical staff leaders,
Senior Management, Clinical Managers Leaders should provide their view and
perspective on a topic being discussed Topics will include:
The planning process used How data is used once it is collected The approach used to change processes and
work flow
Leadership Session How information about new process is
communicated How leaders view the performance of the
PFA or function being discussed Leadership support, direction, planning
and resource allocation Relationship of the PFA to patient safety
and quality How the effectiveness of the PFA is
evaluated
Leadership Session
Leadership SessionQuestions asked at VHA Hospitals
Which of the five columns are your biggest challenge
How do you assess your priorities How do you encourage evidence based
medicine Board’s action on clinical information
provided by physician board members Are they Sentinel events, bad/ unexpected
outcomes, success stories
Leadership SessionQuestions asked at VHA Hospitals
What is your approach to bad outcomes Can you monitor to avoid bad outcomes How are individuals held accountable Talk about resource allocation Does the Board provide a plan Who sees the Strategic Plan How do you get information from the bottom
up
Leadership SessionQuestions asked at VHA Hospitals
What about patient satisfaction How do you account for the difference
between patient perception of quality and professional perception
How are priorities determined How is effectiveness of communication
assessed How is our culture communicated, how are
we changing it to a culture of safety
Leadership SessionQuestions asked at VHA Hospitals
How is community included in planning How does community communicate a need What is the largest challenge with medical
staff What drives employee retention How do you communicate and monitor
processes How do you ensure that you are not on the
front page of the newspaper
Survey Process
Scoring
Requirements for Improvement or RFIs have levels of severity based on the potential risk to patient care or safety.
The higher the risk the more immediately the issue of noncompliance needs to be resolved.
Criticality Levels
Immediate threat to health or safety Inoperable fire alarm Adult strength meds on pediatric crash cart Lack of master alarms for medical gas systems A patient with known antibodies received
transfusions without typing for the corresponding antigens.
Denial of Accreditation and requires Evidence of Standard Compliance in 45 days with a follow up survey
Criticality Levels
Situational Decision Rules Unlicensed facility Unlicensed individual who requires a license Failure to implement corrective action in
response to identified Life Safety deficiency
Denial or Conditional, Evidence of Standard Compliance in 45 days and a follow up survey
Criticality Levels
Direct Impact Requirements (no or few processes between noncompliance and the patient) Sedation/anesthesia – hospital has monitoring
equipment available Pain – hospital staff reassess and responds to
patient’s pain Emergency Meds – emergency meds are
accessible in patient care areasEvidence of Standard Compliance within 45 days
Criticality Levels
Indirect Impact Requirements Leadership standards compliance i.e. when
CEO is absent there is a designee HR – Orientation is completed prior to providing
care, treatment and services. Infection Control – An individual is identified to
perform Infection Control functions.
Evidence of Standard Compliance within 60 days
How are they scoring?
In 2010 RFI overall average is 12.13 per HCO. 2009 14.41 (1Q09 16.45)
Direct average 4.93 this year. 2009 5.76 (1Q09 7.09). 30% decrease
Indirect average 7.20 this year. 2009 8.66 (1Q09 9.36). 22% decrease
Source:15 VHA HCOs
Top Direct RFIs by Chapter
Provision of Care (PC) 20 Environment of Care (EC) 11 National Patient Safety Goals 10 Life Safety 7 Infection Control 7 Information Management 6 Medication Management 5