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It’s Only Accreditation, It’s Only Accreditation, ….and I LIKE It! ….and I LIKE It!

Presented by:Michael Kulczycki, MBAExecutive Director

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Ambulatory Care Accreditation Program

Includes Panelist:Jordan Firestone, MD, PhD, MPH Medical DirectorNASA Ames Research Center – Health Unit

04.28.14

Financial disclosure

Neither speaker has a financial relationship with the provider of service (The Joint Commission) beyond being an employee and a customer.an employee and a customer.

Outcomes – Your Partnership with The Joint Commission

Know “today’s” Joint Commission

Prepare for accreditation as evaluation of your center’s quality

Appreciate how Patient Tracers focusAppreciate how Patient Tracers focus your staff on patient safety & quality

Learn from one customer’s experience

Tips for success…rely on customer service resources of Joint Commission

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Private, not-for-profit organization created & governed by health care professionals (physicians, nurses, administrators consumers)

Background on Joint Commission

administrators, consumers)

Accrediting Ambulatory Care providers since 1975

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Accredits across health care

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The Joint Commission ModelBackground:

– Not-for-profit organization

– Accredits nearly 20,700 health care organizations

Accrediting ambulatory care since 1975:Accrediting ambulatory care since 1975:– Wide variety of ambulatory settings

– AHC program now accredits over 2,080 organizations with 7,500 sites of care

– Includes variations of “Episodic Care”

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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 ‘intra-cycle’ self-assessment

– Focus on processes for ensuring worker (and staff) safety & quality

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Accreditation value

Credibility in local community:– Worker & family awareness– Referral sources

Enhances staff recruitment & retentionF t i tFocuses on systems improvementsNationally recognized…

“Gold Seal of Approval™”

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Others experience – accreditation value

Fosters a disciplined approach to continuous quality improvement

Guides organizational design & accountabilityy

Crystallizes communication about key components of delivery model for worksite health providers, such as "evidence-based medicine" and “leading practices”

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… accreditation value

Enhances cross-functional teamwork across all levels

Prompts documentation of proprietary processes & p p y poutcomes

Shapes the culture of work environment

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Study on Impact of Accreditation

Study = “Quality-Related Activities in Federally Supported Health Centers”

Research conducted by:– University of Illinois Survey Research Lab

Presented at June 2007 Academy of HealthPresented at June 2007 Academy of Health Annual Meeting

Published in peer-reviewed journal

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…Study Conclusions

Accreditation affected both content of improvement areas & frequency:– quality improvement projects, – training, and – competency verification

Accreditation shows “greater likelihood that centers have specific processes in place designed to improve the quality of care”

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Dispelling Joint Commission Myths…

Only for hospitalsOnly for hospitals– Program surveyors only evaluate

ambulatory customers– Account handled by Ambulatory-specific

account executive in Operations

Don’t understand ambulatoryDon’t understand ambulatory– Existing relationships with ACOEM,

UCAOA, CCA– Accredit range of “episodic” providers:

– Worksite/occupational health– Urgent Care– Convenient Care

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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 ambulatory center staff, includingMost ambulatory center staff, including physicians & advanced practice providers, engaged in onsite survey process

– Standards clearly indicate documentation requirements (language & icon )

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…Dispelling Myths

Standards not relevant to patient careStandards not relevant to patient care– Since 2009, final accreditation decision

focuses on “Direct Impact” areas (approx 25% of standards)

– Since 2004, patient-centered evaluation thru tracer process

– By 2015, offer “applicability grid” for worksite health centers

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Collaborate with customers

Input to Joint Commission strategic issues via Ambulatory Advisory Councils

ACOEM represents industry on standards advisory group

ACOEM member as Joint Commission Board member

Inviting input from worksite/occupational health experts on future “applicability grid”

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…Collaborate cont.Input to Ambulatory standards from

episodic care providers, eg:– American Academy of Physician Assistants

– American Association of Nurse Practitioners

– American College of Emergency Physicians

– American College of Occupational & Environmental MedicineEnvironmental Medicine

– American Occupational Therapy Association

– American Physical Therapy Association

– American Telemedicine Association

– Convenient Care Association

– Medical Group Management Association

– National Association for Ambulatory Care

– Urgent Care Association of America

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Ambulatory Care Standards are…

Statements defining the performance expectations, structures, or processes that must be in place for an organization to provide safe,an organization to provide safe, high quality care

Elements of performance = evidence of compliance

Together = A “blueprint” for evaluation

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…Ambulatory Care Standards…

Evaluation organized around 14 chapters, eg:– Provision of Care– Leadership– Performance Improvement

New editions released annually

Electronic version – E-dition –provides profile of standards unique to Episodic Care

Accreditation….is an ‘open book’ process

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…Standards in electronic format

E-dition contains “service profile” for standards applicable to:

M di l ti– Medical practices

– Urgent care

– Worksite health (2015)

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Standards Chapters

Centralized:– Leadership

– Human Resources

– Performance I t

Sites:– Provision of Care

– Infection Prevention

– Environment of CareImprovement

– Environment of Care (planning)

Not applicable:– Life Safety

– Transplant Safety

– Emergency Mgmt

– Information Mgmt

– Medication Management

– NPSGs

– Record of Care

– Waived Testing

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About Ambulatory surveyors…

AHC program consists of 55 surveyors dedicated to Ambulatory

AHC cadre consists of MD’s, RN’s, NP’s and Administrators with previous ambulatory/hospital experience

Clinical experience: surgery center administration, VA, podiatrist, surgeons, anesthesiologists, urgent care, community clinics, internal medicine, dentists, radiologists

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Outcomes – Your Partnership

Know “today’s” Joint Commission

Prepare for accreditation as evaluation of your center’s quality

Appreciate how Patient Tracers focusAppreciate how Patient Tracers focus your staff on patient safety & quality

Learn from one customer’s experience

Tips for success … rely on customer service resources of Joint Commission

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What Does a Survey Look Like? Onsite Survey – Built on Patient Tracers

Patient and Customer-Centric– Observation of and discussion with patient with permission

– Minimal interruption

Educational and InformativeEducational and Informative– Shared observations

– Staff/managers participate

Surveyors– Clinical & administrative professionals experienced in

ambulatory arena

– Collaborative and courteous

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On-site Survey ProcessAgenda works with centers normal

operational systems & schedules

Survey length driven by volume & sites:– < 10,000 = 1 surveyor, 2 days

– 10,000 > 20,000 = 1 surveyor, 3 days

– Additional days for multi-site centers

Few formal interviews– More attention to caregivers

– Focus on direct patient care

Tracer method allows customization:– Settings / Services / Patients

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Patient Tracer Method…

Accounts for nearly 2/3 of survey time

More focused on execution -- actual delivery of care / services

Engages front-line staff what they doEngages front-line staff…what they do, and why do they do it that way

Surveyor ‘connects the dots’ for your staff

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…Patient TracerTraces 3-4 patients through entire

process & facility

Use patient chart as “road map”

Identify performance issues in one or more steps of the process ormore steps of the process – or between processes

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

medication management

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Tracers include:

Observation of direct patient careObservation of medication process (storage,

dispensing or administration)Review of clinical records Staff questions and dialogueReview of Policies (only as needed)Review of Policies (only as needed) Education at various pointsObservation onsite related to: Infection control Environment of care National Patient Safety Goals

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Tracer interaction

Tell me about how you assess your patients?

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System Accreditation

Launched in 2006– 18 completed for AHC program– Multi-site providers = 2,300 total sites

Concept – award single accreditation p gdecision to systems with multiple sites

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Used by variety of providers

Medical group practices

Convenient care

Urgent care

Imaging centers

Vascular access providers

Freestanding emergency care

Mobile diagnostics Imaging centers

Kidney care

VA community outpatient clinics

g

Endoscopy centers

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….. System Features

Designed for regional & national firms

Entire system of multiple sites undergoes accreditation process in concentrated periodconcentrated period

System receives consolidated report of findings leading to 3-year accreditation

System receives accreditation certificate; each site receives certificate

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Outcomes – Your Partnership

Know “today’s” Joint Commission

Prepare for accreditation as evaluation of your center’s quality

Appreciate how Patient Tracers focusAppreciate how Patient Tracers focus your staff on patient safety & quality

Learn from one customer’s experience

Tips for success … rely on customer service resources of Joint Commission

Panelist –

About Ames Research Center75 yrs in Silicon Valley – Moffett Field, CA

Ames is 1 of 10 NASA field centers (~18 sites)

~4000 employees; annual budget >$930M

Ames leads NASA in conducting world-class es eads S co duc g o d c assR & D, with ongoing advancements in:

– Astrobiology & Astrophysics

– Earth Science & Biology

– Spacecraft entry systems

– NextGen air transportation

– Human factors

– Exoplanet discovery

– Supercomputing

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Ames Health Unit

Populations served:~ 1,500 Federal employees + ~2,500 contractors

>> 100,000 Moffett Field visitors per year

~ 3,200+ clinic visits per year

Scope of services:– Urgent/immediate care (Ambulance, MERT, PAD)

– Workers’ Compensation (Federal and State)

– Occupational health exams (FFD/surveillance)

– Health promotion and screening evaluations

– Consultant to Ames management on S&H policies

5.2 FTE staff (2 clinicians plus support)

20%

30%

50%

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Ames Health Unit

Commentary on Accreditation

Note: Not present for prior site visit in 8/2011

(three-year cycle)

Focused Standards Assessment

(mid cycle self assessment)(mid-cycle self-assessment)

Lessons learned + QI opportunities

(has paralleled JC priorities)

Comparison to federal oversight process

(NASA Office of Chief Health & Medical Officer)

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Outcomes – Your Partnership

Know “today’s” Joint Commission

Prepare for accreditation as evaluation of your center’s quality

Appreciate how Patient Tracers will focusAppreciate how Patient Tracers will focus your staff on patient safety & quality

Learn from one customer’s experience

Tips for success….rely on customer service resources of Joint Commission

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Application Process Application:

– Web-based ‘extranet’ platform

– Data submitted (volume, sites, services) drives survey lengthsurvey length & surveyor complement

– YOU designate ready date (initials only)

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Tips for Success…

Submit application 3-6 months in advance, with deposit

Select “ready date” & communicate closely with your account executive

U “R d t G ” li tUse “Ready to Go” list

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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”– Published list of challenging ambulatory standards in Perspectives

– Network with others (QualityCheck)

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…Tips for Success…Use E-dition electronic product to

organize your approach

Understand model for surveyors – how they engage with your center onsite

P b i “ k ”Prepare by using “mock surveys”

Preliminary, onsite report – at time of survey – outlines your immediate next steps to final accreditation decision

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2013 – Top 10 Survey Challenges

Top 10 from ambulatory surveys 2013

Prioritizes “challenges” for customers

Benchmarking opportunity!

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Joint Commission Surveyor “Tips”

It’s OK… not to know the answer, but know who does!

Surveyors are reviewing systems, not individuals

Please ask questions… survey should be interactive and educational

Surveyors will minimize disruptions to your delivery of patient care

Surveyors will notice things you have never seen

If changes are needed in your agenda, please ask

Time will go by very quickly

There are no surprises at the closing

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Resources for Customers…

Joint Commission ConnectTM

(Extranet)– Perspectives - Joint Commission’s

official monthly e-periodical– Leading Practice Library - real-life

solutions from accredited organizations– Targeted Solutions Tool

TM- helpsTargeted Solutions Tool helps

identify performance, barriers and customized solutions regarding persistent issues in the field

QualityCheck – Lists accredited organizations– Used by consumers & payers– www.qualitycheck.org

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… Resources…

Dedicated Customer Service Resources

− Account Executive in Operations

− Standards Interpretation Groupwww.jointcommission.org/standards

– FAQ’s, Online Form to Submit ?’s

or

– Call 630-792-5900, Option 6

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…Additional Resources

Survey Activity Guide– Document List or “Ready-

to-Go List” – helps your organization and the survey team– Organization chart

– Environment of Care plans & annual evaluations

– Infection Control plan & goals

– List of services provided/ locations

– List of contracted services

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Features of Joint Commission Accreditation

Accredited

Focused Standards Assessment (mid-cycle)

On-site Evaluation StandardsInterpretationEducation

Operational Toolsfor Good Management

Risk Reduction Process

State-of-the ArtStandards

Accredited Ambulatory Care

Organization

Patient Tracers

ExperiencedAmbulatorySurveyors

Customer AccountExecutive

Lessons Learned: Leading Practices

Library

ElectronicManual

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Contact

Michael Kulczycki, Executive Director, Ambulatory Care Accreditation ProgramAccreditation Program, The Joint Commission

–630.792.5290

–mkulczycki@jointcommission.org

–www.jointcommission.org/AHC

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Appendix: Additional Considerations

Accreditation “value adds” beyond survey evaluation:– Leading Practice Library

T t d S l ti T l– Targeted Solutions Tools

– Value-Add to Accreditation – Financial Incentives from Liability Providers (unless self-funded)

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Leading Practices LibraryLaunched as web-based

service, free to customers

Offers customer-generated “library”:

– Sample policiesP ti t ti f ti– Patient satisfaction survey

– Safety risk assessment

Sorted by program or by standards chapters

Share your own leading practices with others

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Library is web-based resource

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New ‘value adds’ for Joint Commission customers

Center for Transforming Healthcare

www.centerfortransforminghealthcare.org

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See Quality Progress, July 2009, via link (registration

5353

required): http://bit.ly/gLOaYT

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Applying Robust Process Improvement Methods

Developing solutions

– Through application of same Robust Process Improvement™ (RPI) methods and tools that other industriesmethods and tools that other industries rely on to improve quality and safety

– Share solutions with customers – as part of accreditation package of services – in toolkits

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First solution on hand hygiene

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Improvement Projects

Hand Hygiene– TST launched 2010

Hand-Off Communications– TST launch 2011

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Hand-Off CommunicationsDetails at:

– http://bit.ly/CTH_HandOff

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Value-Add: Liability Providers

Liability providers “vetted” by Joint Commission

10 firms currently serve Ambulatory market

http://bit.ly/TJC_Liability

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Value-Add: Liability Providers

Insurers are listed based upon indicating that a financial consideration related to Joint Commission accreditation is applied whenaccreditation is applied when determining liability coverage

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