Joint Commissions Ambulatory Audio Advisor

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Joint Commissions 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

• Todays 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 Advisor

• We 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 Advisor

• Continuous Readiness
• Next Evolution in Joint Commissions
  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 Advisor

• A 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 Advisor

• Unannounced 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 (lt1,500 cases annually)
• 5-day pre-survey notification provided

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Audio Advisor

• Unannounced 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 Advisor

• Unannounced 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 Process
• Re-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 Advisor

• Unannounced 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-Ws learned in school)
• Seek Help
• FAQ Great resource (National Patient Safety
  Goals Standards)
• SIG Standards Interpretation Group _at_ 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
• Whats acceptable whats 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 Advisor

• Unannounced Survey Process
• The on-site survey
• One step in a continuous process
• Surveyors hired by you!
• - Theyre 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
• Checklist
• Who will surveyors meet first? What does this
  person need to know?
• List of people to call backup list
• Security issues Surveyors cant 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 Advisor

• Unannounced 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 Patients first dont 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 Advisor

• Unannounced 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 youre proud of and things youre
  trying to improve.

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Audio Advisor

• Unannounced 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 Advisor

• Your Turn!
• Were Ready to Respond to Your Questions
• Other Sources
• Will You Be Ready for JCAHOs 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 2006
• JCR 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 Youre Interested in Achieving Ambulatory or
  Office-Based Surgery Accreditation
• Were Eager to Hear From You!
• Michael Kulczycki, Executive Director
• P. 630.792.5290 / mkulczycki_at_jcaho.org
• Mike Dye, Associate Director
• P. 630.792.5259 / mdye_at_jcaho.org
• For Questions Regarding Unannounced Survey
  Process or
• Periodic Performance Review Call Your Account
  Representative
• P. 630.792.3007