© Copyright, The Joint Commission Accreditation Panel – Your Success Factors from The Joint...

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Accreditation Panel – Your Accreditation Panel – Your Success Factors from Success Factors from The Joint Commission The Joint Commission

Michael KulczyckiExecutive DirectorAmbulatory Care Accreditation Program4.26.12

MNASCA AnnEdConf.0412 - 3

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Overview of topics

About The Joint CommissionTips for success in coordinating a

successful survey experiencePatient tracers…focus your staff on

patient safety every dayResources available


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Joint Commission ModelBackground

– Not-for-profit organization– Accredits over 19,500 total organizations– Awards The Gold Seal of Approval™

Accrediting ambulatory since 1975:– ASCs = single-largest segment– Wide variety of other ambulatory settings– AHC program now accredits over 2,000

organizations with 6,500 sites of care


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Collaborate with ASC customers

Input to Joint Commission strategic issues via Surgery Advisory Council

Input to Ambulatory standards via Board committee, for example:– Ambulatory Surgery Center Association– American Society of Anesthesiologists / Society for

Ambulatory Anesthesia– American Society for Cataract & Refractive Surgery– American Society for Gastrointestinal Endoscopy– Association of periOperative Registered Nurses


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Joint Commission Model…

Accreditation partnership == – Independent, outside evaluation

– Components = continuous compliance with ambulatory care standards:–On-site survey, every 3 years–Annual self-assessment during interim

– Focus on processes for ensuring patient (and staff) safety


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Partnership = servicePartnership means more than promise of

customer serviceLive phone coverage & e-mail response at each

phase of accreditation Pre-application via Business Development Application & pre-survey via Ambulatory-specific

Account Executive Post-survey & thru accreditation cycle

Enterprise expectations for customer responsiveness


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…Model

Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working as part-time surveyors

–Survey 30-100+ organizations annually –Sources of consultation & education

Patient-centered accreditation process


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Dispelling Joint Commission Myths…

Only for hospitalsOnly for hospitals– ASCs = largest customer segment &

segment has doubled in 8 years– Offer ASC-specific & Endoscopy-specific

standards – Account handled by Ambulatory-specific

team of account executivesDon’t understand ASCsDon’t understand ASCs

– Accrediting ambulatory providers since 1975


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…Dispelling Myths…Survey process only focus on policiesSurvey process only focus on policies

– Since 2004, over 60% survey time focuses on patient care thru patient tracer method

– Most ASC staff, including surgeons & anesthesiologists, engaged in survey process

– Standards clearly indicate documentation requirements (language & icon )


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…Dispelling MythsPost-survey process lengthy & Post-survey process lengthy &

complicatedcomplicated– Report with summary of findings

delivered ON-SITE– Preliminary decision posted to extranet

< 48 hours– Web-based submission of corrections

from ASC – Final decision posted <10 days from

ASC corrections date


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Overview of topics





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Tips for success…Submit application 3-6 months in advance,

with depositSelect “ready date” & communicate closely

with your account executive“Ready to go” with your list:

Link: http://bit.ly/fZCkcn

For Medicare “deemed status”, provide copy of Medicare 855B approval letter or Intermediary approval link


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…Tips for success…Use educational resources:

– Get answers to your standards questions via phone/e-mail

– Live & distance education via JCR– Published list of “challenging” ambulatory

standards in Perspectives– Network with others (QualityCheck)

Tap experiences of others captured by ASC media (see resources)


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…Electronic Standards…

Available:> E-dition electronic standards option

> All accredited customers & applicants receive one free E-dition & one hardcopy CAMAC standards manual

See: www.jcrinc.com/e-dition/

15 Kaiser Perm March, 2012


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…Tips for successGet comfortable with standards Use E-dition electronic product to

organize your approachUnderstand model for surveyors – how

will they engage with your ASCPrepare by using “mock surveys”Preliminary, onsite report outlines

your immediate next steps to final accreditation decision


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ASC Medicare survey changes (since 2009)

Adds a day for ASCs over 600 cases/yr

Adds survey session/activities:– Increased record review– CDC Infection Control Worksheet

Changes one patient tracer process– Observe operative case beginning to end


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Joint Commission Surveyor “Tips” for the Survey It’s OK…not to know the answer, but know

who does We are reviewing systems, not individuals Please ask questions; survey should be

interactive and educational Surveyors will minimize disruptions to your

delivery of patient care We will notice things you have never seen If changes are needed in the agenda, please ask Time will go by very quickly There are no surprises at the closing


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2011 – Top 10 Survey ChallengesTop 10 ‘Requirements for

Improvement’ scored in 2011Prioritizes “challenges” for customersBenchmarking opportunity!


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Overview





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On-site Survey Process

Accommodates ASCs normal operational systems & schedules

Few formal interviews– More attention to caregivers & direct

patient care

Tracer method allows customization: – Settings / Services / Patients


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Patient Tracer Method

Used since 2004, engages surveyor directly with staff, surgeons, patients

Accounts for nearly 2/3 of survey timeCustomized to ASC servicesMore focused on execution -- actual delivery

of care / servicesFrontline staff…what they do, and why

do they do it that wayConnects the dots for your ASC staff


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…Patient TracerTraces 3-4 patients through ASCs

entire process & facilityUse patient chart as “road map”Identify performance issues in one or

more steps of the process – or between processes

Systems tracer includes dialogue on: – data use, infection prevention & medication

management


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Individual Tracer Activities

Can include: Pre-operative information Patient reception & intake Pre-procedural assessment Intra-operative processes Post-procedure monitoring Emergency procedures Room and equipment

turnover Patient discharge from

facility Patient follow up Data collection

Can involve: Patient Family Surgeon Anesthesiologist Nursing Support staff Vendors Contractors

24


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Overview




(see also Resources section)


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New ‘Value Adds’ for Joint Commission Customers

Leading Practices Library

Center for Transforming Healthcarewww.centerfortransforminghealthcare.org

26


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Summary

Dispel Joint Commission mythsProvide tips on achieving a successful

ASC accreditation surveyPatient tracer processValue-added services for

customers = Resources

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What are your questions?


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Available for assisting MNASCA members

For more information call or E-Mail:

Michael Kulczycki, Executive Director, Business Development 630.792.5290 [email protected]

Mike Dye, Senior Associate Director, 630.792.5259

[email protected]

Darrell Anderson, Senior Specialist, 630.792.5292

[email protected]


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Supplemental Resource materials

Sample survey agendaDetail on accreditation feesDetail on:

– Targeted Solutions Tools– Leading Practice Library

Features of Joint Commission modelWhat others say:

– Customers– ASC media resources


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The Joint CommissionThe Joint CommissionSample 2-day Survey Agenda for (small/start-up) ASC/Deemed SurveyDay 1 8:00 – 9:00 a.m. Surveyor Arrival &

Planning Session 9:00 – 10:00 a.m. Opening Conference &

Orientation to Organization 10:00 – 10:30 a.m. Cont. Surveyor Planning Session 10:30 – 12 :30 p.m. Individual Tracer Activity 12:30 – 1:00 p.m. Lunch 1:00 – 2:00 p.m. Individual Tracer Activity 2:00 – 3:00 p.m. Life Safety Code—Building

Assessment 3:00 – 4:00 p.m. System Tracer – Data

Management 4:00 – 4:30 p.m. Surveyor Planning Session


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……..Survey Agenda..Survey Agenda

Day 2 8:00 – 8:30 a.m. Daily Briefing 8:30 – 9:30 a.m. Leadership Session 9:30 – 11:30 p.m. Individual Tracer 11:30 – 12:30 p.m. Environment of Care,

Equipment & Emergency Management

12:30 – 1:00 p.m. Lunch 1:00 – 2:00 p.m. Competence Assessment &

Credentialing/Privileging 2:00 – 3:30 p.m. Surveyor Report

Preparation 3:30 – 4:30 p.m. CEO Exit Briefing &

Organization Exit Conference


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Dispelling Myths about fees…Accreditation too costlyAccreditation too costly

– Only accreditor with transparent & publicly posted pricing

– Only accreditor with fees spread across 3-year accreditation cycle

– Only accreditor with published fees covering ALL costs, including if deemed status option is used

– Typical ASC < $10,000 for three years, or less than $9.00 per day


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Pricing for ASCs(deemed) – A 3-year plan

Year Case Volume 1 - 600 Case Volume 601 - 5000

Year 1 Fees $1,700 deposit with application (credit, NOT additional fee)$1,950 annual fee, offset by $1,700 deposit credit , balance due = $250

On-site survey = $4,150

$1,700 deposit with application (credit, NOT additional fee)$1,950 annual fee, offset by $1,700 deposit credit, balance due = $250

On-site survey = $5,475

Year 2 Fees $1,950 $1,950

Year 3 Fees $1,950 $1,950

Total Fees $10,000 $11,325


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Center for Transforming Healthcare (CTH)

Targeted

Solutions

Tools1. Hand washing

2. Wrong site surgery

3. Hand off communications

4. Surgical site infections


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TST Benefits TST is accessible via accredited customers’

Joint Commission Connect extranet – at no additional cost

Saves time and resources and uses organization’s current staff

Provides robust process improvement* (RPI) tools to organizations that do not have the necessary resources to implement their own RPI process

* Robust process improvement (RPI) is a way to improve business performance by focusing on specific processes of production


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Coverage of WSS project

See April 2011 issue, for full story: http://bit.ly/SurgStrat_Center


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Leading Practices LibraryLaunched as web-based service,

free to customersOffers customer-generated “library”:

–Sample policies–Patient satisfaction survey–Safety risk assessment

Sorted by program or by standards chapters

Share your own leading practices with others


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Features of Joint Commission Accreditation

Accredited Ambulatory Care

Organization

Periodic Performance Review (PPR)

On-site Evaluation

Unannounced Surveys & Tracer Methodology

ExperiencedAmbulatory Surveyors

StandardsInterpretationEducation

Customer AccountExecutive

Operational Toolsfor Good Management

Lessons Learned-- Leading

Practices Library

ElectronicManual

Risk Reduction Process

NPSGs

State-of-the ArtStandards

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Ambulatory Health Care Accreditation

Accreditation timeframe – all evaluations produce a 3-year accreditation decision

Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working as part-time surveyors

Accreditation Report – provided on-site, final decision < 5 days from post-survey steps


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Ambulatory Service

Ambulatory Care Accreditation

Timely scheduling & customer service from exclusive Ambulatory team

Fully electronic process – from application to post-survey steps

Defined, fixed pricing – include all costs, billed over three-years

Name recognition -- Gold Seal of Approval™


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Tips for success….ASC mediaTap experiences of others captured by

ASC media:– SurgiStrategies Aug. 2010, “Accreditation: A

Roadmap to Success” http://bit.ly/AccredRoadmap8Z2XEq

– SurgiStrategies July 2010, “Raising the Bar” http://bit.ly/RaiseBar

– Outpatient Surgery July 2010, “Accreditation Services: Finding Right Fit” http://bit.ly/RightFit_2010


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What others say:

“… share what a “pleasant” experience the survey was. Now that is a strange term for a survey, but the surveyor helped. We learned from her and she listened to us. She took the stress away, and we felt like all our hard work was validated. So our thanks to Joint Commission for changing the “aura” that used to surround your surveys.”

~ Illinois ASC

“Administrator said surveyor made her feel that TJC wants the organization to succeed (and not just find problems as had been past experience).”

~ Kansas City ASC


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…Others say:

“I could not be more delighted with the service from The Joint Commission: – Account executive has been professional, direct and

informative with every interaction– Our survey was timely as promised yet retained the

requirements of CMS and the rigors of the TJC standards

– Surveyor was knowledgeable, collaborative, direct, professional and courteous.

– Our report was posted immediately…the next morning.

– TJC was a more cost effective survey fee, and in ability to begin doing Medicare patient procedures”

~ COO, ASC management firm

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