Family Health Centers of Baltimore

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Family Health Centers of Baltimore

• The Journey
• to Joint Commission Accreditation

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Presentation Objective

• To review one health centers experience in
  attaining Joint Commission accreditation.
• the planning,
• the challenges,
• the barriers, and
• the successes.
• -

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FHCB History

• Incorporated 1977 in Cherry Hill.
• 1978 Began as S. Balto Family Health Centers
• 1993 Opened 17,703 sq. ft Cherry Hill clinic
• 1995 Added Brooklyn satellite site
• 1998 Built Behavioral Health wing
• 2001 Added Calvert Street Hanover St clinics
• 2002 Changed name to Family Health Centers of
  Baltimore
• May 2005 Added OBGYN practice in the Mercy
  professional office building (POB)

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Family Health Centers of Baltimore Locations

• One Stop Shop at
  Cherry Hill Road
• FHCB at Brooklyn
  4133 Ritchie Highway
• Mead Building
  315 N. Calvert Street
• FHCB OBGYN
  at Mercy Hospital

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Cherry Hill Road Headquarters
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Family Health Centers Of Baltimore

• Urban Health Center 2007 UDS Statistics
• Number of Users 16,960
• Number medical 15,729
• Number Dental 2,843
• Provider FTEs - 13
• Payer Mix
• Medicaid 55
• Medicare 5
• Uninsured 11
• Private 30

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Executive Team
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FHCB Accreditation Leaders

• CEO leadership commitment coach and overseer
• CMO lead providers, and Quality Council,
  assess progress
• CFO information management
• Clinical Services Administrator lead nurse,
  compliance officer, standards expert
• Practice Managers monitor daily adherence to
  all standards
• Providers medication management, patient care
  and education
• Nursing Staff Daily adherence to quality
  controls
• Human Resources Director trainer, credentials
  management

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Ambulatory Care StandardsPCER, from a different
perspective

• Ethics, Rights and Responsibilities (RI)
• Provision of Care, Treatment, and Services (PC)
• Medication Management (MM)
• Surveillance, Prevention, and Control of
  Infection (IC)
• Improving Organizational Performance (PI)
• Leadership (LD)
• Environment of Care (EC)
• Human Resources ( HR)
• Management of Information ( IM)
• National Patient Safety Goals

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Why Joint Commission Accreditation

• Become a Well Oiled Machine
• Enhance competitive edge in the market place
• Reinforce our commitment to patient care quality
• Enhance sustainability efficiencies
• Transform the FHCB culture to a performance
  improvement culture

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PLANNING

• The Approachconcentrate on patient care
  processes, not just the on-site survey process
• A New business model integrating Joint
  Commission standards in how FHCB does business
• Examining FHCB organizational systems
• Shift work from survey preparation to systems
  improvement
• Emphasize issues most relevant to the FHCB
• Determine best practices and processes
• Integrate performance Improvement in problem
  solving
• Self Assessment conducted to develop baseline

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PLANNING

• FHCB began the journey many years ago..
• Get buy-in from leadership
• Train staff to shift the culture
• Hire/re-deploy staff to support culture shifts
• Assess Joint Commission standards at functional
  levels
• Teach compliance awareness, and how to work
  toward an agreed end
• Plan strategically
• Prepare a realistic budget

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PLANNING

• Resources Partners
• Dont Reinvent the Wheel
• NACHC Conference Offerings
• Joint Commission Training Website
• HRSA/BPHC the Collaborative Process (adopted the
  model for improvement), Leadership
• CAMAC
• Webcasts
• Mock Survey Findings
• Colleagues/Other FQHCs/Hospital
  Partner/Consultants

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CHALLENGES

• Creating Opportunities for Training
• Use existing staff meetings site and discipline
• FHCB Performance Improvement Tool Kit
• Pretest and post-test
• Environment of Care- outside experts (Fire
  Department)
• Mock Tracers

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CHALLENGES

• HRSA Contract Process Delay
• Staff Turn-Over
• Staying In Compliance
• Provider Training vs Clinical Productivity
• Resistance To Change

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MEET YOUR CHALLENGES

• Appoint Manager to function as project manager
• Establish task force with members from each site
  to correct operational problems and review
  policies and procedures.
• Finalize plans, set priorities, establish time
  lines
• Develop training program for providers and staff
• Re-evaluate deployment of staff
• Update Policies /Procedures manual (plagiarize)
• Consider off site storage

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BARRIERS

• Budget
• Facility repairs
• Facility maintenance
• Medical Equipment replacement
• Medical record off-site storage
• Other storage
• Consultant expenses
• Staff Time away from clinic provider buy-in and
  participation, all-staff meetings, quality
  improvement staff leaders

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Our On Site Survey
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Four month track record..

• Determine eligible services substance abuse was
  in and then out due to number of constant
  patients.
• Length of the survey website lets you know
• Review data, evidence of continuous improvement
  and standards compliance.
• Conduct dress rehearsal

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Survey Day

• Advantages of being close to Rockville
• Pull down credentials and background of your
  surveyors from the website.
• Confirm board member participation at entrance
  and governance sessions
• Prepare name plates for entrance participants.

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Survey Day

• Make sure staff feel confident and ready to speak
  with surveyors.
• Have coffee and set a calm atmosphere
• Make introductions and initiate discussion at the
  entrance interview, and relax.
• Give the board president opportunity to speak
• Be a very good listener.
• Ask for clarification and ask lots of questions.
• Relax, its gonna be all right!!!

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The FHCB Tracer WHAT WE DID

• Observation of direct patient care
• Performance improvement data discussion with staff

• Staff interviews related to dental patient.
• Review of policies
• Provision of health education

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Survey team leaves the accreditation
decision report with you
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SUCESSES

• Staff were self confident and exhibited real time
  work
• Managers did a great job answering questions
• Surveyors like the fact that staff were willing
  to learn and asked questions along the way
• Board commitment and leadership were evident, and
  acknowledged by the surveyors
• On day two, the surveyors were pretty much doing
  their own thing, and staff went about their daily
  routine.
• Exit Conference details on findings and
  instructions on follow-up.
• FHCB had 4 follow-up items.
• FHCB became accredited on April 21, 2008

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FHCB Survey Follow-Up

• Measures of Success Data due 8/21/08
• Patient education check and document that the
  patient understands what took place during the
  visit.
• Verbalize and document Time Out Policy for dental
  and other surgical procedures
• Give copy of medication list to patient at each
  visit
• Utility management policy needs to be specific
  about procedures during outage.

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The journey has just begun!