strategies for a successful first asc survey experience ......2020/01/28 · strategies for a...
TRANSCRIPT
Strategies for a Successful First ASC Survey Experience: Lessons Learned from a Joint Commission Surveyor
Pamela Roark, RN, Ambulatory Care SurveyorMike Dye, MPH, Sr. Business Development Specialist,
Ambulatory Care Services
January 28, 2020
2© 2019 The Joint Commission. All Rights Reserved.
Listen in through computer audio.
Headset recommended.
Type your questions or just
say hello here.
Select Phone Call to see the number to call,
Access Code and PIN
or
Participating in today’s callAttendee Control Panel
3© 2019 The Joint Commission. All Rights Reserved.
The Joint Commission Disclaimer− These slides are current as of January, 2020. The Joint Commission and the original
presenter reserve the right to change or update the content of the information, as appropriate.
− These will only be available until January, 2021. At that point The Joint Commission reserves the right to review and retire content that is not current, has been made redundant, or has technical issues.
− These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards, their interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
− These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter and The Department of Field Staff Education and Development.
4© 2019 The Joint Commission. All Rights Reserved.
Joint Commission Mission
To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
5© 2019 The Joint Commission. All Rights Reserved.
The Joint Commission:Four Entities – One Vision
All people always experience the
•SAFEST
•HIGHEST QUALITY
•BEST-VALUE
Health care across all settings
6© 2019 The Joint Commission. All Rights Reserved.
Our Principle = Zero HarmZero falls Zero complications of care Zero infections Zero missed opportunitiesZero overuseZero lost revenue
Zero harm events of any kind
Strategies for Success:ASC Survey Preparation
8© 2019 The Joint Commission. All Rights Reserved.
Strategies for SuccessOur Goals:– Conduct a meaningful assessment– Inspire your organization to improve– Provide new information/sharing best
practices– Collaborative/collegial approach– Transparency; communicate findings
throughout the survey
9© 2019 The Joint Commission. All Rights Reserved.
Strategies for Success
− Continuous Survey Readiness!− Regular meeting agenda item =
accreditation− Involve everyone – “Spread the Wealth”− Assign E-dition chapters
10© 2019 The Joint Commission. All Rights Reserved.
Strategies for Success
− Surveyor Activity Guide− “Ready-to-Go” List− Review E-dition− Applicability Grid− Mock Tracers− Resources and Tools Intranet and Extranet− On-Site Survey Activities
11© 2019 The Joint Commission. All Rights Reserved.
Survey Activity Guide (SAG)
Available on your Joint Commission Connect extranet website - includes:
− Survey Activity Guide (SAG)− Preparing for surveyor arrival− Survey document list − Survey activities− What happens after survey?
12© 2019 The Joint Commission. All Rights Reserved.
Survey Activity Guide
13© 2019 The Joint Commission. All Rights Reserved.
Survey Document List− “Ready-to-Go” List− Organize key documents
in a binder− Continuously update
binder – always be “Survey Ready!”
14© 2019 The Joint Commission. All Rights Reserved.
E-dition: On-Line Standards Manual
15© 2019 The Joint Commission. All Rights Reserved.
E-dition (cont.)
− Review the Standards and Elements of Performance
16© 2019 The Joint Commission. All Rights Reserved.
Ambulatory Care Standards Format
17© 2019 The Joint Commission. All Rights Reserved.
Required Written Documentation (RWD)
18© 2019 The Joint Commission. All Rights Reserved.
Applicability Grid
19© 2019 The Joint Commission. All Rights Reserved.
Mock Tracers− Staff member acts as “Surveyor”− Trace patient from admission to discharge− Put yourself in patient’s shoes− Assess compliance with the standards
and Elements of Performance− Sample “mock tracer” tools available
20© 2019 The Joint Commission. All Rights Reserved.
Free Tools and ResourcesJoint Commission Website
21© 2019 The Joint Commission. All Rights Reserved.
Free Tools and Resources (cont.)Joint Commission Connect
22© 2019 The Joint Commission. All Rights Reserved.
Free Tools and Resources (cont.)− Perspectives official monthly
communication− Environment of Care News− Targeted Solution Tools (TSTs)− Frequently Asked Questions (FAQs)− Standards Interpretation Group (SIG)
on-line question submission− AmBuzz ambulatory care blog
23© 2019 The Joint Commission. All Rights Reserved.
Center for Transforming Healthcare (CTH)
• Hand Hygiene• Wrong Site Surgery• Hand-Off
Communications• Preventing Falls• Surgical Site Infections• VTE Prevention
24© 2019 The Joint Commission. All Rights Reserved.
When You Have Questions…− “Call a friend!”
− Accreditation process? Your Account Executive P.(630) 792-3700
− Standards? Connect with Standards
Interpretation Group (SIG)
Strategies for SuccessOnsite Survey Activities
26© 2019 The Joint Commission. All Rights Reserved.
Accessing Your Survey Information− To access information about your survey, proceed to your
Joint Commission extranet site by accessing www.jointcommission.org Click on Login, then Joint Commission Connect under the
Action Center section Enter your login and password
− Notification of scheduled Joint Commission event authorizing the presence of the surveyors for the unannounced survey
− Surveyor(s) name, picture and biographical sketch− Scheduled survey dates− Survey agenda
27© 2019 The Joint Commission. All Rights Reserved.
Accessing Your Survey Information
28© 2019 The Joint Commission. All Rights Reserved.
Getting the Most Value From Your Survey
− Be prepared− Have your files and documents well
organized− Schedule several patient visits so the
surveyor can conduct tracers − Encourage all stakeholders (including
physicians) to be active participants
29© 2019 The Joint Commission. All Rights Reserved.
Three Things Successful Surveys Have in Common
− Engaged leaders who foster teamwork and value the opportunity to learn and improve
− Staff who take ownership for patient safety and quality and feel empowered to make changes
− An organization that "owns" its processes, good or bad
30© 2019 The Joint Commission. All Rights Reserved.
Hints During the Survey
− It’s OK not to know the answer− Avoid the ventriloquist act, let everyone be involved− Please ask questions!− We are reviewing systems, not individuals− Use your surveyor as a resource
31© 2019 The Joint Commission. All Rights Reserved.
Hints During the Survey
− The agenda is flexible, if changes are needed, please ask− We’ll notice things you’ve never seen− Time will go by very quickly− If we ask for documents, please provide them as soon as
possible− You will have an “Aha!” Joint Commission moment
32© 2019 The Joint Commission. All Rights Reserved.
Individual Patient Tracer
− Pre-operative information/communication− Patient reception and intake process− Pre-procedural assessment− Intra-operative processes− Post-procedure monitoring− Emergency procedures− Room and equipment turnover− Patient discharge from facility− Patient follow up
33© 2019 The Joint Commission. All Rights Reserved.
Individual Patient TracerMay Engage:
− Patient− Family− Physician− Nursing− Support staff− Vendors− Contractors− Anyone!
34© 2019 The Joint Commission. All Rights Reserved.
System Tracers− Data Management− Infection Prevention− Medication Management− Leadership− Environment of Care/Emergency Management− Life Safety Code− Competency Assessment− Credentialing and Privileging
Strategies for SuccessAfter the Survey
36© 2019 The Joint Commission. All Rights Reserved.
After the Survey− SAFER Matrix− Preliminary Report− Final Report− Evidence of Standards Compliance (ESC)− Final Accreditation Determination
37© 2019 The Joint Commission. All Rights Reserved.
Survey Analysis for Evaluating Risk (SAFER) Matrix
38© 2019 The Joint Commission. All Rights Reserved.
SAFER Matrix Details
39© 2019 The Joint Commission. All Rights Reserved.
SAFER Matrix: Follow-up Activity
40© 2019 The Joint Commission. All Rights Reserved.
Post Survey Process− Summary of Survey Findings Report will not include
potential accreditation decision− Official survey report posted on organization’s extranet
site post-survey will include the potential accreditation decision
− Survey reports will be posted within 5 to 7 business days after survey unless report requires central office review
− Final accreditation decision will be made after Joint Commission receives and approves Evidence of Standards Compliance (ESC)
41© 2019 The Joint Commission. All Rights Reserved.
Clarification Submission− Clarification process used when organization believes it
was actually in compliance with applicable standard at time of survey and thus should not have been cited as noncompliant.
− Within 10 business days after final report posted to Joint Commission Connect extranet site
− Findings of “lack of required documentation at time of survey” are not eligible for clarification process
− Complete all elements of submission tool
42© 2019 The Joint Commission. All Rights Reserved.
Accreditation− Upon approval of all required ESC submissions− Length of time to receive accreditation determined by
when ESC submitted
43© 2019 The Joint Commission. All Rights Reserved.
2019 Most Challenging Ambulatory Care Standards
44© 2019 The Joint Commission. All Rights Reserved.
Most Challenging Ambulatory Care Standards
− Top 10 Most Challenging Standards− Infection Control− Life Safety− Environment of Care− Human Resources− Medication
Management
45© 2019 The Joint Commission. All Rights Reserved.
High Level Disinfection and Sterilization Scoring 4-1-1 on Survey Enhancements
47© 2019 The Joint Commission. All Rights Reserved.
Hierarchical Approach to IC Standards− Regulation− Centers for Medicare & Medicaid Services (CMS) if
deemed− Instructions for Use− Evidence-Based Guidelines or National Standards− Position Statements − Facility Policy
48© 2019 The Joint Commission. All Rights Reserved.
Hierarchical Approach to IC Standards
49© 2019 The Joint Commission. All Rights Reserved.