Accreditation 2009 - A Joint Commission and DNV NIAHO Update

1. � 2009 University HealthSystem Consortium Accreditation 2009 - A Joint Commission and DNV NIAHO Update

2. �2009 University HealthSystem Consortium 2 Radical Redesign - The SII Standards Improvement Initiative During 2008 the entire Hospital Standards manual was revised for 1/1/09 Purpose was to clarify requirements, delete redundancies, and reorganize chapters Many FAQs were rolled into the standards and elements of performance (EPs) Life Safety Code (fire safety issues) chapter created EC.5.20 with 4 EPs became 18 standards with 119 EPs Part �B� of Statement of Conditions in past was surveyed without having formal objective EPs Now these fire safety issues are represented in the new standards and EPs 2008 about 1,200 EPs � 2009 about 1560 EPs More opportunities for a Requirement for Improvement (RFI)

3. �2009 University HealthSystem Consortium 3 2009 EP New Symbols Clarify Requirements and Criticality Indicates Situational Decision Rule Applies (12 APRs & 7 EPs) Situations resulting in recommendation for PDA or CA LS.01.02.01 Hospital has a ILSM policy for LSC deficiencies Indicates Direct Impact Requirements Apply (325 EPs [+37 EPs 3/26/09] = 362) A requirement for which noncompliance is likely to have direct impact on patient safety or quality of care MM.04.01.01 �EP#8 Hospital Prohibits summary (blanket) orders to resume previous medications Indicates Indirect Impact Requirements (1218 EPs) Requirements if not met can reduce the quality of patient care or safety over time The majority of EPs Indicates that Documentation is Required

4. �2009 University HealthSystem Consortium 4 2009 Scoring �B� Elements of Performance (EPs) � Gone �A� EPs � Score �2� or �0� �C� EPs � One or no occurrences of noncompliance = �2� Two occurrences of noncompliance = �1� Three or more occurrences of noncompliance = �0� Though a �C� EP might be scored �1� the standard will be scored �0� in 2009

5. �2009 University HealthSystem Consortium 5 Levels of Criticality Example: Immediate Threat to Life � Inoperable Fire Alarm or Absence of Master Alarms for Medical Gas Systems Situational Decision Rule � Unlicensed individual, who requires license providing patient care or the hospital provides inaccurate information during the survey Direct Impact Requirement � Hospital Reassesses and responds to pts pain, based on reassessment Indirect Impact Requirement � Pt. receives an H&P no more than 30 days prior to or within 24 hrs of admissionExample: Immediate Threat to Life � Inoperable Fire Alarm or Absence of Master Alarms for Medical Gas Systems Situational Decision Rule � Unlicensed individual, who requires license providing patient care or the hospital provides inaccurate information during the survey Direct Impact Requirement � Hospital Reassesses and responds to pts pain, based on reassessment Indirect Impact Requirement � Pt. receives an H&P no more than 30 days prior to or within 24 hrs of admission

6. �2009 University HealthSystem Consortium 6 Accreditation Decisions Prior to 2009 Automatic thresholds were set based on the number of RFIs for: Preliminary Denial of Accreditation (PDA) Conditional Accreditation (CA) Partially compliant standards were categorized as �Supplemental� Findings Did not count toward any threshold �Slap on the wrist� finding 2009 No automatic thresholds No supplemental findings � all require post survey response (Evidence of Standards Compliance)

7. �2009 University HealthSystem Consortium 7 2009 Threshold Screens

8. �2009 University HealthSystem Consortium 8 �Black-Box� 2009

9. �2009 University HealthSystem Consortium 9 Hospital Deeming Application: January 2009 Update On July 15, 2008 the Medicare Improvements and Providers Act of 2008 became law All accrediting bodies including TJC to complete a formal application to receive hospital deeming authority from CMS Previously TJC had a unique statutory hospital deeming authority directly from the 1965 Medicare statute On January 5, 2009 TJC posted New & Revised 2009 Accreditation Requirements In preparation for TJC submission of its application to CMS for continued hospital deeming authority New requirements will be reviewed by surveyors, but not scored until 7/1/09

10. �2009 University HealthSystem Consortium 10 New & Revised 2009 Accreditation Requirements Includes: 1 revised Standard 13 new Standards 25 revised Elements of Performance 140 new Elements of Performance

11. �2009 University HealthSystem Consortium 11 March 26, 2009Revised � Revised Accreditation Requirements After discussions between TJC and CMS a new set of revisions were released by TJC March 26th decreasing the requirements announced in January Includes: 0 revised Standard 13 new Standards 16 revised Elements of Performance 71 new Elements of Performance New requirements will still be reviewed by surveyors, but not scored until 7/1/09 Element of Performance scoring released April 7, 2009 CMS will be observing TJC surveys and central office between July and September of 2009 Final deeming decision by CMS to be made by end of 2009

12. �2009 University HealthSystem Consortium 12 New Standards - EPs Major revisions: One single set of Restraint/Seclusion standards Recognize doctors of osteopathy Medical staff bylaws to include Requirements for completing & documenting an H&P Statement of duties of each category of MS Must attempt to secure autopsies in all cases of unusual deaths H&P conducted 30 days prior to admission requires update within 24 hrs of admission or prior to surgery whichever comes first Pre and post anesthesia assessments required 48 hrs before and 48 hrs after Policy for handling tissue specimens removed during surgery Operating room register Verbal Order documentation to include time received

13. �2009 University HealthSystem Consortium 13 NPSGs being reviewed during 2009 Over the next year, the current National Patient Safety Goals will undergo an extensive review. As a result, there will be no new NPSGs developed for 2010. Responding to concerns about the challenge some Goals represent and the need for information about effective approaches to addressing these challenges, The Joint Commission and its Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group), which helps develop the NPSGs, are undertaking a thorough review of the goals and the process for their development. The NPSGs highlight serious patient safety issues that need to be addressed by health care organizations. As NPSGs have evolved over time, some have become more specific and detailed, and therefore, require more time and resources to implement Currently not scoring Medication Reconciliation during surveys

14. �2009 University HealthSystem Consortium 14 DNVHC - Det Norske Veritas Health Carehttp://www.dnv.com/focus/hospital_accreditation/ Det Norske Veritas The Norwegian Truth � est. 1864 in Oslo, Norway International, independent, self-supported, tax-paying foundation; 300 offices in 100 countries and more than 9000 employees Maritime, Health Care, IT & Telecom, Finance, Automotive, Food & Beverage, Transport, Energy Operating in US since 1898 Among top 3 ISO Registrars in world 1200 healthcare organizations certified internationally DNVHC - Offices Houston and Cincinnati All American State Dept. facilities that provide health care are certified by DNVHC September 26, 2008 CMS approved DNVHC granting it deeming authority for hospitals

15. �2009 University HealthSystem Consortium 15 DNVHC Accreditation Program NIAHO National Integrated Accreditation for Healthcare Organizations Integration of CMS Conditions of Participation (COP) and ISO 9001 Standards (for the formation and implementation of a Quality Management System)

16. �2009 University HealthSystem Consortium 16 What�s Different about NIAHO Accreditation? DNVHC trains one staff member as a DNV NIAHO � Surveyor � ISO 9001 Certifier Organization pays only travel costs of training Thereafter staff member must commit to 3 surveys per year Surveys are conducted annually 45 days before or after last annual survey No National Patient Safety Goals Specific patient safety activities are left to the organization to determine Tied to the organizations quality management system ISO 9001 For NIAHO survey, no PDA or Conditional Status

17. �2009 University HealthSystem Consortium 17 Different about NIAHO Accreditation DNV Accreditation requires both Compliance with NIAHO Standards, and Compliance with ISO 9001 standards within two years of the first NIAHO Accreditation Or a hospital may choose to pursue ISO 9001Certification A more involved process requiring additional documentation and approval by a separate ISO Certification body

18. �2009 University HealthSystem Consortium 18 DNV NIAHO Accreditation Schedule Timeframe: Year 1: NIAHO & Stage 1 ISO 9001 Surveys Stage 1 is Gap Analysis of current compliance with ISO 9001 standards Year 2: NIAHO & Stage 2 ISO 9001 Surveys Validate ISO 9001 compliance Year 3: NIAHO & Periodic ISO 9001 Surveys A Periodic ISO Survey is a shorter focused survey Year 4: NIAHO & Periodic ISO 9001 Surveys Year 5: NIAHO & ISO 9001 Compliance or Recertification Surveys Year 6: NIAHO & Periodic ISO 9001 Surveys

19. �2009 University HealthSystem Consortium 19 Change is inevitable, except from a vending machine!

20. �2009 University HealthSystem Consortium 20

21. �2009 University HealthSystem Consortium 21

22. �2009 University HealthSystem Consortium 22 Top Standard RFIs � 2004-2008

23. �2009 University HealthSystem Consortium 23 Top Standard RFIs � 2004-2008

24. �2009 University HealthSystem Consortium 24 Top Standard RFIs � 2004-2008

25. �2009 University HealthSystem Consortium 25 Top Standard RFIs � 2004-2008

26. �2009 University HealthSystem Consortium 26 Top Standard RFIs � 2004-2008

27. �2009 University HealthSystem Consortium 27 2008 Most Frequent Joint Commission Hospital RFIs Crosswalk� 2009 Standard Numbers

28. �2009 University HealthSystem Consortium 28 NPSG Compliance 2003-2009

29. �2009 University HealthSystem Consortium 29 NPSG Compliance 2003-2009

30. �2009 University HealthSystem Consortium 30 NPSG Compliance 2003-2009

31. �2009 University HealthSystem Consortium 31 Retired NPSGs

32. �2009 University HealthSystem Consortium 32 Acronyms used in this presentation