Accreditation Seminar — The Joint Commission

1. Accreditation Seminar — The Joint Commission Michael Kulczycki, MBA Executive Director, Ambulatory Care Accreditation Program

2. Session Overview • Accreditation as a management tool • Patient safety issues • Opportunities for improvement • Other factors

3. Accreditation choices: • Primary reason = third party reimbursement • All accreditors represented fill your need.

4. 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……

5. The Joint Commission …your choice Helping Health Care Organizations Help Patients

6. Joint Commission • Background • Not-for-profit organization • Accredits 15,000 total organizations • Accrediting ambulatory since 1975 – ASCs = largest segment • Awards Gold Seal of Approval™

7. 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.

8. 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

9. …..Accreditation components • Emphasis on an organization’s systems • Annual self-assessment process (Periodic Performance Review) • Ongoing improvement & tailoring of ambulatory standards.

10. Accreditation Manual:Ambulatory Care • Program specific statements of: • standards, • rationale, • elements of performance (compliance criteria) • National Patient Safety Goals • Information about accreditation process • Periodic updates

11. 2007 Standards for ASCs • On-site evaluation evaluates compliance with Standards & National Patient Safety Goals • Standards 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)

12. 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

13. Patient Tracer Method • Process driven, initiated by priority focus areas (highlight 4-5 for ASCs) • Customized to ASC services • More focused on execution -- actual delivery of care / services • Frontline staff…what do they do, and why do they do it that way

14. 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

15. Session Overview • Accreditation as a management tool • Patient safety issues • Opportunities for improvement • Other factors

16. 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

17. 2007 National Patient Safety Goals for surgery centers • Patient identification • Communication among caregivers • Medication safety • Health care-associated infections • Reconciliation of medications • Surgical fires • Patient involvement • Universal Protocol for Preventing Wrong Site Surgery

18. 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

19. 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

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

22. Session Overview • Accreditation as a management tool • Patient safety issues • Opportunities for improvement • Other factors

23. 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”

24. ASC Opportunities for Improvement • 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)

25. …. 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

26. …. 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

27. ASCs compared to all AHC – 2006

28. Session Overview • Accreditation as a management tool • Patient safety issues • Opportunities for improvement • Other factors

29. Other factors • State partnerships: • Focused on establishing state recognition • Staff available to partner with state/national associations • Medicare option • New “value” for accreditation • Other partnerships • Summary of advantages

30. 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

31. 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

32. New accreditation driver: Liability recognition

33. 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

34. 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

35. ….. 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™

36. Advantages Upon earning the Gold Seal of Approval™ your center: Has access to a unique extranet site, Joint Commission Connect, for communications Has a single Account Representative, aiding: Updates to information All post-survey steps, conducted electronically Completion of annual self-assessment of compliance Survey process questions

37. 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

38. 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

39. 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

40. 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/

41. Your questions / Next steps?

42. Information • www.jointcommission.org • www.jointcommission.org/HTBAC/AHC • Ambulatory Care Accreditation • 630.792.5286 • mkulczycki@jointcommission.org