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