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msfhfag Presentation Transcript

  • 1. 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.
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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!
  • 8. 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
  • 9. 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
  • 10. 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.”
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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!
  • 16. 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)
  • 17. 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
  • 18. 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)
  • 19. 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.”
  • 20. 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
  • 21. 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 (www.jcrinc.com):
    •  “ 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
  • 22. 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 / mkulczycki@jcaho.org
    • Mike Dye, Associate Director
    • P. 630.792.5259 / mdye@jcaho.org
    • For Questions Regarding Unannounced Survey Process or
    • Periodic Performance Review Call Your Account Representative:
    • P. 630.792.3007