37_Paul_Van_Ostenberg_2.pdf

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t C o m m i s s i o n I n t e r n a t i o n a l

CLINICAL CARE PROGRAM

CERTIFICATION (CCPC)

Paul vanOstenberg, DDS, MS, Senior AdvisorJoint Comm ission Internat ional

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OVERVIEW

General Introduction to CCPC

Publication of 3rd Edition of Standards

Comparison to Hospital Surveys

Eligibility and Program Design

Standards and Chapters

Sample Survey Agenda

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What is Clinical Care Program

Certification?

CCPC is designed toevaluate diseasemanagement and/orcondition –specific care

programs that areprovided in hospitals andother settings

CPGs are used by thosewho demand more

rigorous processes toensure that care is basedon the best availableresearch evidence.

Clinical

Practice

Guidelines

Performance

Measures

JCIStandards

Quality Outcomesfor the

Population



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Value of CCPC Certification

Achieving JCI Certification can validate the quality of

care and services to the patient population through the

program’s ability to demonstrate excellent clinical care

management:

Compliance with consensus-based international

standards, including patient self-management.

Effective use of established evidence based clinical

practice guidelines to manage and optimize care. An organized approach to performance

measurement and improvement activities.



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Accreditation VS Certification

Certification differs from accreditation in that:

Accreditation focuses on an organization's overall

commitment to quality through organization-wide,

patient-centered and health care organization

management systems and processes.

Certification demonstrates excellence within a

single specialty program in fostering better

outcomes for treatment of a specific disease (such

as Diabetes Mellitus ), condition (such as AcuteMyocardial Infarction), or clinical care service (such

as Joint Replacement).



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CCPC and Hospital Survey

Differences More depth to evaluation of actual clinical care

delivered

Standardized care processes//adherence to the CPG

Detailed assessment of performance improvement

activities

Specific wording of and suggested changes to chosen

performance measures

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CCPC and Hospital Survey

Similarities Tracer Methodology

Assessment and Care requirements

Medical Records Requirements

SQE Requirements

International Patient Safety Goals

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Changes in 3rd Edition

Published 1 July 2014

Effective 1 January 2015

Open to more than the 15 programs of the 2nd Edition

Host must now be accredited

The concept of a “Center” introduced

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Eligible Programs for CCPC

Survey

The program is one of the following 15 JCI-approved clinical care programs (examples)

– Acute myocardial infarction

– Heart failure – Primary stroke

– Diabetes Mellitus (type 1 and/or type 2)

– Chronic kidney disease (Stage 1 through IV)

– End stage renal disease

– Palliative care (all types)



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Eligible Programs (continued)

– Traumatic brain injury

– HIV/AIDS management

– Cancer (all types)

– Pain management

– Asthma

– Joint replacement (all types)

– Transplantation (all types) – Chronic obstructive pulmonary disease



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Eligibility for CCPC Survey

Designed and implemented for the population served

Minimum 25 patients meet eligibility and are enrolled in

the program

4 month track record for initial survey compliance

Clinical Practice Guideline are evidence-based and:

– Are sponsored or supported by professional associations or

societies, public or private organizations, government agencies,

etc.

– Are not self-developed by the program staff

– Include evidence if modified to meet the population served



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Eligibility for CCPC Survey

(continued)

Performance measures meet requirements:

– Appropriate and consistent with program’s intent & CPG

– Collected 4 months of data

– Monitored at least four measures Host or parent organization is JCI (no longer any

options in 3rd Edition)



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Organization of

Chapters/Standards International Patient Safety Goals

Program structure and leadership Support

Delivering care

Encouraging patients/families to self-manage diseases

Managing clinical information

Monitoring performance measures for areas of

improvement

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International Patient SafetyGoals (IPSG)



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International Patient Safety

Goals (IPSG)

Goal 1: Identify Patients Correctly

Goal 2: Improve Effective Communication

Goal 3: Improve the Safety of High-Alert

Medications Goal 4: Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

Goal 5: Reduce Risk of Health Care-Associated

Infections Goal 6: Reduce the Risk of Patient Harm

Resulting from Falls



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Program Leadership andManagement (PLM)



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PLM Areas of Focus

Designing and implementing program

Evaluating program

Providing adequate access to care

Conducting program in an ethical manner

Supplying reference resources to staff

Facility safety issues



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Delivering or FacilitatingClinical Care (DFC)

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DFC Areas of Focus

Using qualified, oriented, competent, trained staff

Evaluation of care provided

Delivering care using evidence-based CPG

Individualizing care to meet patient’s needs

Management of co-morbidities/concurrent conditions



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SSM Areas of Focus

Involving patients and families in making

decisions

Evaluating patient and family’s learning needs,

and ability to learn

Educational materials

Lifestyle changes that support self-management



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CIM Areas of Focus

Protecting patient information

Identifying those authorized to access records

Use of standardized documentation Internal and external information needs

Gathering and providing information across

continuum



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CCPC Agenda Issues

1 surveyor for 2 days, or 2 surveyors for 1 day

Surveyors will have reviewed the CPG and your

performance measurement data

Surveyor may request documents to be available upon

arrival in country to enable the survey to go faster

Interview program staff during tracer activities

Interview program patients in a group

On-site suggestions and education for the program

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n t C o m m i s s i o n I n t e r n a t i o n a l

CCPC Agenda Issues

Opening conference, overview of program services,

and discussion of PI measures and data use. Agreement

on four measures to be tracked after the survey.

Unit visits and patient tracers---no trick questions

Closed medical records review

SQE

Program patient interviews

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Mid Cycle Review

Requirements Submitted18 months after survey

Monthly results of 4 performance measures with

analysis and plans for improvements

Any changes to the CPG or program design/scope?

Any changes to program leadership or staff?

Progress update on all findings in original survey

report

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