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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.

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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

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Audio AdvisorWe 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

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Audio AdvisorContinuous 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

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Audio AdvisorA 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

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Audio AdvisorUnannounced 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

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Audio AdvisorUnannounced 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!

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Audio AdvisorUnannounced 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

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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

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Audio Advisor

Unannounced Survey ProcessRe-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.”

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Audio AdvisorUnannounced 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

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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

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Audio AdvisorUnannounced 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

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Audio Advisor

Unannounced Survey Process

Have game plan for first hour of the survey:ChecklistWho 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

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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!

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Audio AdvisorUnannounced 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)

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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

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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)

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Audio AdvisorUnannounced 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.”

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Audio AdvisorUnannounced 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

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Audio AdvisorYour 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 2006JCR 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

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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