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The Joint Commission
Accreditation Experience
Anne Arundel County Providers Presentation
July 14, 2015
Peggy Lavin, LCSW, ACSW, DCSW Senior Associate Director
Behavioral Health Care Accreditation
© Copyright, The Joint Commission
Mission & Vision Reputation & Recognition What It Is & What It Will Do Accreditation Requirements The Surveyor Cadre & The Survey Process Assistance & Resources The Accreditation Process
The Joint Commission
Today’s Agenda
2
Mission and Vision
Our MissionTo 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.
Our Vision“All people experience the safest, highest quality, best-value health care across all settings”
3
Reputation - Across the Healthcare Continuum
Over 20,000 Health Care Organizations Accredited
Ambulatory Physical Health Care
Behavioral Health Care
Critical Access Hospital
Home Physical Health Care
Hospital
Laboratory Services
Nursing Care Centers
5
Reputation
Accrediting Behavioral Health Care organizations since 1969
Experienced in accrediting a broad range of settings/services
2190 Accredited Organizations• Over 8,017 sites• 54% not-for-profit• 27% for profit• 18% governmental agencies/facilities
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Accredited Behavioral Health Care Providers by State
20
2 4
24
3168
56
186
4
13
511439
100
34
347
42
17
27
613586
35
37
133
15
4
14
15
11
16
4
11
16
20
101
4
12
926
2025
5
16
98
10
7
DC 6
31
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Recognition
Excellent recognition by the physical and behavioral health care community for referrals and care coordination
Excellent recognition by 3rd party payers (Medicare/Medicaid/Commercial Insurance)
Valued by liability insurance carriers: http://www.jointcommission.org/liability_insurers
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Recognition
National Level Recognition:Federally deemed by SAMHSA as an approved provider of opioid treatment program accreditation
• There are 1,250 federally certified opioid treatment programs in the United States. The Joint Commission accredits 1/3 of these organizations.
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Recognition
State Level Recognition: Approved accreditor for state requirements or regulatory relief by 196 distinct administrative agencies within 49 states and the District of Columbia
16 states with Medicaid Health Home SPAS; 8 in process
4 states require Behavioral Health Home Certification
www.jointcommission.org/BHCS
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What Is Accreditation?
Accreditation is the process of inviting outside experts to conduct a review of your organization to validate and improve the safety and quality of care, treatment and services.
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What Will Accreditation Do For You?
Demonstrates the organization’s commitment to quality and safety.
Provides a management outline for leadership.
Supports a culture of excellence.
Integrates data use into daily operations.
Supports board members in meeting fiduciary responsibilities.
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What Do Our Accredited Organizations Say?
“We find that The Joint Commission provides state of the art guidance. And it helps our organization maintain state of the art treatment for our consumers.”
Patricia NovakDirector of Quality ImprovementAdult and Child Community Mental Health Center, Indianapolis
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Joint Commission Accreditation Requirements
Requirements found in Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) online via manual called “E-dition”
Based on Recovery/Resilience and Trauma-Informed concepts
Applicability of standards determined by setting(s), service(s)/program(s), and specific population(s)
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The Joint Commission Behavioral Health Care Accreditation Requirements
Care, Treatment, Services
Emergency Management
Environment of Care
Human Resources Management
Infection Control
Information Management
Leadership
Life Safety
Medication Management
National Safety Goals
Performance Improvement
Record of Care, Treatment, & Services
Rights of the Individual
Waived Testing
Sentinel Event Policy
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Outcome Measurement:
Performance Improvement Chapter
Outcomes of care, treatment or services
• Individual’s progress
• Populations outcome(s)
The Joint Commission Behavioral Health Care Accreditation Requirements
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LD.04.01.01: The organization complies with law and regulation
— EP 1: The organization is licensed, certified, or has a permit, in accordance with law and regulation to provide the care, treatment or services for which the organization is seeking accreditation from The Joint Commission.
— EP 2: The organization provides care, treatment or services in accordance with licensure requirements, laws and regulations.
— EP 3: Leaders act on or comply with reports or recommendations from external authorized agencies, such as accreditation, certification, or regulatory bodies.
BHC Standards Sampler
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CTS 02.01.01: The organization has a screening procedure for the early detection of risk of imminent harm to self or others.
─ EP. 1: The screening procedure determines the need for immediate intervention to protect the individual served or others.
─ EP. 2: The organization has a process for responding when an immediate risk of harm is identified.
─ EP. 3: The organization responds when it determines the individual served poses an immediate risk of harm to self or others.
BHC Standards Sampler
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PI.01.01.01: The organization collects data to monitor its performance.
─ EP. 1: The leaders set priorities for data collection.
─ EP. 2: The organization identifies the frequency for data collection.
─ EP. 16: The organization collects data on whether individual served was asked -
─ about treatment goals and needs
─ if her treatment goals and needs were met
─ view of the individual regarding how the organization can improve the safety of treatment provided.
BHC Standards Sampler
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CTS.02.03.07: For organization providing treatment to individuals with addictions: The assessment includes the individual's history of addictive behaviors.
─ EP. 1: For organization providing treatment to individuals with addictions: The history includes age of onset, duration, patterns of use.
─ EP. 2: For organization providing treatment to individuals with addictions: The organization obtains the individual's history of mental, emotional, behavioral, legal and social consequences of dependence or addition.
─ EP. 4: For organization providing treatment to individuals with addictions: The organization obtains the individual's history of physical problems associated with substance abuse, dependence, and other addictive behaviors.
BHC Standards Sampler
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CTS.01.01.01: The organization accepts into treatment only those individuals whose identified treatment needs it can meet.
─ EP. 1: “ icon" The organization has a written process for determining eligibility of individuals.
BHC Standards Sampler
26
D
D
The Joint Commission Surveyor Cadre
“I am always impressed by the experience, patience and thoroughness of our surveyors. With The Joint Commission as a partner in treatment, I feel like we have a wise mentor prodding us to do better, to think more clearly, and to be more efficient.”
Dustin Tibbitts, L.M.F.T. Executive Director InnerChange New Haven RTC, Provo, UT
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The Joint Commission Surveyor Cadre
Experienced behavioral health care professionals
Licensed clinicians
Trained, mentored, and monitored to deliver consistently valuable surveys
Trained to be culturally sensitive to diversity
Diverse cadre
• Experience
• Cultures/Ethnicity(Several Spanish speaking)
• Geography
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The Joint Commission Surveyor Cadre
Each surveyor surveys 12-15 times per year
Average length of service is 11 years
Surveying is a skill set that needs to be exercised
Surveyors share good practices
Surveyors help organizations in their commitment to provide safe and high quality care, treatment and services
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The On-Site Survey Process
Shortest survey is onesurveyor for two days
Surveys can be multiplesurveyors for multiple days
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The Initial On-Site Survey
At least 30 days notice is provided prior to the Actual on-site survey date once it is scheduled
33
The On-Site Survey Process
In sync with an organization’s normal operational systems
Customized to setting(s), service(s) and population(s) served
Focus is on actual delivery of care, treatment, and services–not just paperwork
• The “tracer method” follows a person’s experience in your treatment setting using interviews and observation to determine compliance with accreditation requirements
35
The On-Site Survey Process
Opening Session– Orientation to the Organization:
A discussion that provides an opportunity for the surveyor(s) to learn from you about your organization
• What you do• Who you serve• Your staff• Your philosophy and values• How you are organized
Ensures a meaningful on-site survey experience
36
The On-Site Survey Process
Individual “Tracers” Traces the continuum of care, treatment or services provided
Usually at least 60% of the on-site survey
Directly involves staff who provide care, treatment or services
Follows care, treatment or services provided throughout the organization
Individual served/family is involved as appropriate
Samples from all programs/services operated by organization
Surveyors attempt to minimize disruptions to the organization
37
The On-Site Survey Process
Safety First!
Buildings/Offices
Grounds
Transportation
Review of the Environment:
38
The On-Site Survey Process
Data Session: Discussion of how the
organization uses data
Identification of data to be collected
Aggregation and analysis (turn data into information)
Use of the information to drive performance improvement
Outcomes
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The On-Site Survey Process
Competence of staff session: Job Descriptions Staff selection Verification of education
and licensure Orientation and training
Determination of staffing Patterns
Competence assessment (initial and ongoing)
Performance evaluation
40
The On-Site Survey Process
Other Systems Tracers as Applicable: Medication Management
• Reviews the medication processes from prescribing to administrating
• Only reviews those aspects relevant to the organization
Infection Control• Reviews processes for preventing and responding
to infections
• Varies based on settings(e.g. facility-based vs. community-based)
41
The On-Site Survey Process
Daily Briefing: Start of each day after the first day
Review of the previous day’s activities
Identification of any areas of potential non-compliance with accreditation requirements
Opportunity for organization to clarify misunderstandings
Surveyor(s) offer suggestions for achieving full compliance
42
The On-Site Survey Process
Leadership Session:
Discussion with organization leadership
Last day of survey
Based on observations during the survey
An opportunity for the leaders and surveyor to discuss how the leaders can use the surveyors’ observations to move the organization forward
43
The On-Site Survey Process
Achieve Maximum Consultation: Educate Your Staff About the Survey Process:
Compliance & Education
Encourage organizational staff to be Open to Learn, Share, and Seek to Understand
If An Organization is Eager to Learn, Grow, and Improve, more consultation is likely
How will the organization measure the success of the survey?
Hint: It should not be the number of findings
44
The On-Site Survey Process
Closing Session and Report: Meeting with CEO, if desired, to review report
Meeting with staff chosen by organization
Report
• Organization receives written preliminary report of any compliance areas during the closing session
• Official report is provided on organization's extranet site within 10 days after survey
45
The On-Site Survey Process
The Survey Process After Accreditation: Triennial: 18–36 months after last full survey
Unannounced, except for 7-day notice for:
• Correction Settings
• “Small” Settings (Average daily census < 100)*
• Outpatient and Day Programs*
• 24 Hour Service Settings*
* No exception if program is operated as a component of a hospital
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What Do Our Accredited Organizations Say?
“We talked to several accredited behavioral health care organizations that were not Joint Commission accredited. Interestingly, those organizations felt that
their review was only procedural, and it did not help improve the quality of care. We were only interested in accreditation if it would help us improve. After talking with those organizations, I knew The Joint Commission was the right choice.”
Jeff Shearer, ACSW, LCSW, CAP - Founder Tykes & Teens
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Assistance and Resources
Behavioral Health Care team — Monthly Email Tips ([email protected])
Online tools to aid in the accreditation process www.jointcommission.org/BHCS
Online resources for accreditation activities
— Secure extranet site, eDition (online standards)
Publications and educational opportunities — available through Joint Commission
Resources www.jcrinc.com
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Assistance and Resources
Joint Commission
Behavioral Health Care
Annual ConferenceOctober 15-16, 2015
Rosemont, IL
An opportunity for a deep dive into the accreditation experience with our experts
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Assistance and Resources
Note: Register for webinars or view already conducted webinars at www.jointcommission.org/BHCS
2015 Complimentary Webinars
Jan 14 Basics of Accreditation: Myth-buster Edition
Feb 18 Roadmap to Accreditation: Your Path to Success
Mar 11 Strategies for a Successful Survey
May 13 Integrated Care: Considerations for Quality
Jun 10 Improving Reimbursement in Behavioral Health
Jul 8 Orientation to the Accreditation Requirements
Aug 12 Peer Services and Accreditation: Improving Outcomes
Sept 9 Roadmap to Accreditation: Your Path to Success
Nov 4 Strategies for a Successful Survey
Dec 2 New Standards and Best Practices in Medication-Assisted Opioid Treatment
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Assistance and Resources
Accreditation Workshop
When: August 12 Where: Doubletree by Hilton Philadelphia Valley Forge
301 West DeKalb PikeKing of Prussia, PA 19406
Time: 9:00 am – 1:30 pm (continental breakfast)
To Register or for more info:www.jointcommission.org/accreditation_workshop_0812/
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Assistance and Resources
Joint Commission Account Executive
An “Accreditation Coach” who will: Help you to fill out your application
Schedule and coordinate your initial on-site survey
Guide you through accreditation policies and procedures as you prepare for your survey
Assist you with any post-survey activities
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Assistance and Resources
Standards Interpretation Group (SIG) Joint Commission engineer, clinical social worker,
behavioral health care advanced nurse practitioner Experts on accreditation requirements
• Interpretation of accreditation requirements• Compliance issues• Applicability of standards and elements of performance
Provide examples from similar agencies/organizations
Call 630-792-5900 or submit online
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Assistance and Resources
What do our Accredited Organizations Say?
“Joint Commission’s accreditation process is unmatched in the industry. The support they give us is
unparalleled, whether it’s communication over the phone, on their website, or the various tools they provide us.”
David FettermanQuality Improvement/Compliance ManagerNew Vitae Mental Health Center, Quakertown PA
56
What Do Our Accredited Organizations Say?
“Our organization chose The Joint Commission because it helps us learn about best practices from other organizations,
and it helps us establish protocols in development of our own best practices.”
Denise DunnStandards and Compliance ManagerHazelton, Center City MN
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Strategies for a Successful Accreditation Experience
Appoint an Accreditation Champion— Communicate value and benefits of accreditation
— Provide leadership support
— Inspire staff
— Establish expertise and credibility
— Embed accreditation into daily operations and culture of organization
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Strategies for a Successful Accreditation Experience
Request access to online application for accreditation and manual of accreditation requirements
Ask for an orientation to the manual• Conduct a high level review of accreditation
requirements
• Complete application with a "ready" date
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Strategies for a Successful AccreditationExperience
Submit application and non-refundable deposit
Mine for your gold (current compliance level)
Use the Standards Interpretation Group (SIG)
Implement action plan to "fill the gaps“
Access Survey Activity Guide
Organize policies and procedures (Required Written Document)
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Strategies for a Successful Accreditation Experience
Conduct "mock" survey
Conduct "mock" tracer activities
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"To consult or not to consult. That is the question"Bill Shakespeare
Do It Yourself vs Hiring a Consultant• Time Frames• Cost• Human Resources
Other Resources to Utilize:• Peer Organizations• State or National Associations
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The Joint Commission
The Joint Commission’s Gold Seal of ApprovalTM means your organization has reached for and achieved the highest level of performance recognition available in the behavioral health field.
© Copyright, The Joint Commission
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Behavioral Health Care Accreditation Team
Tracy Griffin Collander, LCSWExecutive Director
[email protected] 630/792-5790
Peggy Lavin, LCSWSenior Associate Director
[email protected]/792-5411
Megan Marx, MPAAssociate Director
[email protected]/792-5131
Darrell Anderson, BASenior Business [email protected]
630/792-5866
Peter Vance, LPCC, CPHQField Director
630/792-578868
Behavioral Health Care Accreditation Team
For Accreditation/Certification Requirements Questions:
Merlin Wessels, LCSW
Associate Director
630/792-5900 Option # 6
(If your question concerns the Life Safety Chapter,
please call 630/792-5900 and ask for a Joint Commission engineer
or email [email protected])
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