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    msfhfag msfhfag Presentation Transcript

    • Joint Commission’s Ambulatory Audio Advisor A complimentary Conference Call series provided for Ambulatory Care organizations and Office-Based Surgery practices seeking Joint Commission accreditation for the first time.
    • Audio Advisor
      • Today’s Subject:
      • Maintaining Continuous Readiness:
      • Why It matters and How the Joint Commission
      • Can Help You Get There!
      • Faculty:
      • Catherine (Cathy) Norins, MHA – Ambulatory Care Surveyor
      • Moderator:
      • Mike Dye – Senior Associate Director, Business Development Ambulatory Care & Office-Based Surgery
    • Audio Advisor
      • We will:
      • Explain “Continuous Readiness”
      • Review the Unannounced Survey Process
      • Discuss Features and Benefits of Periodic Performance Review (PPR)
      • Provide Feedback and Examples Gathered from 2006 On-Site Survey Experience
      • Settings Impacted:
      • Surgical (ASC & OBS), Primary Care, Diagnostic
    • Audio Advisor
      • Continuous Readiness
      • Next Evolution in Joint Commission’s Accreditation Process
      • Shifts process from:
          • Survey preparation “ramp-up”
          • Static review of policies & procedures
          • Short term, labor intensive process
          • Focus on accreditation score
      • Shifts focus to:
          • Actual performance vs. potential to perform
          • Observations of direct patient care
          • Continuous, institutionally-structured process
          • Improving patient safety and quality of care
    • Audio Advisor
      • A Continuous State of Mind!
      • Encourages Continuous vs. Episodic compliance
      • Provides a ‘true-life’ picture of organization performance
      • Enhances organization credibility with:
        • Federal & state regulatory bodies
        • Patients and family members
        • Consumer perceptions
      • Reinforces continuous standards compliance
      • Avoids or reduces regular pre-survey ‘ramp-up’ costs
      • Allows more cost-effective preparation
    • Audio Advisor
      • Unannounced Survey Process
      • Features:
        • Focus on systems improvement & continuous compliance with standards
        • Applies only to re-survey customers
          • Note: ASC deemed status surveys already unannounced
        • Initial surveys continue to utilize announced process
        • Exemptions allowed for uniquely-sized organizations:
          • Low volume (<1,500 cases annually)
          • 5-day pre-survey notification provided
    • Audio Advisor
      • Unannounced Survey Process
      • Benefits:
        • Reinforces importance of accreditation processes year-round, not just 6-9 months prior to survey
        • Emphasizes safe, high-quality patient care on a continuous basis
        • Helps lower staff pre-survey anxiety
        • Encourages staff & facility preparation for next
        • patient, not next survey!
    • Audio Advisor
      • Unannounced Survey Process
      • Central Office reminders:
      • Maintain regular contact with Account Representative
      • Ensure accurate data on e-application:
          • Survey ‘avoid’ dates
          • Patient volume
      • No pre-survey call from surveyor
      • Review Survey Activity Guide & sample agenda
      • Surveyor arrives… verify ID Badge & check “Jayco” extranet site
    • Audio Advisor
      • ‘ Continuous’ Compliance Support
      • Periodic Performance Review (PPR) *
      • Organization self-assessment tool
      • Provides educational opportunity
      • Results submitted annually
      • Scheduled SIG conference-call to review & approve:
          • Plan of action
          • Measures of success
          • Unique organizational processes
      • Organization improvements can be updated as they occur
      • *Not applicable to Office-Based Surgery practices
    • Audio Advisor
      • Unannounced Survey Process
      • Re-review Key Concepts About Accreditation & Continuous Readiness
      • Mindset Change
        • Get ready for the next patient who enters your facility; not JCAHO
        • Run a marathon, not a sprint!
      • Accreditation is a by-product of good day-to-day management
        • Do the right thing, for the right patient, at the right time
        • Consistent execution = 24/7/365 (minimal variation)
        • Continuously improve your BEST performance (PI concepts)
      • Accreditation is about what you currently do every day
        • Look in mirror and ask: “How can we do what we do better?”
        • Standards are logical and practical: “Follow the Yellow Brick Road.”
    • Audio Advisor
      • Unannounced Survey Process
      • Activities that can assist you with Continuous Readiness
      • Conduct your own reviews (Periodic Performance Reviews)
      • Start NOW!
      • Read & understand each standard:
            • ‘ Follow the Yellow Brick Road’
              • Elements of Performance (EP) – the predetermined steps to follow to achieve desired outcome (Standard)
            • Ask ‘How’ your organization does each step (The 5-W’s learned in school)
            • Seek Help
              • FAQ – Great resource (National Patient Safety Goals & Standards)
              • SIG – Standards Interpretation Group @ JCAHO
    • Audio Advisor
      • Unannounced Survey Process
          • Conduct Patient Tracers – following steps of patient:
            • Allocate 4 hours per tracer – maybe one per week; involve MDs
            • Train so process validity
              • ‘ What’s acceptable’ & ‘what’s not’
              • Focus on Patient Safety (NPSG); Information Management (Right person; has right information; at right time)
          • Develop a plan for assuring all standards monitored & reviewed (i.e., annual evaluations of plans)
          • Develop a process to stay current with expectations:
            • Example: Proactive Risk Assessment (FMEA) required 3
            • years ago
    • Audio Advisor
      • Unannounced Survey Process
      • The on-site survey:
        • One step in a continuous process
        • Surveyors hired by you!
          • - They’re your consultants and educators
          • - Validate design of your processes & consistent implementation
      • Application – be sure up-to-date:
        • Hours of operation (i.e., Spring Break)
        • Directions to surveyors as to where to report
      • Ensure surveyors begin work for you promptly – ROI
    • Audio Advisor
      • Unannounced Survey Process
        • Have game plan for first hour of the survey:
          • Checklist
          • Who will surveyors meet first? What does this person need to know?
          • List of people to call & backup list
          • Security issues: Surveyors can’t pass ‘Go’ until ID verified
            • How long will this step take? (15 minutes or 1 hour?)
            • Know how to access “Jayco” extranet
    • Audio Advisor
      • Unannounced Survey Process
      • Where will surveyors work?
        • A place to review initial documents
      • Document Availability
        • Are documents listed in Survey Activity Guide readily available?
        • Tip - create an introductory packet to hand to surveyors immediately
          • Similar to new EE orientation packet: patient brochure; organizational chart
          • Up-to-date? Consider reviewing it every 4 or 6 months
        • What if person responsible for information is on vacation?
        • Remember - survey begins with first impressions!
    • Audio Advisor
      • Unannounced Survey Process
      • Tracer Activity Planning:
      • Selection process by surveyor varies
        • List of patients being seen in specific clinic
          • Interview patients – What is process for interviewing patients in your organization?
        • Back-in to selection process
          • Referral logs (consultations; diagnostic tests)
          • Patients seen in multiple departments & settings (medical; dental; behavioral health)
    • Audio Advisor
      • Unannounced Survey Process
      • Will someone accompany surveyor during tracers?
        • NOT REQUIRED
        • BENEFITS
          • Ears/eyes: Patient’s first; don’t interrupt
          • patient care
          • Assist
            • Time keeper
            • Maintains and obtains documents requested by
            • surveyor (i.e., policies; HR files)
          • Continuity for organization
    • Audio Advisor
      • Unannounced Survey Process
      • Again, goals are:
        • Helping you get ready for next patient
        • Helping you provide the safest and highest quality of care possible
      • How do we do this:
        • We observe ‘how’ you do the things you say you are going to do.
        • Healthcare biggest team sport
        • Observe how you communicate with each other & how you work together as a team for the patient (patient-centric)
    • Audio Advisor
      • Unannounced Survey Process
      • For A Successful Survey Experience:
        • Schedule mock unannounced survey(s)
        • Plan ‘mock’ during busy, not slow times
        • Utilize ‘patient tracer’ method
        • Non-punitive, ‘no fault’ attitude encouraged
        • Urge staff to poke around and ask questions
        • Delegate to and engage all staff:
          • Reception
          • Administration
          • RNs
          • MDs
        • Goal is to demonstrate:
      • “ The things you’re proud of and things you’re trying to improve.”
    • Audio Advisor
      • Unannounced Survey Process
      • Suggested documents to have accessible
      • “ day-one” Unannounced Survey:
      • Performance improvement & infection control data
      • Environment of Care plans & meeting minutes / Statement of Conditions (if applicable)
      • Leadership meeting minutes
      • Organizational chart
      • List of departments and staff members
      • List of available patients to support “patient tracer” survey activities
    • Audio Advisor
      • Your Turn!
      • We’re Ready to Respond to Your Questions
      • Other Sources:
      • “ Will You Be Ready for JCAHO’s Unannounced Surveys in 2006?”   OR Manager , July 2005
      •  “ Accreditation: Live It, Learn It, Love It.” Outpatient Surgery Magazine, Feb. 2006
      • “ JCAHO survey helps Florida center identify ways to improve,” Briefings on Ambulatory Accreditation, April 2006
      • JCR Resources (
      •  “ Continuous PPR: Management Tool,” The Source, April 2005
      • “ Using the PPR Effectively in Unannounced Process,” The Source , Nov. 2005
      •  “ Unannounced Survey Process:  Maintaining Continuous Compliance,” The Source , Nov. 2005
      • “ Accreditation Essentials,” 2-Day Education Programs: Call (toll free) – 877.223.6866
    • Audio Advisor
      • If You’re Interested in Achieving Ambulatory or Office-Based Surgery Accreditation
      • We’re Eager to Hear From You!
      • Michael Kulczycki, Executive Director
      • P. 630.792.5290 /
      • Mike Dye, Associate Director
      • P. 630.792.5259 /
      • For Questions Regarding Unannounced Survey Process or
      • Periodic Performance Review Call Your Account Representative:
      • P. 630.792.3007