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Accreditation Basics for Home Care Organizations: Strategies for Success Presented by: Julia Finken, BSN, MBA, CPHQ, CSSBB The Road to Quality
Accreditation Basics for Home
Care Organizations:
Strategies for SuccessPresented by:
Julia Finken, BSN, MBA, CPHQ, CSSBB
The Road to
Quality
The Joint Commission
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Independent, not-for-profit organization
Accrediting Home Care organizations since 1988
Accredits over 5,000 Home Care programs
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Today’s Discussion includes:
• First steps for a provider considering accreditation Eligibility requirements
How to apply
• Basics of the accreditation experience Standards to support your quality efforts
Strategies to enhance compliance
• Demonstrating your performance excellence Unique onsite survey experience
• Sustaining quality and sharing your success Quality distinction within the industry
Access to helpful tools and resources
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Why Joint Commission Accreditation?
Our Customers say it best…
“It’s the industry’s most highly regarded quality
framework for delivering consistent best-in-class care.”
“It provides opportunity to learn from the industry’s most
trusted name in quality and safety – on survey, from
their Standards team and through their many, free
online tools.”
Home Care Providers Eligible for Accreditation
• Home Health
• Hospice
• Personal Care and Support
• Pharmacy
• DMEPOS
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Pre-application Considerations
• Available accreditation options:
Accreditation
Accreditation with federal recognition
Deemed status for home health
Deemed status for hospice
Recognition for DMEPOS providers
Eligibility Requirements
Company is operational and providing care
Traditional accreditation and DMEPOS recognition
• Must have served 10 clients/patients, minimum of 2 active at time of survey
State notified that agency will use The Joint Commission for deemed
Home health deemed status
• Must have served 10 skilled patients, minimum of 7 active at time of survey
Hospice deemed status
• Must have served 5 patients, minimum of 3 active at the time of survey
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Additional Requirements for Deemed Status Applicants ONLY
Approved CMS Form 855a
State notified that agency will use The Joint Commission for deemed status
Successful test transmission of OASIS data (Home Health only)
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Applying for Accreditation is Easy
• You determine when you are ready to apply Create a “reverse road map”
Be realistic with your goals and expectations
• Reviewing the standards Register online for the Free 60-day access to help determine a
realistic target date
• Access to the application Register online for access to your extranet
• Access to supportive team members Business Development
Standards “Help Desk”
Account Executive
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• Visit http://www.jointcommission.org/accreditation/home_care.aspx
• Call the Home Care line at 630-792-5070
Request an Application
Access to Joint Commission Connect
Completing the Application
• Who has access to the extranet?
• Submit accurate organizational information Names, addresses, titles
Services provided
Hours of operation
• Submitting payment
• Scheduling the survey What is the “Ready Date”
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Getting Ready for Survey
• Make the E-dition your online handbook
• Compare performance to standards
• Make compliance everyday work
• National Patient Safety Goals
• Take advantage of the resources available to help you
Standards E-dition
As You Begin Survey Preparation
• Understand and identify laws/regulations for your state
• Use the Standards Manual as a Reference Guide Review Written Documents Required
Review National Patient Safety Goals
• Risk Areas/Clinical Service Emergency Preparedness
Infection Control
Human Resources
Leadership
Performance Improvement
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Accreditation Survey Prep
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Considerations for Deemed Status Survey Prep
• Home Health – Conditions of Participation Professional Advisory Group
Home Health CoPs: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf
• Hospice – Conditions of Participation Planning for scope of service
Hospice CoPs: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
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The Onsite Survey
• Patient/Client-centric & educational Observation of patient/client care with permission
Individual and system tracers guide the time
• Determining Compliance Observations shared as they are made
Leaders/managers encouraged to participate
Preliminary, printed findings provided on site
• Minimal interruption of care activities; flexible Survey agenda accommodates operational systems
and schedules
Joint Commission Surveyors
• Home Care Professionals Professional Experience in Home Care
Clinicians and administrators
Collaborative
Open communication
• Rigorous hands-on initial education
• Ongoing professional education
• Announced vs. Unannounced Posted on extranet at 7:30 a.m.
Surveyor bio and picture
Survey agenda
• Opening Conference - orientation to the organization
• Surveyor Planning
• Staff interviews
• Individual tracer activities, patient/client record review
• Systems tracers
• Daily Briefings
• Leadership session
• Exit Conference
Typical Onsite Survey Agenda
Other Survey Prep Tips
• Check your Extranet site daily
• Keep manuals, contracts, personnel files and documentation ready and accessible
• Once the surveyor arrives, have plan ready to notify the field
• Have a daily list of scheduled visits ready to go every morning
• Have your supervisor available or access to them
• The more you engage with your surveyor, the more meaningful your survey experience
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• On-site survey report will be posted on your extranet site within 10 days
• If your organization has a standard out of compliance – providers must submit evidence of standards compliance within a 45 – 60 day window
• Initial surveys, your accreditation decision is effective from the day The Joint Commission approves your FINAL evidence of standards compliance.
• For Joint Commission to recommend Medicare Certification to CMS: Standard-level deficiencies must be corrected
Condition-level deficiencies for first time surveys require a repeat survey
CMS is notified of our recommendations; they make the final certification notification
After the Survey
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• Based on services provided and individuals served
• Annual and on-site survey fees based on average daily patient/client volumes
• On-site survey fee Inclusive of all surveyor travel and expenses
Non-deemed surveys typically 1-2 days
Deemed status surveys typically at least 3 days
• Accreditation awarded for three-year cycle
Home Care Fees
Sustaining Quality…Sharing Success
• Industry perspective
• National voice
• Quality check
• Practical tools for performance excellence
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Joint Commission Perspectives newsletter - published monthly
Access to the customer-only Leading Practices Library
Home Care Bulletin, a complimentary newsletter
Online Media Kit with ideas to help publicize your achievement
Marketing support through a listing on Quality Check
Center for Transforming Healthcare
For Accredited Organizations
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Next Steps!
Go to:• http://www.jointcommission.org/accreditation/home_
care.aspx Register for the Free 60-day access to the electronic
standards (E-dition)
Review accreditation information
Assess your readiness Request the application
Questions? Contact the Home Care Team Phone: 630.792.5070
Email: [email protected]
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Supportive Resources
If you have a question about…... Please contact…...
GETTING STARTED:
How to get started
The overall accreditation process
The cost of accreditation
How to get a free trial of the standards
How to request an application
THE BUSINESS DEVELOPMENT TEAM:
Call: 630-792-5070
Email: [email protected]
Website: www.jointcommission.org
MANAGING THE ACCREDITATION PROCESS:
Completing the application
Scheduling a survey date
Specific issues related to ongoing
accreditation
AN ACCOUNT EXECUTIVE:
Call: 630-792-3007
OUR STANDARDS:
Complying with specific standards
THE STANDARDS HELP DESK:
Call: 630-792-5900, Option 6
Website: www.jointcommission.org/Standards
MANUALS, EDUCATION AND TRAINING:
Obtaining standards manual
Registering for a Joint Commission
education program
Staff training resources
JOINT COMMISSION RESOURCES (JCR):
Call: 877-223-6866
Email: [email protected]
Website: www.jcrinc.com
Time for Your Questions!
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Standards Interpretation Help Desk: 630-792-5900
Joint Commission Resources: 877-223-6866 or www.jcrinc.com
Brenda Lamberti, BS
Business Development Specialist
630-792-5252 or
Home Care Team ContactsJoint Commission Home Care Program
Help Desk: 630-792-5070 or [email protected]
www.jointcommission.org/accreditation/home_care.aspx
Margherita Labson
BSN, MSHSA, CPHQ, CCM, CGB
Executive Director
630-792-5284 or
Julia Finken
BSN, MBA, CPHQ, CSSBB
Associate Director
630-792-5283 or
