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I’m Accredited Now What?
A Guide to Supportive Resources for the Newly Accredited Organization
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Presenters
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From The Joint Commission:
Julia Finken BSN, MBA, CPHQ, CSSBB, Associate Director, Home CareKathryn Zaba, MA, CRC, Senior Account Executive, Home Care
Joe Misenko, Associate Director, Intra-cycle MonitoringDea Greathouse RN, MSHA, Associate Director, Standards Interpretation Group
Guest Presenter
Patti Atteberry, RN, MSN, Director of Professional Practice, OSF Home Care Services
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May 21, 2015
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Publicity Kit
Gold Seal DownloadSample News ReleasesFact Sheets About TJC AccreditationSearch for Local Media to Promote
Your TJC AccreditationBrochure: “We Received the Gold Seal
of Approval from the Joint Commission”Other
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Continuous Compliance Infrastructure
Team ApproachAssign Key Responsibilities to Key Job Positions
– Consider Assigning by TJC ChapterDefine Clear Expectations
– Maintenance of Ongoing Compliance with evidence
– Periodic Reporting to Quality CommitteeReporting CalendarAccountability Embedded in Performance
Appraisal
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Role of the Account Executive The Joint Commission assigns an Account
Executive to an organization after receiving its E-App.
This person serves as the primary contact between the organization and The Joint Commission. He or she coordinates survey planning and handles policies, procedures, accreditation issues or services, and inquiries throughout the accreditation cycle.
An organization can find contact information for its account executive on its Joint Commission Connect
site or by calling 630-792-3007.
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Contacting the Account Executive
The Account Executive can be contacted via phone, email, fax, or USPS. – Most communication is done via phone and
email. Account Executives respond to both email and phone messages in a timely manner. – Please note your HCO ID number in all correspondence.
– If an Account Executive is not available, a back-up is assigned. Organizations may also speak to an operator to find an Account Executive who can help with general questions.
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Milestone One – 9 Month Application Submission
The General Application/Update Contacts link will appear under the What’s Due section 30 days before the submission due date.
The link will look similar to the picture below:
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9 Month Application Submission
The organization will review the General Application by clicking the ‘Next’ button, allowing the organization to view each section of information.
The organization should review the entire General Application, starting at TAB 1 – Your Organization.
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9 Month Application Submission
The organization can make changes to the application as needed.– Special importance should be focused on
the following:– Accuracy of Unduplicated Admissions and
Average Daily Census– Address and Phone Number– Branch Locations or Additional Sites– Services Provided– Ownership Information
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9 Month Application Submission
The Security Admin link on the extranet allows for contact updates. – An update will be automatically prompted
upon most submissions. If the organization closes this, it can always be reach via the Security Admin link on the extranet.
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Identify key staff that will be responsible for follow up of any 45 or 60 day evidence of standards compliance for non compliant standards post survey
ESC 45 and 60 day Clarification submission Deemed status – For Condition Level
Deficiency’s
Evidence of Standard Compliance (ESC)
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Measure of Success
Identify key staff that will be responsible for creating and monitoring standards that require a Measure of Success– MOS icon – Appropriate Sample Size– Sampling method– 90% or higher compliance over four months– Based on patient population– Considered minimal requirements– Numerator (total number of compliant records/visits– Denominator (total number of records/visits)– Submission reviewed by Central Office
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Continuous Compliance
Maintain Documents, Policies and Procedure
Regularly Access the E-dition, Extranet Site Resources and ICM tool
Maintain Budgets and Capital Expense plans
Maintain Human Resource files
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Continuous Compliance
Maintain an updated organizational chart
Review the previous ESC submission to ensure implementation was successful and ongoing
Ensure all meetings have:– Documented detailed minutes– Appropriate membership of staff– Are following policy
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Continuous Compliance
Maintain Policy and Procedure Review
Perform identified data collection
Perform analysis on collected data
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Record of Care
Perform random audits on patient records
– Review for complete orders– Review for care plans– Review for following the physician orders – Review for accuracy, legibility, and
completion on time– Assists you in identifying improvement
areas
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Clinical – Individual Tracers
Perform Individual Tracers with all disciplines to determine compliance and gaps where the organization may be vulnerable
Ensure staff have supplies and equipment that are to be provided by the organization
Complete supervisory visits as per policy/regulation
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Clinical – Individual Tracers
Home health, Hospice or Personal Care aide tracers
Care plan is current and specific with duties on frequency or type
Visit notes reflect what is ordered on the plan of care
Perform supervisory visits as required by law and regulation or policy
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Clinical – Durable Medical Equipment
Maintain equipment maintenance up to date and documentation of that maintenance. EQ.01.03.01
Maintain equipment storage clearly marked and equipment stored in the appropriate section. EQ.01.05.01
Continue to monitor the State law/Respiratory Practice Act to determine what equipment can be delivered and set up by non-licensed personnel. LD.04.01.01.
Maintain required licenses per State regulations. (DME license)Maintain competencies for staff at appropriate intervals.Comply with DOT regulations for transport of oxygen (shipping
papers, vehicle placarded if required) at all times.
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Clinical – Pharmacy
Maintain pharmacy license and individual pharmacist license
Maintain a formulary and update at least annuallyMaintain documentation of destroyed or returned
drugsContinue to monitor high alert and hazardous drugs
for addition to the list of current drugsMonitor care plans and medication profiles
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Human Resources
Verification of Staff qualifications/licensureOrientation of StaffStaff trainingStaff competency upon hire and at least once
every three yearsStaff performance evaluations
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Organizational - Resources
Free Webinars and Webinar ReplaysStandards Interpretation Group (SIG)Dedicated Account Executive (AE)FSA Tool –Focused Standard
AssessmentPerspectives (Top 10 Standards)Home Care Bulletin
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Intracycle Monitoring
Using the ICM Profile
and
FSA Tool(Focused Standards Self-Assessment)
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Extranet Site
TJC Home Care Agency
One Renaissance Boulevard
Oakbrook Terrace, IL 61036
HCO ID 999999
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FSA Scoring SummaryViews selectable in the left navigation column
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FSA Reports TabViews selectable in the left navigation column
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Organization Preparation
and Assessment Methods and Styles Vary
Time and ResourcesStaff InvolvementOrganization is Key
Focus Assessment on Most Important Processes (Use FSA)
Prioritize, Prioritize, Prioritize
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18 Month Application Submission
The organization will review the General Application by clicking the ‘Next’ button, allowing the organization to view each section of information.
The organization should review the entire General Application, starting at TAB 1 – Your Organization.
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27 Month Application Submission
The organization will review the General Application by clicking the ‘Next’ button, allowing the organization to view each section of information.
The organization should review the entire General Application, starting at TAB 1 – Your Organization.
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27 Month Application Submission
The 27 Month General Application submission is unique as it will drive the survey complement for the triennial event.– The organization should take special note to add
the following:– Avoid dates– Accurate Unduplicated Annual Admissions and
Average Daily Census– Volumes are one key factor in determining
survey length
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27 Month Application Submission
The Account Executive will review the application, as well as make contact with the organization. – The contact may be by phone or email.
The Account Executive will discuss current operations at the organization briefly to confirm no additional changes are needed in the application prior to scheduling.
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27 Month Application Submission
The Account Executive will encourage the organization use Resources and Tools– E-dition– Survey Agenda– Survey Activity Guide– Leading Practice Library– Standards Interpretation Group
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Key Strategies to Achieve Ongoing Compliance – A
Providers Perspective
Patti Atteberry, RN, MSN, Director of Professional Practice, OSF Home Care Services
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Account Executive
Standards Interpretation Help Desk: 630-792-5900Joint Commission Resources: 877-223-6866 or www.jcrinc.com
Brenda Lamberti, BSSenior Business Development Specialist 630-792-5252 or [email protected]
Home Care Team ContactsJoint Commission Home Care Program
Help Desk: 630-792-5070 or [email protected]/accreditation/home_care.aspx
Margherita Labson
BSN, MSHSA, CPHQ, CCM, CGBExecutive Director 630-792-5284 [email protected]
Julia Finken
BSN, MBA, CPHQ, CSSBBAssociate Director630-792-5283 [email protected]
Monnette Geronimo
Business Development Specialist 630-792-5251 or [email protected]