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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.

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The Joint Commission Leadership Preparation

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  1. The Joint Commission Leadership Preparation May 17, 2010

  2. Opening Conference

  3. Opening Conference • Governing body, senior leaders, medical staff leadership • Approximately 15 minutes • Introductions • Agenda discussion with surveyors • Priority Focus Process and System Tracers described

  4. 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

  5. Orientation to our OrganizationSession

  6. 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

  7. 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

  8. Orientation to our OrganizationSession Topics • Community involvement • Leadership’s role in emergency management planning • Cleaning, disinfection and sterilization • Patient Flow • Organ procurement and donation

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Leadership Session

  15. 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

  16. 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

  17. Leadership Session

  18. 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

  19. 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

  20. 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

  21. 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

  22. Survey Process

  23. 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.

  24. 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

  25. 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

  26. 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 areas Evidence of Standard Compliance within 45 days

  27. 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

  28. 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

  29. 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

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