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The Survey Process in 2011

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

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The Survey Process in 2011

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  1. 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) Healthcare Engineering Consultants

  2. 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) Healthcare Engineering Consultants

  3. 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 Healthcare Engineering Consultants

  4. 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 Healthcare Engineering Consultants

  5. The Unannounced Survey Timeline • Unannounced Surveys will Occur: • Between 30 and 36 monthsfrom thedate 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 Healthcare Engineering Consultants

  6. 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! Healthcare Engineering Consultants

  7. Meeting the Scoring Challenges Understanding Survey Scoring Decisions Healthcare Engineering Consultants

  8. 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 Healthcare Engineering Consultants

  9. 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 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 Healthcare Engineering Consultants

  10. 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 Examples include: - Failure to implement interim life safety measures - Failure to meet PFI timelines on SOC Healthcare Engineering Consultants

  11. 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 Examples include: - Failure to perform risk assessments - Improper disposal of hazardous medications - Insufficient PM on life support equipment Healthcare Engineering Consultants

  12. 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 Healthcare Engineering Consultants

  13. Joint Commission Scoring Decisions • Meeting or exceeding the “Direct Impact” number results in “outlier” status and SIG review • Note: May be revised or eliminated in 2011 Healthcare Engineering Consultants

  14. Joint Commission Scoring Decisions “EC” Scoring Categories Healthcare Engineering Consultants

  15. Joint Commission Scoring Decisions “EM” Scoring Categories Healthcare Engineering Consultants

  16. Joint Commission Scoring Decisions “LS” Scoring Categories for Hospitals Healthcare Engineering Consultants

  17. Joint Commission Scoring Decisions “EC”, “EM” and “LS” Scoring Categories Note: Minimal changes in scoring categories in 2011 Healthcare Engineering Consultants

  18. Joint Commission Standards Scoring “A” Scores: High priority, One and Done! 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! Good News (sort of!) – This is only an “indirect” impact requirement! Healthcare Engineering Consultants

  19. Joint Commission Standards Scoring “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 Healthcare Engineering Consultants

  20. 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 Healthcare Engineering Consultants

  21. 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 Healthcare Engineering Consultants

  22. 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) Healthcare Engineering Consultants

  23. 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.) Healthcare Engineering Consultants

  24. The Top Sentinel Events for 2010 Healthcare Engineering Consultants

  25. The Top Ten Health Technology Hazards - 2010 Healthcare Engineering Consultants

  26. “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 Healthcare Engineering Consultants

  27. 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 Healthcare Engineering Consultants

  28. 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 Healthcare Engineering Consultants

  29. 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 Healthcare Engineering Consultants

  30. The 2011 Survey Process Questions? Healthcare Engineering Consultants

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