© Copyright, The Joint Commission Accreditation Seminar — The Joint Commission Michael Kulczycki, MBA Executive Director, Ambulatory Care Accreditation.
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Accreditation Accreditation Seminar — Seminar — The The Joint CommissionJoint CommissionMichael Kulczycki, MBA
Executive Director, Ambulatory Care Accreditation Program
WASCA 2007 Seminar 2
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Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
Other factors
WASCA 2007 Seminar 3
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Accreditation choices:
Primary reason = third party reimbursement
All accreditors represented fill your need.
WASCA 2007 Seminar 4
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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……
WASCA 2007 Seminar 5
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The Joint Commission …your choice
Helping Health Care Organizations Help Patients
WASCA 2007 Seminar 6
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Joint Commission
Background– Not-for-profit organization– Accredits 15,000 total
organizations– Accrediting ambulatory
since 1975 – ASCs = largest segment
– Awards Gold Seal of Approval™
WASCA 2007 Seminar 7
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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.
WASCA 2007 Seminar 8
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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
WASCA 2007 Seminar 9
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…..Accreditation components
Emphasis on an organization’s systems
Annual self-assessment process (Periodic Performance Review)
Ongoing improvement & tailoring of ambulatory standards.
WASCA 2007 Seminar 10
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Accreditation Manual:Ambulatory Care
Program specific statements of:– standards,– rationale, – elements of performance
(compliance criteria) National Patient Safety
Goals Information about
accreditation processPeriodic updates
WASCA 2007 Seminar 11
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2007 Standards for ASCsOn-site evaluation evaluates compliance with
Standards & National Patient Safety GoalsStandards 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)
WASCA 2007 Seminar 12
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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
WASCA 2007 Seminar 13
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Patient Tracer Method
Process driven, initiated by priority focus areas (highlight 4-5 for ASCs)
Customized to ASC servicesMore focused on execution -- actual
delivery of care / servicesFrontline staff…what do they do, and
why do they do it that way
WASCA 2007 Seminar 14
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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
WASCA 2007 Seminar 15
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Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
Other factors
WASCA 2007 Seminar 16
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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
WASCA 2007 Seminar 17
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2007 National Patient Safety Goals for surgery centers
1. Patient identification
2. Communication among caregivers
3. Medication safety
7. Health care-associated infections
8. Reconciliation of medications
11. Surgical fires
13. Patient involvement Universal Protocol for Preventing
Wrong Site Surgery
WASCA 2007 Seminar 18
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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
WASCA 2007 Seminar 19
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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
WASCA 2007 Seminar 20
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NPSG Compliance Data for 2003—2006(Freestanding Ambulatory Care Surveys: % Non-compliance)
NPSG requirement 2003 2004 2005 2006
1a: Two identifiers 7.3% 8.0% 3.7% 6.9%
1b: Time out before surgery (UP) 6.0% 6.7% 13.9% 24.2%
2a: Read-back verbal orders 5.5% 7.6% 10.7% 9.2%
2b: Standardize abbreviations 19.6% 16.3% 17.9% 24.0%
2c: Improve timeliness of reporting --- --- 1.2% 8.3%
2e: Hand-off communications --- --- --- 2.5%
3a: Concentrated electrolytes 2.5% 1.1% 1.7% ---
3b: Limit concentrations 1.5% 0.2% 0.0% 0.9%
3c: Manage look-alike/sound-alike drugs --- --- 3.5% 8.5%
3d: Label medications & solutions --- --- --- 4.1%
4a: Preoperative verification (UP) 2.3% 1.8% 4.5% 1.6%
4b: Surgical site marking (UP) 4.3% 4.0% 5.7% 7.6%
7a: CDC hand hygiene guidelines --- 1.8% 6.9% 11.5%
7b: HC-associated infection & RCA --- 0.0% 2.2% 0.0%
8a: Medication reconciliation – list --- --- 1.0% 24.4%
8b: Medication reconciliation – reconcile --- --- 0.7% 25.8%
11a: Surgical fire --- --- 2.0% 1.2%
WASCA 2007 Seminar 21
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WASCA 2007 Seminar 22
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Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
Other factors
WASCA 2007 Seminar 23
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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”
WASCA 2007 Seminar 24
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ASC Opportunities for Improvement
1. 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)
WASCA 2007 Seminar 25
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…. 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
WASCA 2007 Seminar 26
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…. 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
WASCA 2007 Seminar 27
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ASCs compared to all AHC – 2006
All AHC(n=430)
Surgery Centers(n=170)
Standard % Standard %
PC.16.10 27% PC.16.10 28%
PI.3.20 27% NPSG 8a 26%
NPSG 8a 26% PI.3.20 22%
MM.2.20 25% NPSG 8b 20%
NPSG 8b 25% NPSG 2 17%
UP 1 24% UP 1 17%
NPSG 2 24% EC.4.10 16%
EC.4.10 17% HR.4.50 15%
HR.4.10 16%
WASCA 2007 Seminar 28
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Session Overview
Accreditation as a management tool
Patient safety issues
Opportunities for improvement
Other factors
WASCA 2007 Seminar 29
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Other factors
State partnerships:– Focused on establishing state recognition – Staff available to partner with
state/national associationsMedicare optionNew “value” for accreditationOther partnershipsSummary of advantages
WASCA 2007 Seminar 30
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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
WASCA 2007 Seminar 31
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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
WASCA 2007 Seminar 32
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New accreditation driver: Liability recognition
WASCA 2007 Seminar 33
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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
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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
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….. 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™
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Advantages
Upon earning the Gold Seal of Approval™ your center:Upon earning the Gold Seal of Approval™ your center:
Has access to a unique extranet site, Has access to a unique extranet site, Joint Commission Connect, Joint Commission Connect, for communicationsfor communicationsHas a single Account Representative, aiding:Has a single Account Representative, aiding:
Updates to informationUpdates to informationAll post-survey steps, conducted electronicallyAll post-survey steps, conducted electronicallyCompletion of annual self-assessment of complianceCompletion of annual self-assessment of complianceSurvey process questionsSurvey process questions
WASCA 2007 Seminar 37
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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
WASCA 2007 Seminar 38
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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
WASCA 2007 Seminar 39
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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
WASCA 2007 Seminar 40
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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/
WASCA 2007 Seminar 41
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Your questions / Next steps?
WASCA 2007 Seminar 42
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Information
www.jointcommission.orgwww.jointcommission.org/HTBAC/AHCAmbulatory Care Accreditation
– 630.792.5286– mkulczycki@jointcommission.org
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