1 The Accreditation Process Part 2: Before, During, After and
Between the Surveys
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2 Speaker Information Mark E. Schario, MS, RN, FACHE Field
Director Accreditation and Certification Operations The Joint
Commission
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3 BEFORE THE SURVEY
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4 Eligibility for Preliminary Accreditation The Early Survey
Policy is available to any organization that is currently not
accredited, except an organization that has been denied
accreditation. An organization must declare during the application
process that it wishes to be surveyed under this policy. The First
Survey When an organization chooses to be surveyed under the Early
Survey Policy, The Joint Commission conducts two on-site surveys,
both of which will be announced, unless the organization is using
accreditation to meet deemed status purposes. The Joint Commission
can conduct the first survey as early as two months before the
organization begins its operations, provided that the organization
meets the following criteria: It is licensed, or, has a provisional
license according to applicable law and regulation.
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5 Eligibility for Preliminary Accreditation (Continued) The
building in which the services will be offered or from which the
services will be coordinated is identified, constructed, and
equipped to support such services; It has identified its CEO or
administrator, its director of clinical or medical services, and
its nurse executive, if applicable; It has identified the date it
will begin operations. Generally, the first survey uses a limited
set of standards and assesses only the organizations physical
facilities, policies and procedures, plans, and related structural
considerations. For this reason, organizations surveyed under this
policy are not recognized by CMS to meet the requirements for
Medicare certification.
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6 Eligibility for Preliminary Accreditation (Continued)
Preliminary Accreditation Decision The Joint Commission grants
Preliminary Accreditation to an organization that is in
satisfactory compliance with a limited set of the standards and
their EPs assessed in the first survey (See the Early Survey Policy
Option chapter). An organization that is not in satisfactory
compliance must reapply and begin the accreditation process again.
The Preliminary Accreditation decision includes assignment of an
additional announced survey against the full set of applicable
standards within six months of the first survey. (Note: The survey
will be unannounced for organizations seeking to meet CMS deemed
status requirements.) The survey assesses the organizations
compliance with all applicable EPs.
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7 Eligibility for Preliminary Accreditation (Continued) For an
organization that has begun its operations when the survey is
conducted, if it does not receive any RFIs, the effective date for
its Preliminary Accreditation decision is the day after the survey
is conducted. If the organization receives at least one RFI and
therefore must submit an acceptable ESC report that resolves all
RFIs, the effective date for Preliminary Accreditation is the date
of the acceptable ESC submission. For an organization not in
operation at the time of the survey, if it does not receive any
RFIs, the effective date for its Preliminary Accreditation decision
is the day after it begins its operations. If the organization
receives at least one RFI and therefore must submit an acceptable
ESC report that resolves all RFIs, the effective date for
Preliminary Accreditation is the date of the acceptable ESC
submission. (Note: Any organization not in operation at the time of
survey must confirm in writing the date it begins operating.)
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8 Eligibility for Preliminary Accreditation (Continued) A
Preliminary Accreditation decision remains in effect until the
organization has completed a second, full survey or until The Joint
Commission has withdrawn the Preliminary Accreditation.
Organizations may stay in Preliminary Accreditation for one year.
The Joint Commission may withdraw Preliminary Accreditation in the
following situations: If an organization that was not providing
services at the time of the first survey does not begin providing
services when expected If an organization does not meet the survey
eligibility criteria If an organization fails to accept the date of
the second survey and If an organization is found to be not in
satisfactory compliance with the applicable standards and their EPs
In any of these cases, the organization must begin the
accreditation process again.
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9 Eligibility for Preliminary Accreditation (Continued) The
Second Survey The second survey under the Early Survey Policy is an
announced full accreditation survey. (Note: The second survey will
be unannounced for organizations seeking to meet CMS deemed status
requirements.) The Joint Commission conducts this survey at either
of the following times: Approximately six months after the first
survey At a time frame selected by the organization within six
months of the acceptance of its first ESC for organizations seeking
to meet CMS deemed status requirements Based on survey results, the
organizations accreditation decision then changes to one of the
following: Accredited Accreditation with Follow-up Survey
Contingent Accreditation Preliminary Denial of Accreditation Denial
of Accreditation (See Accreditation Decision Categories on page
ACC-64 for descriptions of these decisions in the CAMH)
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10 Eligibility for Preliminary Accreditation (Continued) The
effective date of the accreditation decision is the day after the
second survey if the organization does not receive any RFIs. If the
organization receives at least one RFI and therefore must submit an
acceptable ESC report that resolves all RFIs, the effective date
for Preliminary Accreditation is then set retroactively to the date
of the acceptable ESC submission. The organizations accreditation
cycle begins the day after the second survey was conducted, unless
The Joint Commission reached a decision to deny accreditation.
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11 Electronic Application for Accreditation When an
organization notifies The Joint Commission that it wants to become
accredited, The Joint Commission provides the organization with
information explaining how to access and complete the E-App on the
organizations secure Joint Commission Connect site. Initial
applications are valid for one year. An organization needs to
complete and submit its E-App upon initial application for survey,
and will be asked to verify the information annually. An
organization can provide updates to the E-App at any time, as it
can access the E-App 24 hours a day, 7 days a week. (See Changes
Affecting E-App Information on page ACC-85 in the CAMH)
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12 Accuracy of the Application Information The Joint Commission
schedules surveys based on information provided in an organizations
E-App. Based on the information provided, The Joint Commission
determines the number of days required for a survey and the number
and type of surveyors. Inaccurate or incomplete information in the
E-App may necessitate an additional survey, which could delay the
processing of survey findings and rendering of an accreditation
decision. It may also cause the organization to incur additional
survey charges.
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13 Accreditation Contract and Business Associate Agreement
Organizations seeking Joint Commission accreditation for the first
time or reaccreditation with The Joint Commission must submit a
signed accreditation contract and a signed Business Associate
Agreement. The contract outlines the responsibilities of both the
organization and The Joint Commission relative to the accreditation
process. This contract is separate from the E-App. Contracts are
available for printing and approval via each organizations secure
Joint Commission Connect site. Governmental organizations may enter
into unique contracts with The Joint Commission in accordance with
the scope of services available from The Joint Commission and the
laws for contracting that bind that government entity.
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14 Priority Focus Process (PFP) An important component of the
Joint Commissions accreditation process is the PFP, which guides
the surveyor(s) in planning and conducting the on-site survey. It
focuses survey activities on the organization-specific issues that
are most relevant to safety and quality of care (referred to as
priority focus areas or PFAs). PFP can be considered a process for
standardizing the PFAs for review during survey. PFP uses an
automated tool, which takes available data from a variety of
sourcesincluding the E-App, previous survey findings, complaint
data, and publicly available external dataand integrates them to
identify clinical/service groups (CSGs) and PFAs for the hospital.
PFP converts these data into information that focuses survey
activities, increases consistency in the accreditation process,
customizes the accreditation process to make it specific to a given
hospital, guides tracer activities (see Tracer Methodology on page
ACC-50 in the CAMH)
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15 Priority Focus Process (PFP) (Continued) Each hospital will
receive PFP information for its top PFAs and CSGs on its Joint
Commission Connect site. Complex organizations that are surveyed
under more than one accreditation program will receive
accreditation program-specific PFP information and
organization-level PFP information that summarizes all
accreditation programs data and information. From these sources,
the PFP identifies for each hospital the PFAs on which the
surveyor(s) will focus during the initial part of the on-site
survey. The surveyor(s) will use the PFP in the following ways: The
surveyor(s) assigned to the hospital will have access to the
hospitals PFP information via the surveyor extranet. The
surveyor(s) will review the PFP information for hospital-specific
PFAs as well as for hospital-specific CSGs. As part of the survey
planning process, the surveyor(s) will begin to assess and plan his
or her tracer activities.
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16 Priority Focus Process (PFP) (Continued) During the on-site
survey, the surveyor(s) will use the hospitals active patient list
to select tracer patients. As the survey progresses, the
surveyor(s) may find other priority areas that need to be addressed
and may begin to focus less on the PFP suggested list and more on
what he or she is finding. The PFP will also be used for a hospital
undergoing its initial survey. For initial surveys, The Joint
Commission will only be able to feed E-App data, external data (as
applicable), and Office of Quality Monitoring data (as applicable)
into the PFP.
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17 Priority Focus Process (PFP) (Continued) After these data
are transformed to become the PFP information, the process for
initial surveys is no different from the process for any other type
of survey. The data will be aggregated in the same manner to
determine the PFAs and CSGs for the hospital. PFP data are updated
quarterly, as changes warrant. (Note: Organizations will receive an
updated report only if there is a change to one or more PFAs and/or
CSGs in their programs since the previous PFP Summary Report. Due
to the systems nature of the PFAs and CSGs, it is possible that
there may not be a change from one quarter to the next.) The PFP
Reports are shared with surveyors before the on-site survey to
focus the survey and can also be used by organizations to support
continuous performance improvement activities.
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18 Priority Focus Areas (PFAs) PFAs are processes, systems, or
structures in a health care organization that significantly impact
safety and/or the quality of care, treatment, and services
provided. The PFAs provide a consistent yet customized approach to
providing an initial focus for the on-site survey process, and they
may assist the health care organization at the time of its
PPR.
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19 Priority Focus Areas (PFAs) (Continued) PFAs guide the
surveyor with assessing standards compliance in relation to the
individual tracer activities. Outside formal
conferences/interviews, much of the survey will consist of
reviewing issues in the form of tracers. The tracer methodology
incorporates the use of the PFP information, follows the care,
treatment, or service experience for individuals initially
identified by CSGs, and allows the surveyor to identify performance
issues that may be related to PFAs for your organization (see
Tracer Methodology on page ACC- 50 in the CAMH). Definitions for
each of the PFA categories follow.
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20 Priority Focus Areas (PFAs) (Continued) Assessment &
Care/Services Assessment & Care/Services for patients comprise
the execution of a series of processes that are fluid in nature to
accommodate needs of patients including, as relevant, screening;
assessment; planning care, treatment, and/or services; provision of
care; ongoing reassessment of care; and discharge planning,
referral for continuing care, or discontinuation of services.
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21 Priority Focus Areas (PFAs) (Continued) Successful
implementation of improvements in Assessment & Care/Services
relies on the full support of leadership. Subprocesses of
Assessment & Care/Services include the following: Screening
Assessment Planning care, treatment, or services Provision of care,
treatment, or services Reassessment Discharge planning or
discontinuation of services
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22 Priority Focus Areas (PFAs) (Continued) Communication
Communication is the process by which information is exchanged
between individuals, programs/services, or organizations. Effective
Communication successfully permeates every aspect of a health care
organization, from the provision of care, treatment, and services
to performance improvement, resulting in a marked improvement in
the quality of care delivery and functioning. Subprocesses of
Communication include the following: Provider and/or staffpatient
communication Patient and family education Staff communication and
collaboration Information dissemination Multidisciplinary
teamwork
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23 Priority Focus Areas (PFAs) (Continued) Credentialed
Practitioners Credentialed Practitioners are health care
professionals whose qualifications to provide care, treatment, and
services have been verified and assessed, resulting in the
assignment of clinical responsibilities. The Credentialed
Practitioners category varies from organization to organization and
from state to state. It includes licensed independent practitioners
and others who are permitted to provide care, treatment, and
services to patients under the direction of a sponsoring physician.
Licensed independent practitioners are permitted by law and the
health care organization to provide care, treatment, and services
without clinical supervision or direction within the scope of their
license and consistent with individually assigned clinical
responsibilities or individually granted privileges.
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24 Priority Focus Areas (PFAs) (Continued) Equipment Use
Equipment Use incorporates the selection, delivery, setup, and
maintenance of equipment and supplies to meet the needs of patients
and staff. It generally includes movable equipment, as well as
management of supplies that staff members use (for example, gloves,
syringes). (Equipment Use does not include fixed equipment such as
built-in oxygen and gas lines and central air conditioning systems;
such items are included in the Physical Environment PFA.) Equipment
Use includes planning and selecting; training and orientation;
maintaining, testing, and inspecting; educating and providing
instructions; delivery and setup; and risk prevention related to
equipment and/or supplies. Subprocesses of Equipment Use include
the following: Selection Maintenance strategies Periodic evaluation
Orientation and training
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25 Priority Focus Areas (PFAs) (Continued) Infection Control
Infection Control includes the prevention,
surveillance/identification, and control of infections among
patients, employees, physicians and other licensed independent
practitioners, contract service workers, volunteers, students, and
visitors. Infection Control is a systemwide, integrated process
that is applied to all programs, services, and settings.
Subprocesses of Infection Control include the following: Prevention
and control Surveillance/identification Reporting Measurement
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26 Priority Focus Areas (PFAs) (Continued) Information
Management Information Management is the interdisciplinary field
concerning the timely and accurate creation, collection, storage,
retrieval, transmission, analysis, control, dissemination, and use
of data or information, both within an organization and externally,
as allowed by law and regulation. In addition to written and verbal
information, supporting information technology and information
services are also included in Information Management. Subprocesses
of Information Management include the following: Planning
Procurement Implementation Collection Recording
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27 Priority Focus Areas (PFAs) (Continued) Subprocesses of
Information Management continued: Protection Aggregation
Interpretation Storage and retrieval Data integrity Information
dissemination
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28 Priority Focus Areas (PFAs) (Continued) Medication
Management Medication Management encompasses the systems and
processes used to provide medication to individuals served by the
organization. Usually a multidisciplinary, coordinated effort of
health care staff who implement, evaluate, and constantly improve
the processes of selecting, procuring, storing, ordering,
transcribing, preparing, dispensing, administering (including self-
administering), and monitoring the effects of medications
throughout the patients continuum of care. Medication Management
involves educating patients and, as appropriate, their families
about each medication, its administration and use, and potential
side effects.
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29 Priority Focus Areas (PFAs) (Continued) Subprocesses of
Medication Management include the following: Selection Procurement
Storage Prescribing or ordering Preparing Dispensing Administration
(including self-administration) Education Monitoring
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30 Priority Focus Areas (PFAs) (Continued) Organizational
Structure Organizational Structure is the framework for an
organization to carry out its vision and mission. Implementation is
accomplished through corporate bylaws and governing body policies,
organization management, compliance, planning, integration and
coordination, and performance improvement. Organizational Structure
includes the organizations governance, as well as business ethics,
contracted organizations, and management requirements. Subprocesses
of Organizational Structure include the following: Management
requirements Corporate bylaws and governing body plans Organization
management Compliance Planning Business ethics Contracted
services
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31 Priority Focus Areas (PFAs) (Continued) Orientation &
Training Orientation is the process of educating newly hired staff
in health care organizations to organization wide, department,
program, service, and job-specific competencies before they provide
care, treatment, or services to patients. Newly hired staff
includes, but is not limited to, regular staff employees,
contracted staff, agency (temporary) staff, float staff, volunteer
staff, students, housekeeping, and maintenance staff.
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32 Priority Focus Areas (PFAs) (Continued) Training refers to
the development and implementation of programs that foster staff
development and continued learning, address skill deficiencies, and
thereby help ensure staff retention. More specifically, training
entails providing opportunities for staff to develop enhanced
skills related to revised processes that may have been addressed
during orientation, new care techniques for patients, or expanded
job responsibilities. Whereas orientation is a one-time process,
training is a continuous one. Subprocesses of Orientation &
Training include the following: Organizationwide orientation
Program/service orientation Job-specific orientation Training and
continuing or ongoing education
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33 Priority Focus Areas (PFAs) (Continued) Patient Safety
Patient Safety entails a framework for proactively identifying the
potential and actual risks to safety, identifying the underlying
cause(s) of the potential or actual risk, and making the necessary
improvements to reduce risk. Also entails establishing processes to
respond to sentinel events, identifying risks through root cause
analysis, and making necessary improvements. Involves a
systems-based approach that examines all activities within an
organization that contribute to maintaining and improving patient
safety, including performance improvement and risk management, to
ensure that the activities work together, not independently, to
improve care and safety.
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34 Priority Focus Areas (PFAs) (Continued) This systems-based
approach is driven by organization leadership; anchored in the
organizations mission, vision, and strategic plan; endorsed and
actively supported by medical staff and nursing leadership;
implemented by directors; integrated and coordinated throughout the
organizations staff; and continuously re-engineered using proven,
proactive performance improvement modalities. Effective reduction
of errors and other factors that contribute to unintended adverse
outcomes in an organization requires an environment in which
patients, their families, and organization staff and leaders can
identify and manage actual and potential risks to safety.
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35 Priority Focus Areas (PFAs) (Continued) Subprocesses of
Patient Safety include the following: Planning and designing
services Directing services Integrating and coordinating services
Reducing and preventing errors Using Sentinel Event Alerts The
Joint Commissions National Patient Safety Goals Clinical practice
guidelines, if available Actively involving patients in their care,
treatment, or services
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36 Priority Focus Areas (PFAs) (Continued) Physical Environment
The Physical Environment refers to a safe, accessible, functional,
supportive, and effective physical environment for patients, staff
members, workers, and others. This is accomplished by: managing
physical design; construction and redesign; maintenance and
testing; planning and improvement; and risk prevention, defined in
terms of utilities, fire protection, security, privacy, storage,
and hazardous materials and waste. Physical Environment may include
the home in the case of in-home programs and foster care.
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37 Priority Focus Areas (PFAs) (Continued) Subprocesses of
Physical Environment include the following: Physical design
Construction and redesign Maintenance and testing Planning and
improvement Risk prevention
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38 Priority Focus Areas (PFAs) (Continued) Quality Improvement
Expertise/Activities Quality Improvement Expertise/Activities
identifies the collaborative and interdisciplinary approach to the
continuous study and improvement of the processes of providing
health care services to meet the needs of consumers and others.
Quality Improvement Expertise depends on understanding and revising
processes on the basis of data and knowledge about the processes
themselves. Quality Improvement Activities involve identifying,
measuring, implementing, monitoring, analyzing, planning, and
maintaining processes to ensure they function effectively. Examples
of Quality Improvement Activities include designing a new service,
flowcharting a clinical process, collecting and analyzing data
about performance measures or patient outcomes, comparing the
organizations performance to that of other organizations, selecting
areas for priority attention, and experimenting with new ways of
carrying out a function.
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39 Priority Focus Areas (PFAs) (Continued) Subprocesses of
Quality Improvement Expertise/Activities include the following:
Identifying issues and establishing priorities Developing measures
Collecting data to evaluate status on outcomes, processes, or
structures Analyzing and interpreting data Making and implementing
recommendations Monitoring and sustaining performance
improvement
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40 Priority Focus Areas (PFAs) (Continued) Rights & Ethics
Rights & Ethics includes patient rights and organizational
ethics as they pertain to the care of patients. Rights & Ethics
addresses issues such as patient privacy, confidentiality, and
protection of health information, advance directives (as
appropriate), organ procurement, use of restraints, informed
consent for various procedures, and the right to participate in
care decisions. Subprocesses of Rights & Ethics include the
following: Patient rights Organizational ethics pertaining to
patient care Organizational responsibility Consideration of patient
Care sensitivity Informing patients and/or family
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41 Priority Focus Areas (PFAs) (Continued) Staffing Effective
staffing entails providing the number of competent personnel with
the appropriate skills mix to meet the needs of a health care
organizations patients based on the organizations mission, values,
and vision. As such, it involves defining competencies and
expectations for all staff. Subprocesses of Staffing include the
following: Competency Skill mix Number of staff
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42 DURING THE SURVEY
Slide 43
43 During the Survey During an accreditation survey, The Joint
Commission evaluates an organizations performance of functions and
processes aimed at continuously improving patient outcomes. The
survey process focuses on assessing performance of important
patient centered and organization functions that support the safety
and quality of care, treatment, and services. This assessment is
accomplished through evaluating an organizations compliance with
the applicable standards in this manual, based on the following
activities and information: Tracing the care, treatment, and
services delivered to patients Verbal and written information
provided to The Joint Commission On-site observations and
interviews by Joint Commission surveyors Review of documents
provided by the organization
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44 During the Survey (Continued) The Joint Commissions
accreditation process seeks to help organizations identify and
correct problems and improve the safety and quality of care,
treatment, and services provided. A survey is designed to be
individualized to each organization, to be consistent, and to
support the organizations efforts to improve performance. The Joint
Commission determines the length of a survey based on information
supplied in the E-App that describes the organizations size and
scope of services. Joint Commission surveyors may conduct some
survey activities on evenings, nights, and weekends, as necessary,
for full surveys of three or more days. These off-shift visits do
not occur before the opening conference at the start of the
survey.
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45 The On-Site Survey This section includes information
relevant to an organization that has applied for an accreditation
survey and is ready for the survey process. It provides an overview
of the survey process, including use of the PFP. The Joint
Commissions accreditation process focuses on systems critical to
the safety and the quality of care, treatment, or services. It
represents a shift from a focus on survey preparation to a focus on
continuous operational improvement by encouraging hospitals to
incorporate the standards as a guide for routine operations. Under
this accreditation process, the unannounced full survey is the on-
site evaluation piece of a continuous process. The accreditation
process encourages organizations to embed the standards into
routine operations to achieve and maintain excellent operational
systems on an ongoing basis. Initiatives such as the continuous PPR
and the sharing of PFP information facilitate this.
Slide 46
46 Unannounced Surveys The Joint Commission generally conducts
surveys in an unannounced fashion except for situations in which it
would not be logical or feasible to conduct an unannounced survey.
Table 1, on page ACC-43, outlines specific exceptions to
unannounced surveys and the length of advance notice. An
organization can undergo an unannounced survey between 18 and 36
months after its previous full survey. Predetermined criteria based
on PFP data across multiple quarters as well as trends in the
performance of these data will determine the timing of an
organizations full unannounced survey.
Slide 47
47 Unannounced Surveys (Continued) With an unannounced survey,
an accredited organization will receive no notice of its survey
date prior to the start of the survey. In concert with the
unannounced survey process, the following procedures will be
implemented: Accredited organizations are able to identify up to 15
days in their survey eligibility range (between 18 and 36 months
after their last full unannounced survey) in which an unannounced
survey should be avoided. These 15 days should not include federal
holidays but may include regional events during which it may be
difficult to conduct a survey. The Joint Commission will make every
effort to accommodate the organization regarding avoiding these 15
days. However, The Joint Commission reserves the right to conduct a
survey during an avoid period if the reason(s) given to avoid a
survey at that time is such that a survey can be reasonably
accomplished.
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48 Unannounced Surveys (Continued) An organization is required
to demonstrate how it communicates on an ongoing basis to its
public that if members of the public have any quality-of-care or
safety concerns, they should notify The Joint Commission (see
APR.09.01.01 in the APR chapter). On the day of the unannounced
survey, by 7:30 A.M. in the organizations local time zone (for
organizations within the United States and its territories), The
Joint Commission will post on the organizations secure Joint
Commission Connect site the letter of introduction, the survey
agenda, and the biography and picture of each surveyor assigned to
conduct the survey. For organizations outside of these locations,
notifications will be posted by 7:00 A.M. eastern time.
Slide 49
49 Unannounced Surveys (Continued) If an organization knows of
a surveyor who works (or has worked) at the organization or a
competing organization, or, has had personal experience with the
surveyor that represents a potential conflict, the organization is
asked to identify the individual(s) in its E-App or notify The
Joint Commission via phone or e-mail as soon as possible so that
another surveyor may be assigned.
Slide 50
50 Survey Team Composition Based on the size and complexity of
the organization being surveyed, an accreditation survey may be
conducted by one surveyor or a team of surveyors. The composition
of an organizations survey team is based on the information
provided in its E-App. On surveys with more than one surveyor, one
of the surveyors is designated as the team leader. The team leader
is responsible for integration, coordination, and communication of
on-site survey activities. In addition to being one of the
surveyors conducting the survey, the team leader serves as the
primary point of on-site contact between the organization and The
Joint Commission. Among other responsibilities, the team leader
leads the opening conference and the daily and exit briefings.
Slide 51
51 Life Safety Code Specialist Scope of Service A Life Safety
Code Specialist will be part of the survey for a minimum of two
days on all surveys. The Life Safety Code Specialist is responsible
for evaluating specific environment of care and Life Safety Code
accreditation criteria and educating the organization during the
survey about related compliant and not compliant areas,
opportunities for improvement, and remedial action that may be
required.
Slide 52
52 ISO Certification Option The Joint Commission and SGS Group
now offer hospitals in the United States the option of pursuing
both accreditation and certification to various ISO (International
Organization for Standardization) and industry best practice
standards. SGS is a worldwide verification, inspection,
certification, and testing company that provides independent
certification and quality assurance services. This program combines
The Joint Commissions health care quality and safety standards,
survey process, and accountability performance measures with SGS
management system audits, including certification to the ISO 9001
quality management system standards. The combination of
accreditation and ISO certification offers hospitals the tools to
maintain best practices and lower costs across the entire operation
while remaining focused on their core service: delivering quality
health care to patients.
Slide 53
53 ISO Certification Option (Continued) While The Joint
Commission accreditation decision and the SGS ISO certification
decision are separate, the survey activities of SGS and The Joint
Commission can be combined during the organizations routine
accreditation survey approximately every three years. A
surveillance or recertification audit is then annually conducted by
SGS. The ISO option can be customized. Health care organizations
can pursue certification at the system level, the hospital level,
or the department (such as radiology, laboratory, pharmacy, food
service, or health information management) level. All areas of an
organization are eligible to be certified. In addition, hospitals
can select from a menu of certifications and testing including ISO
9001 (quality management system), ISO 14001 (environmental
management), ISO 27001 (information security), OHSAS 18001
(occupational health and safety), ISO 17025 (testing and
calibration laboratories), and food safety testing and
certification.
Slide 54
54 Survey Agenda The Joint Commission reviews the data in a
hospitals E-App and posts a sample agenda on the organizations
secure Joint Commission Connect site. Also available on the secure
site is the organizations Survey Activity Guide, which includes a
list of initial materials that the surveyor will request to review
at the onset of the survey. The organizations Joint Commission
account executive will contact the hospital and provide the
anticipated number of days and number of surveyors that will be
assigned for the on-site survey. On the first day of an on-site
survey, surveyors will work with the hospital to ensure the
schedule considers the organizations operations and needs. During
the survey, the surveyor will work with the hospital to determine
the best time for scheduling survey activities so they coincide
more effectively with patient care and administrative operations.
The on-site survey process focuses on continuous operational
improvement in support of safe, high-quality care, treatment, and
services. The survey agenda will include the elements described in
the following slides.
Slide 55
55 Survey Agenda (Continued) Surveyor Planning Session During
this session, the surveyor(s) will review data and information
about the hospital to plan the survey agenda. This will include any
information from previously conducted Joint Commission activities,
such as MOS generated from a full PPR, Option 1 or Option 2, and
other hospital documents that have been gathered for review. The
surveyor(s) will select the first patients for tracing based on
what they learn from the review of data and information during this
session. Opening Conference and Orientation to the Organization.
During the opening conference, the surveyor(s) describes the
structure and content of the survey to organization staff, while
the organization staff provides the surveyor(s) with information
about the organization. At this time, the hospital will briefly
explain its structures, mission, vision, and relationship with the
community. This provides the surveyor(s) with baseline information
about the organization that can help focus subsequent survey
activities.
Slide 56
56 Survey Agenda (Continued) Surveyor Team Meeting On surveys
conducted by more than one surveyor, scheduled team meetings
provide an opportunity for the surveyor(s) to share information and
observations, plan for upcoming survey activities, and plan for
communication and coordination with the organization. Individual
Tracer Activity During the individual tracer activity, the
surveyor(s) will do the following: Follow the course of a type of
care, treatment, or service provided to the patient by the hospital
Assess the interrelationships among disciplines and
services/programs and the important functions in the care,
treatment, or services provided Evaluate the performance of
processes relevant to the care, treatment, or service needs of the
patient, with particular focus on the integration and coordination
of distinct but related processes Identify vulnerabilities in the
care processes See Tracer Methodology on page ACC-50 in the CAMH
for more information.
Slide 57
57 Survey Agenda (Continued) Program-Specific Tracers
Program-specific tracers will be conducted if they apply to the
organization being surveyed and at the surveyors discretion. These
program-focused activities take place during time noted on the
agenda for individual tracer activity. See Tracer Methodology on
page ACC-50 for more information. System Tracers System tracers are
interactive sessions with the surveyor(s) and organization staff
that explore the performance of important patient-related functions
that cross the organization. The surveyor(s) will explore critical
risk points with organization staff and provide education when
indicated during the system tracer sessions. System tracers may
include the following: Data management Infection control Medication
management, if within the scope of the organization
Slide 58
58 Survey Agenda (Continued) As surveyors perform individual
tracers to determine standards compliance as it relates to care
delivered to the selected patient, they also begin to learn about
the organizations overall systems. Information gathered during
individual tracers is then considered from a multi-patient,
cross-organization perspective during system tracers for high-risk
processes. See Tracer Methodology on page ACC-50 in the CAMH for
more information.
Slide 59
59 Survey Agenda (Continued) Daily Briefings During the daily
briefing session, surveyors will communicate to organization staff
their observations on the previous days survey findings and any
significant patterns or trends that are becoming evident in the
survey, if requested to do so. During the daily briefing, the
surveyor(s) will do the following: Facilitate leaders understanding
of the survey process and the findings that contribute to the
accreditation decision Report on findings from the previous days
survey activities Emphasize patterns or trends of significant
concern that could lead to noncompliance determinations Highlight
any positive findings or exemplary performance Allow the hospital
to provide information that may have been missed during the
previous survey day Allow the organization to supply additional
information that would demonstrate compliance with a standard that
a surveyor has indicated may be an RFI
Slide 60
60 Survey Agenda (Continued) Review the agenda for the survey
day ahead and make any necessary adjustments based on hospital
needs or the need for more intensive assessment of an issue If the
organization has additional information that would demonstrate
compliance with a standard that a surveyor has indicated may be an
RFI, the organization should supply that information to the
surveyor(s) as soon as possible. Special Issue Resolution This
session provides an opportunity for the surveyor(s) to follow up on
potential findings that could not be resolved in other survey
activities.
Slide 61
61 Survey Agenda (Continued) Competence Assessment and Medical
Staff Credentialing and Privileging This activity will help the
hospital and the surveyor(s) identify specific issues and do the
following: Evaluate the process the hospital uses to collect
relevant data for decisions for credentialing and privileging
Evaluate the consistent implementation of the credentialing and
privileging process Evaluate processes for the granting of and the
appropriate delineation of privileges Determine whether
practitioners practice within the limited scope of delineated
privileges Link results of peer review and focused monitoring to
the credentialing and privileging process Identify vulnerabilities
in the credentialing, privileging, and appointment process Evaluate
ongoing professional practice evaluation (OPPE) and focused
professional practice evaluation (FPPE) processes
Slide 62
62 Survey Agenda (Continued) Environment of Care Session This
session is an opportunity for the surveyor and hospital to review
and evaluate the following: The processes in place for managing
risk in the physical environment (for example, safety and security,
fire safety, hazardous materials and wastes, medical equipment)
Emergency Management Session This survey activity will allow the
organization and the surveyor(s) to do the following: Discuss the
four emergency management categories: mitigation, planning,
response, and recovery Review and discuss organization plans for
managing critical areas of their operations so that they can
effectively respond regardless of the emergency Review emergency
management processes, such as identifying risks, interactions with
other health care organizations, interactions and communication
with the community, and drills, critiques, and performance
improvement
Slide 63
63 Survey Agenda (Continued) Life Safety Code Building
Assessment This session, as applicable, will help the organization
and the surveyor(s) do the following: Identify areas of concern in
the organizations processes for designing buildings to Life Safety
Code** requirements Identify areas of concern in the organizations
processes for maintaining buildings to Life Safety Code
requirements Identify areas of concern in the organizations
processes for identifying and resolving Life Safety Code problems
Determine the organizations degree of compliance with relevant Life
Safety Code requirements Identify or determine the action(s)
necessary to address any identified Life Safety Code problems
Slide 64
64 Survey Agenda (Continued) Leadership Session During the
leadership session, surveyors discuss the following with leaders:
Information gathering and baseline assessment of leadership-level,
system issuessystem standards, management oversight and direction,
and other leadership responsibilities Ongoing initiatives to
improve delivery of health care Safety program and National Patient
Safety Goals Oversight by governance or the board Surveyor Report
Preparation The surveyor(s) will use this time to compile, analyze,
and organize the data he or she has collected throughout the survey
into a Summary of Survey Findings Report reflecting the
organizations compliance with standards (see page ACC-58).
Slide 65
65 Survey Agenda (Continued) Exit Briefing and Organization
Exit Conference During the Exit Briefing the surveyor(s) will
review the outcome of the survey with the most senior leader,
usually the CEO or administrator, or the leadership team. The
surveyor will present the survey findings and review the Summary of
Survey Findings Report, discuss any concerns senior leaders have
with the report, and determine the need for any special
arrangements for the Organization Exit Conference. (A written
report is not provided at the completion of a for-cause unannounced
survey.) During the Organization Exit Conference the surveyor(s)
will report the outcome of the survey and present the survey
findings (if desired by senior leaders), review the issues of
standards compliance that have been identified during the survey,
allow the hospital a final on-site opportunity to question the
survey findings or provide additional material regarding standards
compliance, and review required follow-up actions, as
applicable.
Slide 66
66 Tracer Methodology The tracer methodology is the cornerstone
of The Joint Commission on-site survey. The tracer methodology
incorporates the use of PFP information to follow the experience of
care, treatment, or services for a number of individuals (initially
identified by CSGs) through the organizations entire health care
process. Tracers allows the surveyor(s) to identify performance
issues (that may be related to PFAs) in one or more steps of the
process, or in the interfaces between processes. The three types of
tracers are described in the following sections.
Slide 67
67 Program-Specific Tracers The goal of the program-specific
tracer activity is to identify safety concerns within different
levels and types of care, treatment, or services. Program-specific
tracers bring a targeted focus on important issues relevant to the
following information: Types of care, treatment, or services
offered by the organization Programs being surveyed The
organizations PFAs Topics for the program-specific tracers were
identified through a review of expert literature, research, input
from the field, and subject matter expertise. Accreditation
programspecific tracers evaluate program-specific issues and
compliance with relevant standards that impact patient safety.
Table 2 on page ACC-51 contains hospital-specific tracer
activities, including applicability and objectives. Note:
Program-specific tracers will only be conducted if they apply to
the specific organization being surveyed. Program-specific tracers
occur during survey time designated for Individual Tracer
Activity.
Slide 68
68 Individual Tracer Activity The individual tracer activity is
conducted during an on-site survey and is designed to trace the
care experiences that a patient had while at the hospital. The
tracer methodology is a way to analyze a hospitals system of
providing care, treatment, or services using actual patients as the
framework for assessing standards compliance. The surveyor(s) will
use the following general criteria to select initial individual
tracers: Patients in top CSGs for that organization Patients who
cross programs (for example, home care patients discharged from a
hospital or individuals served by behavioral health care
organizations who present at an ambulatory care facility in complex
organizations) Patients related to individual-based system tracer
topics (see System Tracer Activity following), such as infection
control or medication management Patients receiving complex
services, such as surgery or treatment in an intensive care unit
Please see the Survey Activity Guide on the Joint Commission
Connect for more detailed information on other program-specific
criteria for tracer selection.
Slide 69
69 Individual Tracer Activity (Continued) Patients selected for
initial individual tracer activity will most likely be those
identified in the hospitals PFP information as listed in the CSGs.
Based on identified CSGs, the surveyor(s) will identify individual
tracers and follow specific patients through the hospitals
processes. A surveyor will not only examine the individual
components of a system but will also evaluate how the components of
a system interact with each other. In other words, a surveyor will
look at the care, treatment, or services provided by each
department/unit/program and service, as well as how
departments/units/programs and services work together. The
surveyor(s) may start where the patient is currently located. He or
she can then move to where the patient first entered the
organizations systems; an area of care provided to the patient that
may be a priority for that organization; or to any areas in which
the patient received care, treatment, or services. The location and
order will vary. Along the way, the surveyor(s) will speak with the
health care staff member(s) who actually provided the care to that
individual tracer patientor, if that staff member(s) is not
available, will speak with another staff member(s) who provides the
same type of care, treatment, or services.
Slide 70
70 Individual Tracer Activity (Continued) Surveyors use
individual patient tracers and systems tracers to review patient
medical records. For hospitals seeking deemed status, surveyors
will review records for 10% of the average daily census or a
minimum of 30 inpatient records or 20 for small general acute care
hospitals (but not for surgical or other specialty hospitals) with
an average daily census of 20 patients or fewer. Based on the
findings of the surveyor(s), he or she may select similar patients
to trace. The tracer methodology permits surveyors to further
investigate if there is a reason to believe that an issue needs
further exploration.
Slide 71
71 System Tracer Activity System tracers explore one specific
system or process across the organization, focusing, when possible,
on the experiences of specific patients or activities relevant to
specific patients. This differs from individual tracers in that
during individual tracers, the surveyor(s) follows a patient
through his or her course of care, evaluating all aspects of care
as opposed to a system. During the system tracer sessions, the
surveyor(s) evaluates the system or process, including the
integration of related processes and the coordination and
communication among disciplines and departments in those processes.
A system tracer includes an interactive session (involving a
surveyor and relevant staff members) in tracing a system within the
organization based on information from individual tracers. Points
of discussion in the interactive session include the following: The
flow of the process across the hospital, including identification
and management of risk points, integration of key activities, and
communication among staff/units involved in the process
Slide 72
72 System Tracer Activity (Continued) Strengths in the process
and possible actions to be taken in areas needing improvement
Issues requiring further exploration in other survey activities A
baseline assessment of standards compliance Education by the
surveyor, as appropriate The three topics evaluated with system
tracers are Data use, infection control, and medication management.
Whether all system tracers are conducted varies based on survey
length, but the data use system tracer is performed on every
hospital survey. If survey length does not permit the conduct of an
infection control or medication management system tracer, the given
area is assessed through other survey activities.
Slide 73
73 System Tracer Activity (Continued) Data Management. The data
management system tracer focuses on how the hospital collects,
analyzes, interprets, and uses or manages data to improve patient
safety and care. Infection Control. The infection control
individual-based system tracer explores the hospitals infection
control processes. The goals of this session are to assess the
hospitals compliance with the relevant infection control standards,
identify infection control issues that require further exploration,
and determine actions that may be necessary to address any
identified risks and improve the safety of patients. Medication
Management. The medication management individual-based system
tracer explores the hospitals medication management processes while
focusing on subprocesses and potential risk points (such as handoff
points). This tracer activity helps the surveyor(s) evaluate the
continuity of medication management from procurement of medications
through the monitoring of their effects on patients.
Slide 74
74 Patient Flow Tracer The patient flow tracer addresses
potential treatment delays, medical errors, and unsafe practices
that may occur during periods of patient congestion and if patient
flow does not occur smoothly throughout the hospital. The only
standard that specifically includes the words patient flow is
Leadership Standard LD.04.03.11. However, patient flow problems
stress the hospitals entire system. When this occurs, noncompliance
with many Joint Commission standards, core measures, and National
Patient Safety Goals may be evident.
Slide 75
75 Patient Flow Tracer (Continued) Patient flow Standard
LD.04.03.11 details leadership responsibilities for evaluating
patient flow, accepting responsibility, and making necessary
changes to improve throughput. Leaders must develop and implement
plans to evaluate patient flow in the entire organization. They
must identify problems in the hospital and take action to prevent
barriers to patient flow. If patient flow problems are identified
during the survey, the surveyor will interview hospital leaders
about actions they have taken to mitigate consequences of patient
congestion, how they have shared accountability with medical staff,
evidence of their shared accountability, inpatient flow indicators
throughout the hospital, how indicator results are reported to
leadership, and how this information has been used to improve
patient flow.
Slide 76
76 Patient Flow Tracer (Continued) When evaluating patient
flow, Joint Commission surveyors will look for compliance with all
standards and requirements. Standard LD.04.03.11 addresses patient
flow from a performance improvement perspective. Surveyors will
ensure that a hospital is not just looking at one area (for
example, emergency department, laboratory, or radiology), but at
its processes in its entire system. Literature shows that patient
flow problems emerge in various departments and units in different
hospitals; therefore, the hospital needs to evaluate all of its
areas to identify where it needs to focus. In addition to Standard
LD.04.03.11, there are many other standards and EPs that can be
cited when the flow of patient care is disrupted.
Slide 77
77 Second Generation Tracers As part of a natural evolution of
the current tracer process, second generation tracers are a deep
and detailed exploration of a particular area, process, or subject.
A surveyor conducting any type of tracer at a hospital might notice
something involving a high-risk area that requires a more in- depth
look. The following are seven high-risk topics in hospitals that
surveyors might need to explore in more detail: Cleaning,
disinfection, and sterilization Patient flow across the care
continuum Contracted Services Diagnostic imaging Ongoing
professional practice (OPPE) and focused professional practice
evaluation (FPPE) Assessment Staffing
Slide 78
78 The Role of Staff in Tracer Methodology To help the
surveyor(s) in the tracer methodology process, staff will be asked
to provide the surveyor(s) with a list of active patients,
including the patients names, current locations in the hospital,
and diagnoses/conditions, as appropriate. The surveyor(s) may
request assistance from hospital staff for selection of appropriate
tracer patients. As the surveyor(s) moves around a hospital, he or
she will ask to speak with the staff members who have been involved
in the tracer patients care, treatment, or services if available.
If those staff members are not available, the surveyor(s) will ask
to speak to another staff member who would perform the same
function(s) as the member who has cared for or is caring for the
tracer patient. Although it is preferable to speak with the direct
caregiver, it is not mandatory because the questions that will be
asked are questions that any caregiver should be able to answer in
providing care, treatment, or service to the patient being
traced.
Slide 79
79 Immediate Threat to Health or Safety The Joint Commission
defines Immediate Threat to Health or Safety as a threat that
represents the most immediate risk and has or may potentially have
serious adverse effects on the health or safety of the patient,
resident, or individual served. Such a situation may occur anywhere
in an organization. (See Accreditation Participation Requirement
[APR].09.04.01.) If a surveyor identifies any condition that he or
she believes poses a serious threat to public or patient health or
safety, he or she will notify the organizations CEO and Joint
Commission headquarters staff immediately. The president of The
Joint Commission, or his or her designee if the president is
unavailable, can then issue an expedited Preliminary Denial of
Accreditation decision based on the threat. An organization
notified of a Preliminary Denial of Accreditation decision due to
an Immediate Threat to Health or Safety situation does not have a
right to clarify the survey findings relative to the situation.
Since a Preliminary Denial of Accreditation is an official
accreditation decision category, the decision is posted on Quality
Check.
Slide 80
80 Immediate Threat to Health or Safety (Continued) The
organizations CEO and appropriate governmental authorities are
informed of this decision and the findings that led to this action.
After notification of the Preliminary Denial of Accreditation
decision, an organization has up to 72 hours to do the following:
Eliminate the Immediate Threat to Health or Safety situation
entirely Or If the situation is such that it will take the
organization more time to fully eliminate it (such as situations
involving building construction), then the organization must
implement emergency interventions to abate the risk to patients
(for example, cease performing a certain procedure, implement
additional safety measures) within 72 hours. If the situation is
not fully eliminated within 72 hours, the organization will have a
maximum of 23 days to do so.
Slide 81
81 Immediate Threat to Health or Safety (Continued) The
Accreditation Committee of the Joint Commission Board of
Commissioners confirms or reverses the Preliminary Denial of
Accreditation decision at its next meeting. The Accreditation
Committee may take into consideration an organizations corrective
actions or responses to a serious threat situation. The
organization can provide information to demonstrate that a serious
threat to health or safety has been corrected prior to the
Accreditation Committees consideration of the Preliminary Denial of
Accreditation decision. In these situations, the corrective action
is considered when a single issue leads to the adverse finding and
the organization demonstrates that it did the following: Took
immediate action to completely remedy the situation Prepared a
thorough and credible root cause analysis Adopted systems changes
to prevent a future recurrence of the problem
Slide 82
82 Immediate Threat to Health or Safety (Continued) If the
organization demonstrates that it has taken corrective action, The
Joint Commission will conduct an abatement survey to validate the
implementation of the corrective action and that the immediate
threat situation is no longer present. If the abatement survey
confirms the absence of the Immediate Threat to Health or Safety
situation, The Joint Commission will remove the Preliminary Denial
of Accreditation decision (assuming there are no other reasons for
the Preliminary Denial of Accreditation). Therefore, the sooner an
organization eliminates the Immediate Threat to Health or Safety
situation, the shorter the period of time the organization will be
in Preliminary Denial of Accreditation.
Slide 83
83 Immediate Threat to Health or Safety (Continued) Upon
resolution of an Immediate Threat to Health or Safety situation,
the organizations accreditation status will change from Preliminary
Denial of Accreditation to Contingent Accreditation and remain as
such until an accreditation follow-up survey is conducted to assess
the organizations sustained implementation of appropriate
corrective actions. See Figure 2 on page ACC-58 for a visual
representation of the process flow for Immediate Threat to Health
or Safety situations.
Slide 84
84 The Summary of Survey Findings Report Following evaluation
of an organizations performance of functions and processes, the
surveyor (or survey team) reviews the results of integrated
individual findings. The surveyor (or survey team) produces the
organizations Summary of Survey Findings Report. The surveyor (or
survey team leader) meets with the organizations CEO prior to the
closing conference and provides him or her with a copy of the
preliminary report. The CEO determines whether this report is
distributed at the closing conference. The surveyor (or survey
team) uses the report contents in making closing conference
presentations.
Slide 85
85 The Summary of Survey Findings Report (Continued) Shortly
after a survey, an organizations report of survey findings is
posted on the organizations secure Joint Commission Connect site.
The report includes RFIs, as appropriate. If a hospital does not
receive any RFIs, its accreditation decision is rendered at the
same time that the hospitals Summary of Survey Findings Report is
available, and it is effective the day after the completion of the
survey. If a hospital receives RFIs, then the hospitals
accreditation decision is rendered following the submission of an
acceptable ESC report. (See Accreditation Effective Date on page
ACC-66 and Evidence of Standards Compliance [ESC] Process on page
ACC-67 in the CAMH for more information.)
Slide 86
86 AFTER THE SURVEY
Slide 87
87 How Accreditation Decisions Are Made The Joint Commission
defines criticality as the immediacy of risk to patient safety or
quality of care as a result of noncompliance with a Joint
Commission requirement (for example, an EP, National Patient Safety
Goal, Universal Protocol). The four levels of criticality are as
follows: Immediate Threat to Health or Safety Situational Decision
Rules Direct Impact Requirements Indirect Impact Requirements
Slide 88
88 How Accreditation Decisions Are Made (Continued) Reference
pyramid on pg 61 in the CAMH Immediate Threat to Health or Safety
The top (sharp end) of the pyramid represents the most immediate
risk (marked with a in the manual). This component of the model
represents a risk that currently exists Immediate Threat to Health
or Safety situations that are identified on site have or may
potentially have serious adverse effects on the health or safety of
patients. Upon resolution of an Immediate Threat to Health or
Safety situation, the organizations accreditation status will
change from Preliminary Denial of Accreditation to Contingent
Accreditation and remain as such until a follow-up survey is
conducted to assess the organizations sustained implementation of
appropriate corrective actions.
Slide 89
89 How Accreditation Decisions Are Made (Continued) Situational
Decision Rules The second level of the pyramid includes situations
(marked with a in the manual) that automatically trigger a
recommendation for Preliminary Denial of Accreditation, Contingent
Accreditation, or Accreditation with Follow-up Survey based on such
issues as loss of facility licensure, provision of care by
unlicensed individuals who require such a license, and failure to
implement corrective action in response to identified Life Safety
Code deficiencies. In follow-up to these situations, organizations
must demonstrate resolution of the situation through the ESC
process. An on-site survey is conducted to validate implementation
of corrective action.
Slide 90
90 How Accreditation Decisions Are Made (Continued) Direct
Impact Requirements The third level of the pyramid involves direct
impact requirements (a standard, EP, National Patient Safety Goal,
or APR marked with A). Such requirements have a direct impact on
patients if noncompliance is likely to create an immediate risk to
patient safety or quality of care, treatment, and services. The
immediate risk usually results because there are no or few
processesor no or few protective defenses intervening between the
noncompliance and the impact on the safety or quality of a patients
care, treatment, and services.
Slide 91
91 How Accreditation Decisions Are Made (Continued) Indirect
Impact Requirements The requirements at the bottom (blunt end) of
the pyramid pose less immediate risk to patient care or safety than
direct impact requirements, but noncompliance increases risk to
patient safety or quality of care, treatment, or services over
time. If there are no direct impact EPs out of compliance, any
remaining indirect impact Eps under that standard must be addressed
in an ESC submission within 60 days. The organizations
accreditation decision will be held in abeyance pending submission
of ESC within the established time frames. As with the direct
impact requirements, failure to resolve instances of partial
compliance or insufficient compliance with indirect impact
requirements will lead to progressively more adverse accreditation
decisions.
Slide 92
92 Accreditation Decision Categories The Joint Commission
revised its decision categories to better distinguish organizations
with serious patterns and trends in the provision of care,
treatment, or serviceswhich require follow-up more quicklyfrom
those with less serious compliance issues. There are six categories
of accreditation that an organization can achieve based on a Joint
Commission survey. See Figure 4 on page ACC-66 in the CAMH for the
continuum of accreditation decisions now possible following a full
or other survey activity.
Slide 93
93 Accreditation Decision Categories (Continued) The Joint
Commissions six accreditation decision categories are as follows:
1.Preliminary Accreditation. The organization demonstrates
compliance with selected standards in the surveys conducted under
the Early Survey Policy. 2.Accredited. The organization is in
compliance with all standards at the time of the on-site survey or
has successfully addressed all RFIs in an ESC within 45 or 60 days
following the posting of the Accreditation Survey Findings Report
and does not meet any other rules for other accreditation
decisions. 3.Accreditation with Follow-up Survey. The organization
is not in compliance with specific standards that require a
follow-up survey within 30 days to 6 months.
Slide 94
94 Accreditation Decision Categories (Continued) 4.Contingent
Accreditation The organization has: Successfully abated an
Immediate Threat to Life (ITL) situation through direct observation
or other method, Fails to successfully address all requirements of
the Accreditation with Follow-up Survey decision, shows some
evidence of engaging in possible fraud or abuse, demonstrates
patterns or trends of noncompliance at an initial survey, and/or is
not recommended for certification by CMS after undergoing its first
Joint Commission survey for deemed status or Medicare recognition
purposes. In most cases, a follow-up survey in 30 days will be
required to show resolution of the issues that led to the decision.
If an organization receives this decision because it was not
recommended for certification by CMS or demonstrates systemic
patterns or trends of noncompliance at an initial survey, the
organization will remain in Contingent Accreditation until the
organization can be recommended for certification or it meets a
rule for Preliminary Denial of Accreditation or Denial of
Accreditation.
Slide 95
95 Accreditation Decision Categories (Continued) 5.Preliminary
Denial of Accreditation. There is justification to deny
accreditation to the organization as evidenced by: An Immediate
Threat to Health or Safety to patients or the public, and/or
Submission of falsified documents or misrepresented information,
and/or Lack of a required license or similar issue at the time of
survey, and/or Failure to resolve the requirements of Contingent
Accreditation, and/or Significant noncompliance with Joint
Commission standards. The decision is subject to review and appeal
by the organization prior to the determination to deny
accreditation. (See Review and Appeal Procedures on page ACC-97.)
6.Denial of Accreditation. The organization has been denied
accreditation. All review and appeal opportunities have been
exhausted
Slide 96
96 Accreditation Effective Date The effective date of the
accreditation decision varies based on the type of and acceptance
of follow-up activities. (See Evidence of Standards Compliance
[ESC] Process on page ACC-67 in the CAMH) For organizations that do
not receive any RFIs, the accreditation decision will be effective
the day after the last day of survey. Otherwise, an accreditation
decision is rendered following the submission of the ESC report
resolving all RFIs, which is retroactive to the day after the last
day of the full survey For organizations undergoing an initial
survey, the accreditation decision becomes official the day of the
Accreditation Committee meeting or an acceptable ESC resolving all
RFIs is submitted (if that occurs after the Accreditation Committee
meeting). For organizations receiving Preliminary Denial of
Accreditation or Denial of Accreditation, the decision becomes
effective the day the decision is rendered by the Accreditation
Committee. When an organizations accreditation decision becomes
official, it is publicly disclosable and is posted on Quality
Check.
Slide 97
97 Corrective ESC An acceptable corrective ESC report must
detail the following: Action(s) that the organization took to bring
itself into compliance with a requirement The title of the
person(s) responsible for implementing the corrective actions or
approving a revised policy, procedure, or process Compliance at the
EP level and include an MOS, if applicable An acceptable ESC report
is due within 45 or 60 calendar days (depending on whether the EP
relates to a direct or indirect impact requirement) following the
posting of the Accreditation Survey Findings Report. The required
time frame will be specified in the survey report. Following a
successful submission of the ESC report, the organization receives
an accreditation decision. However, the organizations accreditation
decision is retroactive to the day after the last day of the
survey, unless the organization is undergoing its first Joint
Commission survey. In that case, the effective date for
accreditation is the date on which the acceptable ESC is
submitted.
Slide 98
98 Corrective ESC (Continued) The organizations ESC
submission(s) will be evaluated by Central Office using the same
scoring guidelines used by the surveyors at the time of survey and
by health care organizations when they conduct their PPR (see the
Sample Sizes section that follows). The Joint Commission will
consider the ESC acceptable when the hospital has demonstrated
resolution of all RFIs. If the hospital has not met a rule for
Accreditation with Follow-up Survey, Contingent Accreditation, or
Preliminary Denial of Accreditation and the ESC submission(s) is
determined to be acceptable, its decision will be Accredited, and
it will be required to submit the data for applicable MOS for each
EP, if required, four months later.
Slide 99
99 Corrective ESC (Continued) On-Site ESC Usually, the ESC will
be an electronic submittal to The Joint Commission, but there will
be times when an ESC also will be conducted on site by a surveyor.
If an on-site evaluation is required to assess compliance with the
relevant standards, a copy of the hospitals electronic ESC is
provided to the surveyor conducting the on-site ESC. The on-site
ESC process provides the opportunity to evaluate the organizations
success in correcting the issues. It also allows the surveyor to
provide coaching and guidance to the organization supporting its
efforts to achieve and maintain compliance with the standards. A
final decision letter will be posted to the hospitals secure,
password-protected Joint Commission Connect site when its ESC has
been reviewed and an accreditation decision has been rendered. A
Quality Report will then be posted on Quality Check on The Joint
Commissions website. For more information, see The Joint Commission
Quality Report (QR) chapter.
Slide 100
100 Corrective ESC (Continued) Sample Sizes If, during an
on-site survey, your hospital has been found to be not compliant,
or partially compliant, with one or more EPs, you must demonstrate
ESC for each standard that is not compliant. The ESC must address
compliance at the EP level. When an EP within a not compliant
standard requires an MOS, your hospital must demonstrate whether
each MOS identified in the organizations ESC report was met.
Assessment of MOS compliance is conducted for a four-month period
following the date of ESC approval. Your hospital should select
records as a part of its sample following the date of ESC approval
and use the required sample sizes. MOS percentage compliance rates
are derived from the average of all four months.
Slide 101
101 Corrective ESC (Continued) You need an average of 90% or
higher compliance over 4 months for a successful ESC. When
demonstrating an ESC, the following percentages determine your EP
score: 90% through 100% of your sample size is in compliance =
score 2 80% through 89% of your sample size is in compliance =
score 1 Less than 80% of your sample size is in compliance = score
0 Note: Hospitals are encouraged, but not required, to use the same
percentages when conducting a PPR. However, an MOS cannot be
accepted in a PPR if it does not meet requirements.
Slide 102
102 Measure of Success (MOS) Report An MOS ( M ) is a numerical
or quantifiable measure, usually related to an audit to determine
if an action was effective and sustained, due four months after
notification of an acceptable ESC. The MOS report should
demonstrate whether each MOS identified in the hospitals ESC report
was reached. Central Office will evaluate the MOS results. If the
MOS results are acceptable, no further action will be required of
the hospital. If it is determined that a hospitals MOS submission
is unacceptable, its accreditation decision may be changed to
Accreditation with Follow-up Survey and/or the hospital may be
required to submit a second set of MOS results in another four
months.
Slide 103
103 Measure of Success (MOS) Report (Continued) If the
hospitals first ESC submission is determined to be acceptable and
the second MOS submission is determined to be acceptable, its
accreditation decision will be changed to Accredited, and no
further action will be required of the hospital. If the second MOS
submission is determined to be unacceptable, a recommendation for
Accreditation with Follow-up Survey will be presented to the
Accreditation Committee. The organizations ESC submission and
sustained implementation of it, including the MOS, are subject to
review in random unannounced surveys.
Slide 104
104 The Process for Accreditation with Follow-up Survey,
Contingent Accreditation, or Preliminary Denial of Accreditation If
an organization is notified that a recommendation is to be made to
the Joint Commissions Accreditation Committee for Accreditation
with Follow-up Survey, Contingent Accreditation, or Preliminary
Denial of Accreditation, the organization has 10 calendar days to
provide information to clarify any of the RFIs cited in its
Accreditation Survey Findings Report through its ESC report and
demonstrate that it was in fact in compliance with one or more
standards in question at the time of survey. A Clarification
Validation Survey (CVS) may be conducted to ensure that the
organization was, in fact, in compliance with Joint Commission
standards at the time of survey rather than relying solely on
information submitted by the organization. (See Clarification
Validation Survey on page ACC-90 in the CAMH for more
information.)
Slide 105
105 The Process for Accreditation with Follow-up Survey,
Contingent Accreditation, or Preliminary Denial of Accreditation
(Continued) Whenever an organization submits written or electronic
information after receiving a Preliminary Denial of Accreditation
decision, The Joint Commission may conduct a CVS to validate the
information and assure compliance with Joint Commission standards
before making a final decision to remove the organization from the
Preliminary Denial of Accreditation decision.
Slide 106
106 The Process for Accreditation with Follow-up Survey,
Contingent Accreditation, or Preliminary Denial of Accreditation
(Continued) If the organization does not meet a rule for
Preliminary Denial of Accreditation, Contingent Accreditation, or
Accreditation with Follow-up Survey, it will be awarded
accreditation (if it is compliant with all standards) or it will be
required to submit an ESC (if it still has RFIs). if the
organization continues to meet a decision rule for Preliminary
Denial of Accreditation, Contingent Accreditation, or Accreditation
with Follow-up Survey, The Joint Commission will recommend to the
Accreditation Committee that the organization remain in Preliminary
Denial of Accreditation, Contingent Accreditation, or Accreditation
with Follow-up Survey. The organization will have 5 business days
from receipt of notification to submit a written response directly
to the Accreditation Committee.
Slide 107
107 Preliminary Denial of Accreditation for Organizations
Without Proper License, Certificate, or Permit Without Proper
License, Certificate, or Permit If a hospital does not possess a
license, certificate, and/or permit, when required by applicable
law and regulation, to provide the health care services for which
the hospital is seeking accreditation, Joint Commission staff may
initiate the Preliminary Denial of Accreditation process under
decision rule PDA04. (see 2012 Accreditation Decision Rules on page
ACC-92 in the CAMH)
Slide 108
108 Preliminary Denial of Accreditation for Organizations
Without Proper License, Certificate, or Permit (Continued) The
process for Preliminary Denial of Accreditation in such
circumstances is as follows: If at the time of survey the hospital
does not have a required license, certificate, or permit, the
hospital will be notified that it meets a rule for Preliminary
Denial of Accreditation, and The Joint Commission will initiate
such action. If it obtains the required license, certificate, or
permit or is able to provide proof of application during the
clarification process, PDA04 will be removed, but the RFI will
remain in the survey report. The hospital will not be presented to
the Accreditation Committee unless it meets a decision for
Preliminary Denial of Accreditation, Contingent Accreditation, or
Accreditation with Follow-up Survey based on another decision
rule.
Slide 109
109 Plan of Action (POA) A POA is a detailed description of how
a hospital plans to bring into compliance any standard identified
as not compliant in the PPR. The POA must include the planned
action to be taken and target implementation dates. If the EP
requires an MOS when lack of compliance exists, you must also
describe the MOS or how you plan to measure your successful
implementation of your POAs.
Slide 110
110 BETWEEN SURVEYS
Slide 111
111 Sentinel Event Follow Up Accredited hospitals are expected
to identify and respond appropriately to all sentinel events as
defined by the hospital. The hospital is required to conduct a
thorough and credible root cause analysis develop an action plan in
a manner and time frame acceptable to The Joint Commission as
specified in the Sentinel Event Policy, and Submit to The Joint
Commission or otherwise provide evidence of an acceptable response
to the sentinel event. (See the Sentinel Events [SE] chapter in the
CAMH for more information.)
Slide 112
112 Accreditation Status of Organizations That Cease Services
After a Disaster The Joint Commission will discontinue the
accreditation of hospitals that have been closed or out of service
for more than six months as a result of a disaster. The complete
process for determining the accreditation status of hospitals that
cease services after a disaster follows: Up to 30 Days. For
hospitals that resume services within the first 30 days after a
disaster and/or the hospitals decision to cease operations, the
hospitals original Joint Commission accreditation status will stay
in effect. The time frame for complying with any outstanding Joint
Commission requirements (such as the PPR or ESC) will pause until
the hospital resumes operation. In most cases, The Joint Commission
will not need to survey the affected hospital to reassess its level
of standards compliance. If The Joint Commission decides to conduct
a survey, the hospitals accreditation decision will be driven by
the interim survey findings.
Slide 113
113 Accreditation Status of Organizations That Cease Services
After a Disaster (Continued) Up to 90 Days. For hospitals that
resume services from 31 to 90 days after a disaster, The Joint
Commission will conduct an extension survey to determine the
hospitals accreditation status. The circumstances surrounding the
hospitals closure will determine the surveys length and scope. Up
to Six Months. For hospitals that resume services from 91 days up
to six months after a disaster, The Joint Commission will require
an on-site survey to assess the environment of care. This survey
will preferably take place one to two weeks after services are
resumed. These hospitals must receive clearance to operate from the
fire marshal and other local/state authorities before resuming
services. In addition, The Joint Commission will conduct a second
on-site survey approximately four months after services have been
resumed to evaluate sustained compliance with Joint Commission
standards and requirements. The track record requirement for
demonstrating standards compliance will be four months.
Slide 114
114 Accreditation Status of Organizations That Cease Services
After a Disaster (Continued) More Than Six Months. For hospitals
that do not resume services within six months after a disaster or
decide to cease operations, The Joint Commission will discontinue
its accreditation. If the hospital resumes services, it must
reapply to become accredited. In such cases, the accreditation
process will involve at least two surveys. The first survey will be
conducted at the hospitals request and will assess the hospitals
ability to provide safe patient care. The hospital may qualify for
an accreditation award as a result of this survey. However, at this
point the hospital will not be recognized by CMS to meet the
requirements for Medicare certification. The second survey will be
conducted approximately four months later to assess sustained
compliance with Joint Commission requirements. The track record
requirement for demonstrating standards compliance will be four
months.
Slide 115
115 Accreditation Status of Organizations That Cease Services
After a Disaster (Continued) The Joint Commission will continue to
list all affected hospitals as Accredited up to six months after a
disaster, unless interim survey findings dictate otherwise. While
working with affected hospitals in the aftermath of a catastrophic
event, The Joint Commission will be sensitive to these hospitals
needs and will work with responsible state and federal agencies to
help reestablish the hospitals operations as well as their
qualification for accreditation. If your hospital is affected by a
natural disaster, please notify your hospitals account executive as
soon as possible. Once notified, The Joint Commission can cancel
any accreditation-related events and offer assistance, if needed.
If you dont know who serves as your hospitals assigned account
executive, call 630-792-3007.
Slide 116
116 Accreditation Status of Organizations That Cease Provision
of Services for a Period of Time Accredited Joint Commission
hospitals may stop providing care, treatment, and services to
patients or may not have any patients for a period of time for
reasons other than natural or man-made disasters. The Joint
Commission will discontinue the accreditation of hospitals that
have ceased providing care, treatment, and services for more than
six months. The complete process for determining the accreditation
status of such hospitals follows: Up to 60 Days. If a hospital does
not have any patients for up to 60 days, The Joint Commission will
continue the hospitals current accreditation status.
Slide 117
117 Accreditation Status of Organizations That Cease Provision
of Services for a Period of Time (Continued) Up to Six Months. If a
hospital does not have any patients from 60 days to less than six
months, but then resumes patient services within six months, The
Joint Commission will continue the hospitals current accreditation
status only if the hospital has an extension survey. This extension
survey would generally take place within a week of the hospitals
request. The purpose of this survey is to evaluate the hospitals
capability for resuming services and whether it is performing at
current accreditation levels. More Than Six Months. If a hospital
does not have any patients for six months or longer, The Joint
Commission will consider the hospital no longer accredited. If the
hospital resumes services, it will have to apply for a full survey
in order to evaluate its current compliance with Joint Commission
standards.
Slide 118
118 Reentering the Accreditation Process For a previously
accredited hospital to be designated as new, it must not have
participated in the accreditation process during the previous four
months. If a hospital is reentering the accreditation process
before four months have passed, it must demonstrate a continuous
12-month track record of compliance with the standards.
Slide 119
119 Extension Surveys The Joint Commission conducts an
extension survey when an accredited hospital acquires a new
service, program, or site for which The Joint Commission has