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Intracycle Monitoring Process and Focused Standards Assessment

Intracycle Monitoring Process and Focused Standards Assessment. Patton Healthcare Consulting. Joint Commission -101. The Joint Commission Non-Profit Accredits 80% of Hospitals in the Nation ~ 90%+ of the beds Deemed Status Provider for Medicare Certification by CMS

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Intracycle Monitoring Process and Focused Standards Assessment

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  1. Intracycle Monitoring Process and Focused Standards Assessment Patton Healthcare Consulting

  2. Joint Commission -101 • The Joint Commission • Non-Profit • Accredits 80% of Hospitals in the Nation ~ 90%+ of the beds • Deemed Status Provider for Medicare Certification by CMS • Composed of Representatives of Professional Organizations

  3. Standards & Requirements • APR • Environment of Care • Emergency Management • Human Resources • Infection Control • Information Management • Leadership • Life Safety • Medication Management • Medical Staff • NPSG • Nursing • Provision of Care • Performance Improvement • Record of Care • Rights • Transplant Safety • Waived Testing

  4. Annual Internal “Self Assessment” Former Process known as Periodic Performance Review (PPR) • Required annually – though not due in year of survey • Due date established by TJC • Measures of Success (MOS) required for non-compliant EPs • Audit data to demonstrate your compliance once fixed • If requested had to be shown to surveyors during triennial survey • Results were used to help “guide” surveyors

  5. The New and Improved Intracycle Monitoring Process • PPR Process Retired as of Nov. 2012 • New Intracycle Monitoring (ICM) Jan 2013 • You will now submit a Focused Standards Assessment (FSA) • You still have same submission options • You can request a TJC call • You can submit specific questions/online chat • Surveyors will not ask for FSA MOS data

  6. FSA Replaces the PPR • The new FSA is an abbreviated set of standards/EPs deemed to be high risk* • Will include high risk EPs – designated in manual with an “R” icon – most of direct impact and some indirect impact • About 500 EPs are “R” or high risk • NPSG are all “R”s • You will also have to score previous findings

  7. High Risk* • Proximity to the patient • Probability of harm • Severity of harm • Number of patients at risk

  8. ICM Profile • An online workspace on your extranet site • Includes the FSA tool and quick links to FAQs, Leading Practice Library™, TST™, etc. • The FSA is required at approximately 12 and 24 months from last survey date • Not required at the 36 month anniversary • Full FSA submission, or options 1, 2, and 3

  9. Full FSA or one of the 3 Options • According to TJC, historically • 75% of hospitals submitted the full PPR • 15% did Option 1 (attest that you did PPR) • 10% did either Option 2 or 3 (surveyor comes on site, Option 2 provided a written report, Option 3 = no report) • TJC would like to steer those who choose Option 1 to Full or Options 2 or 3 • Option 2 or 3 survey limited to just FSA

  10. The FSA Tool • The AMP tool is designed to be “pulled in” from the ICM Profile extranet page • It is auto-loaded with the risk-selected FSA standards/EPs/ NPSGs • Along with the standards/EPs found non-compliant in your last survey • Capability for on-the-fly free-text/chat questions to Standards Interpretation

  11. Sharing Options with ICM Profile • Onsite survey teams have access to • Previous survey findings and follow up reports • Accreditation application data • ORYX Reports, Quality Check Reports • You may “opt-in” to allow the onsite team to see the full ICM profile with or without your FSA (self-assessment)

  12. ICM/FSA Goals • You are scoring as if you were the Surveyor to determine compliance! • Rigorously complete the FSA tool • Score yourself at each applicable EP • Identify where evidence that you are compliant can be found (annotate) • Identify areas of weakness/vulnerability • Identify data that demonstrates compliance

  13. Scoring Basics:What You Score Yourself On • You must be compliant with: • The applicable standards/EPs including the situational decision rules • The FAQs published by the Joint Commission • Anything in Perspectives • Your own internal policies • The surveyor will hold you to the most stringent where differences exist!

  14. Read the Book 10/21/2014 14

  15. READ THIS NEWSLETTER Get it Distributed

  16. And Look on the Website, Print All FAQ’shttp://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards

  17. Standards • Consist of Three Parts: • Standard Statement • Rationale and/or Notes (not in the excel file) • Elements of Performance (EP) • These are the score-able elements

  18. FSA Scoring SampleThe CAMH

  19. Scoring of Standards • Standards are NOT scored per se • You score only the Elements of Performance (EP) under the standard • If one EP is non compliant or partial, the standard is considered non compliant by The Joint Commission.

  20. How EP’s are Scored • Category A • Relate to structural and process requirements, such as policy • Scored as either exist or not. Either compliant or not. All or nothing.

  21. How EP’s are Scored • Category C • Based on the number of times you do NOT meet a EP • Scored by the surveyors as: • 0 = Insufficient Compliance = 3 or > instances of non-compliance • 1 = Partial Compliance = 2 instances of non-compliance • 2 = Satisfactory Compliance = 0 – 1 instance of non-compliance • In other words …. Two observations is NON-COMPLIANT

  22. How EP’s are Scored • “D” for Documentation Requirement • Conceptually a great idea – identify those issues where you just have to do it vs. those where you have to do it, and document that you did it. • Many D’s appear to be missing; when the body of the EP says document • Example: NPSG.08.02.01, EP 1 – Communicate the medication reconciliation list and the communication among providers is documented. • Many C elements with MOS, but no D – how would you measure these?

  23. How EP’s are Scored: • Measure of Success • Some EP’s have a “Measure of Success” (MOS) associated with them. • Requires an Audit - a quantifiable measurement if found out of compliance during FSA or on-site survey. • Remember this important change! The on-site surveyor may no longer request to see your historical MOS data on any EP you found out of compliance on a previous PPR or FSA. (Though you may opt-in to let them view your FSA results)

  24. MOS – Sample Size • Sample Size Requirements for Category C Standards • Recommended for use in FSA • Population size up to 100 = 30 cases or 100% if < 30 • Population size 101 – 500 = 50 cases • Population size > 500 = 70 cases

  25. SEVERITY LEVELS FOR EP’S Immediate Threat “Situational” CONT / PDA Decision Rules 2 3 Direct Impact – 45 days Indirect Impact - 60 days

  26. Immediate Threat 2 “Situational” Decision Rules 3 Direct Impact Indirect Impact Situational Decision RulesShort Cut to Trouble • Severity “2” • Very bad news, may result in Preliminary Denial (PDA) decision • Examples include: • Unlicensed practice • “Busted plan” • Failed ILSM or Failure to Assess for ILSM • Use of surveyors as consultants • Falsification

  27. Immediate Threat 2 “Situational” Decision Rules 3 Direct Impact Indirect Impact Situational Decision Rules cont. New Decision Rules CONT02 – Failure to resolve all prior findings that resulted in Accreditation with Follow Up (AFU) • CONT03 – Credible evidence indicates possible fraud has occurred. New Survey Type: • Accreditation with Follow Up (AFU08) an onsite follow up survey w/in 45 days in Medicare certified hospitals for a condition level deficiency(s) • (AFU01-02) Systemic pattern of repeat findings of direct or indirect standard • AFU03 Failure to address all RFI in an ESC/MOS

  28. For Each Standard/EP Ask yourself, ask your staff: Do we do this? Where is it written we do this? How well, or how often do we do this? Show me the evidence that we do this Validate the “doing” with high risk and high priority standards 28

  29. FSA Scoring – How To: Complete the sections for: • Annotate Supporting Evidence • (Policy # and/or Data) • Observations • Compliant? Yes/No • Action Items • Responsible Person

  30. In summary: Why Do the FSA? • It’s required! • Get staff ready for the survey • Find it before the survey team does • Allows you to fix it or find another way • Focus on • Actual performance • Execution, not your potential to do it right • Assemble evidence that you are at least 90% compliant for those things that are frequently scored. You are huge. Measure internal compliance • Opportunity to request resources, if needed.

  31. FSA Focuses on the Priority Issues • The 2013 standards have 1900 EPs that can be scored • The Joint Commission does >90% of its scoring on about 25 standards/NPSGs • Focus on the top scored direct and indirect EPs • Focus on all NPSGs • Focus on any NEW standards or FAQs • Focus on previously scored issues

  32. The FSA is Complete, Now What?Bullet Proof Weak Areas • Internal FSA tracers/data will highlight these • Formalize decisions in writing, do risk analysis, communicate decisions • Communicate top hot spots • In pocket guides, in games, in annual education, screen savers, table tent cards • Engineer to sustain compliance • Make the right thing to do the easiest thing to do

  33. Questions? • Kurt Patton • Kurt@PattonHC.com • Jennifer Cowel • JenCowel@PattonHC.com • John Rosing • JohnRosing@PattonHC.com • Mary Cesare Murphy • MCM@PattonHC.com

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