TJC Surveys Resume — Know What to Expect Webinar · TJC Surveys Resume — Know What to Expect Webinar June 30, 2020 Welcome Robyn Thomason Director Education Program Development

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TJC Surveys Resume —Know What to Expect Webinar

June 30, 2020

Welcome

Robyn ThomasonDirector Education Program DevelopmentCalifornia Hospital Association

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Questions

Online questions only

Type your question in the Q & A box, press enter.

Continuing Education

Continuing education credits will be offered for this program for nursing. (Note: Approval still pending for compliance CEs.)

Full attendance and completion of the online evaluation and attestation of attendance are required to receive CEs for this webinar.

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Overview

Kiyomi BurchillVice President, PolicyCalifornia Hospital Association

Faculty

Gail Weinberger is the Director, Stakeholder Relations at TJC. With over 30 years there, Ms. Weinberger currently is responsible for relationship management with key TJC stakeholders including various advisory groups and state hospital associations. Previously, as the Director, Accreditation & Certification Policy & Administration, she was very involved with monitoring the changing healthcare landscape and its effect on TJC accreditation/certification process.

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Faculty

Chad Larson is the Executive Director of the Hospital Accreditation at TJC. In this role, he builds new client and partner relationships and leads strategic initiatives intended to provide value-added services within the hospital accreditation program.

Prior to his current role, he served as Director of Business Operations where he led the administration and management of operational, financial, and planning activities for the organization.

CHA Staff/Facilitator

Lois Richardson has a multifaceted job at CHA. She is responsible for evaluating the legal impact of proposed legislation/regulations on California hospitals and providing legal advice to CHA’s advocacy staff. In addition, she is the author of numerous CHA publications, including among other things, the Consent Manual, California Health Information Privacy Manual and California Hospital Survey Manual, and Cal/OSHA Safe Patient Handling Regulation Guidebook.

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Review of the Joint Commission’s Planfor the Resumption of Surveys/Reviews

Gail E. Weinberger, MA Chad Larson, MBADirector, Stakeholder Relations Executive Director, Hospital ProgramThe Joint Commission The Joint Commission

10© 2020 The Joint Commission. All Rights Reserved.

Agenda

Feedback from you on …

1. The Joint Commission’s decision process for for the resumption of surveys/reviews

2. Components of the survey process that may need to change

3. Additional considerations and support needs going forward

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In planning to resume surveys/reviews,

the key determinant is safety!

Safety for the organization!

Safety for the survey team!


Our plan is gradual and flexibleas states lift stay-at-home orders

and coronavirus cases decline!

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Decision Process for Determining Low-Risk Areas


https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

NY Times Data

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Two Data Points in Determining a “Low Risk” County

1. Current two weeks/Previous two weeks = < 1

2. Number of cases per 1,000 people = < 0.5

THEN

The County is identified as “low risk” or a GO county.

Note: A county may change from a GO/No Go if there is a downward trend.

AND


Go to TJC home page. Click Resources and the click Research from the drop‐down

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Select Operations Support Research home page. Once on the OSR home page then scroll down to

the dashboard

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JC OnlineArticleAnnouncingResumptionof Survey/ReviewActivity

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Account Executives Calls to Hospitals


If conditions at theorganization changesafter the call

The organization’s survey may not occur!

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California Counties Identified as “Low Risk”

June 3rd June 23rd

Contra Costa Contra Costa

Sacramento El Dorado

San Joaquin Mendocino

San Luis Obispo Sacramento

Shasta San Francisco

Stanislaus San Joaquin

San Luis Obispo

Santa Cruz

Shasta

Stanislaus


If there are any unique, additional factors that can/may influence the safety of the

survey, please share this information with yourAccount Executive!

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Modifications to theOn-Site Survey


Focus

− Will be on the organization’s current practices of providing safe, high quality care

− Will consist of a thorough assessment

− But, will not include a retroactive review of compliance between March 1, 2020 through the end of the emergency declaration

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− Limiting the number of people in group meetings

− Conducting tracers on patient units

− Avoiding areas with aerosolized procedures

− Driving in separate cars to off-site locations

Physical Distancing


Personal Protection Equipment (PPE)

− Surveyors will be required to wear masks and any other PPE required by the organization

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Use of Technology

− Record review

− Interviews with staff

− More staff are working remotely

− Simulation of high risk areas


High Risk Procedures by Program

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High Risk Procedures by Program (cont.)

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Standards Programs Implementation Date

Perinatal Safety HAP 1/1/2021Hospital Redeeming HAP 7/1/2020

Suicide NPSG 15 application to CAH CAH 7/1/2020NPSG Phase 1 Editorial Revisions & Moves to Standards

AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME

7/1/2020

Introduction to Standard LD.04.03.09 change for "off‐site"

AHC, BHC, CAH, HAP, NCC 7/1/2020

Burden Reduction Changes not implemented at March 2020 release (b/c waiting on CMS approval)

CAH, HAP 9/13/2020

Implementation Date for New/Revised Hospital Standards

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CMS Related Issues

− Virtual Surveys

− CoPs/Waivers

− Extensions of Anniversary Dates

− Lifting of Public Health Emergency

− Survey of Hospital-Based Outpatient Services


Areas in Hospital-Based Outpatient Services Requiring Review

− Life Safety Code Drawings

− Means of Egress

− Locked/blocked exits

− Exit access

− Exit discharge Illumination

− Battery back-up

− Corridor widths

− Corridor obstructions

− Visible exit signs

− Above Ceiling

− Electrical Outlets

− Electrical Panel

− Safety Data Sheets (SDS)

− Security/Access

− Smoke\Fire Barriers

− Fire Extinguishers Inspection

− Mounting and Visibility of Extinguishers

− MRI locations

− Biohazardous and Pharmaceutical Waste

− Alcohol-based hand rub (ABHR) Dispensers

− Eye Wash Stations

− Storage Rooms

− Medical Equipment

− High-level disinfection

− Compounding

− Cylinder Storage

− Sprinkler Heads/System

− Fire Drills

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Potential for Virtual Surveys or a Hybrid Virtual/Onsite Survey

− More care is provided by telemedicine/telehealth

− More organization staff are working remotely

− Need capability to survey high-risk areas

− Review documents prior to arriving on-site


Status of Virtual Surveys

− Involves both a virtual component & a

subsequent, limited survey

− Have been conducted in Nursing Care Centers,

hospital initials and Home Care

− Interest in DSC, LAB, ASC and the VA

− Proposals into CMS

− No follow-up survey for AFSs & MEDDEFs− Currently, addressing expansion, security concerns,

what areas/document can be reviewed virtually and cost

structure

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Checklist of Documents Required During a Hospital Virtual Survey

Examples of Required Documents

− Hospital license

− CLIA Certificates

− An organization chart

− List of all contracted services

− Agreement with outside blood supplier

− Performance improvement data from the past 12 months

− Analysis from a high risk process

− Infection Control Plan

− Medical Staff Bylaws and Rules and Regulations


Resources Available at www.jointcommission.org/COVID

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Example of a Recent Resource Posted on Website


1. What do you think of the Joint Commission’s decision process for the resumption of surveys/reviews?

2. What do you think of the proposed changes to the survey process?

3. What would you like the Joint Commission to do to help support you going forward?

Questions

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Contact Information

Chad Larson, MBAExecutive Director, Hospital Accreditation ProgramAccreditation and Certification OperationsThe Joint [email protected]

Gail Weinberger, MADirector, Stakeholder RelationsAccreditation and Certification OperationsThe Joint [email protected]

Kiyomi BurchillVice President, PolicyCalifornia Hospital [email protected]

Closing

Any Questions?

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Thank You and Evaluation

Thank you for participating in today’s webinar. An online evaluation will be sent to you shortly.

For education questions, contact:

CHA Education at (916) 552-7637 or [email protected]

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