Strategies for a Successful First ASC Survey Experience ......2020/01/28 · Strategies for a Successful First ASC Survey Experience: Lessons Learned from a Joint Commission Surveyor

Strategies for a Successful First ASC Survey Experience: Lessons Learned from a Joint Commission Surveyor

Pamela Roark, RN, Ambulatory Care SurveyorMike Dye, MPH, Sr. Business Development Specialist,

Ambulatory Care Services

January 28, 2020

2© 2019 The Joint Commission. All Rights Reserved.

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Joint Commission Mission

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.


The Joint Commission:Four Entities – One Vision

All people always experience the

•SAFEST

•HIGHEST QUALITY

•BEST-VALUE

Health care across all settings


Our Principle = Zero HarmZero falls Zero complications of care Zero infections Zero missed opportunitiesZero overuseZero lost revenue

Zero harm events of any kind

Strategies for Success:ASC Survey Preparation


Strategies for SuccessOur Goals:– Conduct a meaningful assessment– Inspire your organization to improve– Provide new information/sharing best

practices– Collaborative/collegial approach– Transparency; communicate findings

throughout the survey


Strategies for Success

− Continuous Survey Readiness!− Regular meeting agenda item =

accreditation− Involve everyone – “Spread the Wealth”− Assign E-dition chapters


Strategies for Success

− Surveyor Activity Guide− “Ready-to-Go” List− Review E-dition− Applicability Grid− Mock Tracers− Resources and Tools Intranet and Extranet− On-Site Survey Activities


Survey Activity Guide (SAG)

Available on your Joint Commission Connect extranet website - includes:

− Survey Activity Guide (SAG)− Preparing for surveyor arrival− Survey document list − Survey activities− What happens after survey?


Survey Activity Guide


Survey Document List− “Ready-to-Go” List− Organize key documents

in a binder− Continuously update

binder – always be “Survey Ready!”


E-dition: On-Line Standards Manual


E-dition (cont.)

− Review the Standards and Elements of Performance


Ambulatory Care Standards Format


Required Written Documentation (RWD)


Applicability Grid


Mock Tracers− Staff member acts as “Surveyor”− Trace patient from admission to discharge− Put yourself in patient’s shoes− Assess compliance with the standards

and Elements of Performance− Sample “mock tracer” tools available


Free Tools and ResourcesJoint Commission Website


Free Tools and Resources (cont.)Joint Commission Connect


Free Tools and Resources (cont.)− Perspectives official monthly

communication− Environment of Care News− Targeted Solution Tools (TSTs)− Frequently Asked Questions (FAQs)− Standards Interpretation Group (SIG)

on-line question submission− AmBuzz ambulatory care blog

https://www.jointcommission.org/standards_information/jcfaq.aspx?ProgramId=1&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=


Center for Transforming Healthcare (CTH)

• Hand Hygiene• Wrong Site Surgery• Hand-Off

Communications• Preventing Falls• Surgical Site Infections• VTE Prevention


When You Have Questions…− “Call a friend!”

− Accreditation process? Your Account Executive P.(630) 792-3700

− Standards? Connect with Standards

Interpretation Group (SIG)

https://www.jointcommission.org/standards_information/jcfaq.aspx?ProgramId=1&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=

Strategies for SuccessOnsite Survey Activities


Accessing Your Survey Information− To access information about your survey, proceed to your

Joint Commission extranet site by accessing www.jointcommission.org Click on Login, then Joint Commission Connect under the

Action Center section Enter your login and password

− Notification of scheduled Joint Commission event authorizing the presence of the surveyors for the unannounced survey

− Surveyor(s) name, picture and biographical sketch− Scheduled survey dates− Survey agenda

http://www.jointcommission.org/


Accessing Your Survey Information


Getting the Most Value From Your Survey

− Be prepared− Have your files and documents well

organized− Schedule several patient visits so the

surveyor can conduct tracers − Encourage all stakeholders (including

physicians) to be active participants


Three Things Successful Surveys Have in Common

− Engaged leaders who foster teamwork and value the opportunity to learn and improve

− Staff who take ownership for patient safety and quality and feel empowered to make changes

− An organization that "owns" its processes, good or bad


Hints During the Survey

− It’s OK not to know the answer− Avoid the ventriloquist act, let everyone be involved− Please ask questions!− We are reviewing systems, not individuals− Use your surveyor as a resource


Hints During the Survey

− The agenda is flexible, if changes are needed, please ask− We’ll notice things you’ve never seen− Time will go by very quickly− If we ask for documents, please provide them as soon as

possible− You will have an “Aha!” Joint Commission moment


Individual Patient Tracer

− Pre-operative information/communication− Patient reception and intake process− Pre-procedural assessment− Intra-operative processes− Post-procedure monitoring− Emergency procedures− Room and equipment turnover− Patient discharge from facility− Patient follow up


Individual Patient TracerMay Engage:

− Patient− Family− Physician− Nursing− Support staff− Vendors− Contractors− Anyone!


System Tracers− Data Management− Infection Prevention− Medication Management− Leadership− Environment of Care/Emergency Management− Life Safety Code− Competency Assessment− Credentialing and Privileging

Strategies for SuccessAfter the Survey


After the Survey− SAFER Matrix− Preliminary Report− Final Report− Evidence of Standards Compliance (ESC)− Final Accreditation Determination


Survey Analysis for Evaluating Risk (SAFER) Matrix


SAFER Matrix Details


SAFER Matrix: Follow-up Activity


Post Survey Process− Summary of Survey Findings Report will not include

potential accreditation decision− Official survey report posted on organization’s extranet

site post-survey will include the potential accreditation decision

− Survey reports will be posted within 5 to 7 business days after survey unless report requires central office review

− Final accreditation decision will be made after Joint Commission receives and approves Evidence of Standards Compliance (ESC)


Clarification Submission− Clarification process used when organization believes it

was actually in compliance with applicable standard at time of survey and thus should not have been cited as noncompliant.

− Within 10 business days after final report posted to Joint Commission Connect extranet site

− Findings of “lack of required documentation at time of survey” are not eligible for clarification process

− Complete all elements of submission tool


Accreditation− Upon approval of all required ESC submissions− Length of time to receive accreditation determined by

when ESC submitted


2019 Most Challenging Ambulatory Care Standards


Most Challenging Ambulatory Care Standards

− Top 10 Most Challenging Standards− Infection Control− Life Safety− Environment of Care− Human Resources− Medication

Management


High Level Disinfection and Sterilization Scoring 4-1-1 on Survey Enhancements


Hierarchical Approach to IC Standards− Regulation− Centers for Medicare & Medicaid Services (CMS) if

deemed− Instructions for Use− Evidence-Based Guidelines or National Standards− Position Statements − Facility Policy


Hierarchical Approach to IC Standards


Documents

Strategies for a Successful First ASC Survey Experience ......2020/01/28 · Strategies for a Successful First ASC Survey Experience: Lessons Learned from a Joint Commission Surveyor