The Nuts and Bolts of The Nuts and Bolts of Joint Commission Joint Commission
Accreditation:Accreditation:Changes for 2006Changes for 2006AARC 51AARC 51stst International Respiratory International Respiratory
CongressCongress
Bob Floro, RRTBob Floro, RRTAssociate Director Associate Director
Joint Commission Home Care Accreditation Joint Commission Home Care Accreditation ProgramProgram
December 6, 2005December 6, 2005
TodayToday
Requirement Changes and Additions - Requirement Changes and Additions - 20062006– APR’sAPR’s– NPSG’sNPSG’s– StandardsStandards
Accreditation and Survey ProcessesAccreditation and Survey Processes Unannounced Surveys and Unannounced Surveys and
Annualization Plans Annualization Plans
Requirement Changes Requirement Changes and Additions - 2006and Additions - 2006
Accreditation Accreditation Participation Participation
RequirementsRequirements
APR’sAPR’s APR 1 Official records and reportsAPR 1 Official records and reports APR 2 Report changes in application APR 2 Report changes in application
informationinformation APR 3 Permits surveysAPR 3 Permits surveys APR 10 Misrepresentation of informationAPR 10 Misrepresentation of information APR 11 Misrepresentation of accreditation APR 11 Misrepresentation of accreditation
statusstatus APR 12 Surveyor not used for APR 12 Surveyor not used for
accreditation-related counseling services accreditation-related counseling services APR 13 Survey observation by surveyor APR 13 Survey observation by surveyor
management staffmanagement staff
Accreditation Participation Accreditation Participation RequirementsRequirements
APR 8 Public noticeAPR 8 Public notice– EP 1 – If individual has any concerns EP 1 – If individual has any concerns
about patient care or safety, individual about patient care or safety, individual is encouraged to contact organization’s is encouraged to contact organization’s managementmanagement New 2006
APR 14 (Revised)APR 14 (Revised)
Effective January 1, 2006Effective January 1, 2006
Addresses annual requirements for Addresses annual requirements for Periodic Performance Review Periodic Performance Review
New 2006
APR 17 (New)APR 17 (New)
Effective July 1, 2005Effective July 1, 2005– EP 1 - Staff educated that any EP 1 - Staff educated that any
employee who has concerns about employee who has concerns about safety or quality of care may report safety or quality of care may report these concerns to Joint Commissionthese concerns to Joint Commission
– EP 2 - Staffed informed that no EP 2 - Staffed informed that no disciplinary action taken if they reportdisciplinary action taken if they report
– EP 3 - Organization demonstrates EP 3 - Organization demonstrates commitment by taking no retaliation commitment by taking no retaliation disciplinary actions against disciplinary actions against employees who reportemployees who report
APR 18 (New) APR 18 (New)
Effective July 1, 2005Effective July 1, 2005
Organization adheres to Joint Organization adheres to Joint Commission published guidelines for Commission published guidelines for describing information in its Quality describing information in its Quality ReportReport– TruthfulTruthful– Accurate Accurate
APR 19 (New) APR 19 (New)
Effective June 1, 2005 Effective June 1, 2005
Meet all requirements for timely Meet all requirements for timely submission of data and information to submission of data and information to Joint Commission Joint Commission
2006 National Patient 2006 National Patient Safety Goals for HMESafety Goals for HME
Joint Commission 2006Joint Commission 2006National Patient Safety Goals National Patient Safety Goals
(NPSGs) for HME (NPSGs) for HME
1. Patient identification1. Patient identification
2. Communication among caregivers2. Communication among caregivers
7. Health care-associated infections7. Health care-associated infections
8. Medication reconciliation8. Medication reconciliation
9. Patient falls9. Patient falls
13. Patient involvement in safety13. Patient involvement in safety
Goal 1Goal 1 Improve the accuracy of Improve the accuracy of patient identification.patient identification.
1A1A Use at least two patient Use at least two patient identifiers whenever identifiers whenever administering administering medicationsmedications or blood products; or blood products; taking taking blood samplesblood samples and other specimens and other specimens for clinical testing, or providing any for clinical testing, or providing any other other treatments or procedurestreatments or procedures..
Clinical Respiratory Services ONLYClinical Respiratory Services ONLY
Goal 2Goal 2 Improve the effectiveness Improve the effectiveness of communication among of communication among
caregivers. caregivers. 2A2A For For verbal or telephone ordersverbal or telephone orders or for or for
telephonic telephonic reporting of critical test resultsreporting of critical test results, verify , verify the complete order or test result by having the the complete order or test result by having the person receiving the order or test result "read-person receiving the order or test result "read-back" the complete order or test result.back" the complete order or test result.
2B2B Standardize a list of abbreviations, acronyms Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the and symbols that are not to be used throughout the organization.organization.
2C2C Measure, assess and, if appropriate, take Measure, assess and, if appropriate, take action to improve the action to improve the timeliness of reportingtimeliness of reporting, and , and the timeliness of receipt by the responsible the timeliness of receipt by the responsible licensed caregiver, of licensed caregiver, of critical test resultscritical test results and and values. values. (CRS RT only)(CRS RT only)
2E2E Implement a standardized Implement a standardized approach to "hand off" approach to "hand off" communications, including an communications, including an opportunity to ask and respond to opportunity to ask and respond to questions. questions.
Goal 2Goal 2 Improve the effectiveness Improve the effectiveness of communication among of communication among
caregivers. caregivers.
New 2006
Goal 7Goal 7 Reduce the risk of health Reduce the risk of health care-associated infectionscare-associated infections
7A7A Comply with current Centers for Comply with current Centers for Disease Control and Prevention (CDC) Disease Control and Prevention (CDC) hand hygiene guidelines.hand hygiene guidelines.
7B7B Manage as sentinel events all Manage as sentinel events all identified cases of unanticipated death or identified cases of unanticipated death or major permanent loss of function major permanent loss of function associated with a health care-associated associated with a health care-associated infection.infection.
Goal 8Goal 8 Accurately and completely Accurately and completely reconcile medications across the reconcile medications across the
continuum of care.continuum of care.
8A8A Implement a process for obtaining Implement a process for obtaining and documenting a complete list of the and documenting a complete list of the patient's current medications upon the patient's current medications upon the patient's entry to the organization and patient's entry to the organization and with the involvement of the patient. This with the involvement of the patient. This process includes a comparison of the process includes a comparison of the medications ordered for the patient while medications ordered for the patient while under the care of the organization to those under the care of the organization to those on the list. on the list. CRS ONLYCRS ONLY
New 2006
Goal 9Goal 9 Reduce the risk of patient Reduce the risk of patient harm resulting from falls.harm resulting from falls.
9B9B Implement a fall reduction Implement a fall reduction
program and evaluate the program and evaluate the effectiveness of the programeffectiveness of the program
New 2006
Goal 13Goal 13 Encourage the active Encourage the active involvement of patients and their involvement of patients and their families in the patient's care as a families in the patient's care as a
patient safety strategy.patient safety strategy.
13A13A Define and communicate the Define and communicate the means for patients and their families means for patients and their families to report concerns about safety and to report concerns about safety and encourage them to do so.encourage them to do so.
New 2006
NPSG Interpretive NPSG Interpretive GuidelinesGuidelines
On Joint Commission Website On Joint Commission Website www.jcaho.orgwww.jcaho.org
Program-specificProgram-specific Used by surveyorsUsed by surveyors Promotes consistencyPromotes consistency
For More Information on the For More Information on the NPSGsNPSGs
The Home Care The Home Care Accreditation ManualAccreditation Manual
and Standards and Standards (New for 2006)(New for 2006)
Standards Review and Standards Review and RewriteRewrite
All standards extensively reviewed and All standards extensively reviewed and modified every 2 yearsmodified every 2 years
– Internal EvaluationInternal Evaluation StandardsStandards ResearchResearch Accreditation OperationsAccreditation Operations Surveyor management & DevelopmentSurveyor management & Development Home Care ProgramHome Care Program
– External EvaluationExternal Evaluation Advisory CouncilsAdvisory Councils Professional and Technical Advisory Committee (PTAC)Professional and Technical Advisory Committee (PTAC) Standards and Survey Process (SSP)Standards and Survey Process (SSP) Board of CommissionersBoard of Commissioners
Components of 2006 Components of 2006 StandardsStandards
StandardsStandards are statements defining are statements defining performance expectations, structures and performance expectations, structures and processes.processes.
Rationale Rationale is background, purpose and is background, purpose and educational informationeducational information
Elements of performance (EPs) Elements of performance (EPs) are are specific statements of expectations and specific statements of expectations and are the only scorable part of the standard. are the only scorable part of the standard.
111 Home Medical 111 Home Medical Equipment Standards - 2006Equipment Standards - 2006
RI RI (19)(19) RIGHTS, ETHICS
AND RESPONSIBILITIES
PCPC (18) (18) PROVISION OF CARE,
TREATMENT AND SERVICES
MM MM (8)(8) MEDICATION
MANAGEMENT(CRS ONLY)
IC IC (5)(5)INFECTION
SURVEILLANCEPREVENTION
CONTROL
PI PI (6)(6) IMPROVING
ORGANIZATION PERFORMANCE
LD LD (21)(21)LEADERSHIP
EC EC (23)(23)ENVIRONMENTAL
SAFETY AND EQUIPMENT
MANAGEMENT
HR HR (7)(7)MANAGEMENT OF
HUMAN RESOURCES
IM IM (10)(10)MANAGEMENT OF
INFORMATION
Sample Standard
Standard RI.2.30 Patients are involved in decisions about care, treatment, and services provided.The standard above applies to the following services:
HMEHME CRCRSS
RTRT
RI.2.3RI.2.300
XX XX XX
Rationale for RI.2.30 Making decisions about care, treatment, and services sometimes presents questions, conflicts, or other dilemmas for the [organization] and the [patients], family, or other decision makers. These dilemmas may involve issues about admission; care, treatment, and services; or discharge. The [organization] works with [patients], and when appropriate their families, to resolve such dilemmas.
Sample Standard
Elements of Performance for Elements of Performance for RI.2.30RI.2.30
The elements of performance below The elements of performance below apply to the following services:apply to the following services:
HMEHME CRSCRS RTRT
EP 1EP 1 XX XX XX
EP 2EP 2 XX XX XX
EP 3EP 3 XX XX XX
EP 4EP 4 XX XX XX
EP 5EP 5 XX XX XX
(M) C (M) C 1. Patients are involved in decisions about their care,1. Patients are involved in decisions about their care, treatment, and services.treatment, and services.
(M) C(M) C 2. Patients are involved in resolving dilemmas about 2. Patients are involved in resolving dilemmas about care,care,
treatment, and services.treatment, and services.
(M) C(M) C 3. A surrogate decision maker, as allowed by law, is 3. A surrogate decision maker, as allowed by law, is identified when a patient cannot make decisions about his or identified when a patient cannot make decisions about his or her care, treatment,her care, treatment,
and service.and service.
(M) C(M) C 4. The legally responsible representative approves care, 4. The legally responsible representative approves care, treatment, and service decisions.treatment, and service decisions.
(M) C(M) C 5. The family, as appropriate and as allowed by law, with 5. The family, as appropriate and as allowed by law, with permission of the [patient] or surrogate decision maker, is permission of the [patient] or surrogate decision maker, is involved in care, treatment, and service decisions.involved in care, treatment, and service decisions.
Sample Standard
Ethics, Rights and Ethics, Rights and ResponsibilitiesResponsibilities
RI.1.20 Potential conflicts RI.1.20 Potential conflicts {PROBLEMATIC}{PROBLEMATIC}
RI.2.40 - Informed ConsentRI.2.40 - Informed Consent– Implementation issuesImplementation issues– Consent for care vs. consent for Consent for care vs. consent for
treatmenttreatment
Ethics, Rights and Ethics, Rights and ResponsibilitiesResponsibilities
RI.2.90 – Informed of unanticipated RI.2.90 – Informed of unanticipated outcomesoutcomes– implementation issuesimplementation issues– Reviewable Sentinel EventsReviewable Sentinel Events
RI.2.160 Right to pain management RI.2.160 Right to pain management – No longer applicable for HME, Clinical No longer applicable for HME, Clinical
Respiratory, or Rehab TechnologyRespiratory, or Rehab Technology
Provision of Care, Provision of Care, Treatment, ServicesTreatment, Services
– PC.2.20 The organization defines PC.2.20 The organization defines assessment activitiesassessment activities
Understand applicable bulletsUnderstand applicable bullets
EP 11 - No longer applicable for Clinical EP 11 - No longer applicable for Clinical Respiratory Respiratory
Provision of Care, Provision of Care, Treatment, ServicesTreatment, Services
PC.5.20 Physician orders PC.5.20 Physician orders {COMPLIANCE {COMPLIANCE PROBLEM #2 FOR HME} PROBLEM #2 FOR HME}
PC.5.50 – Care provided in an PC.5.50 – Care provided in an interdisciplinary and collaborative mannerinterdisciplinary and collaborative manner– How to implement with limited How to implement with limited
resourcesresources
Medication ManagementMedication Management
Nothing applicable for HME onlyNothing applicable for HME only
To be discussed in Clinical To be discussed in Clinical Respiratory Services sectionRespiratory Services section
Surveillance, Prevention, and Control of Surveillance, Prevention, and Control of Infection (New Chapter for 2005)Infection (New Chapter for 2005)
IC.1.10 IC ProgramIC.1.10 IC Program IC.2.10 Identifying risks IC.2.10 Identifying risks
{Surveillance implementation {Surveillance implementation issues}issues}
IC.3.10 Priorities based on risksIC.3.10 Priorities based on risks IC.4.10 Strategies to implement IC.4.10 Strategies to implement
goalsgoals IC.5.10 Program evaluation IC.5.10 Program evaluation
Surveillance, Prevention, Surveillance, Prevention, and Control of Infectionand Control of Infection
IC.6.10 Influx of infectious patients IC.6.10 Influx of infectious patients {Implementation issues for HME}{Implementation issues for HME}
IC.7.10 Qualified individualsIC.7.10 Qualified individuals IC.8.10 CollaborationIC.8.10 Collaboration IC.9.10 Adequate resourcesIC.9.10 Adequate resources
Improving Organization Improving Organization PerformancePerformance
Categories within PI chapterCategories within PI chapter– PI.1.10 Data collectionPI.1.10 Data collection
EP 4 – Med Management - Applicable to EP 4 – Med Management - Applicable to Clinical RespiratoryClinical Respiratory
EP 5 – Blood products - Not applicable to EP 5 – Blood products - Not applicable to any HMEany HME
Improving Organization Improving Organization PerformancePerformance
Categories within PI chapterCategories within PI chapter– PI.2.10 Data aggregation and analysis PI.2.10 Data aggregation and analysis
{COMPLIANCE PROBLEM #6 FOR HME} {COMPLIANCE PROBLEM #6 FOR HME} – PI.2.20 Undesirable trends analyzedPI.2.20 Undesirable trends analyzed– PI.2.30 Processes for sentinel eventsPI.2.30 Processes for sentinel events– PI.3.10 Data use for performance PI.3.10 Data use for performance
improvementimprovement
PI.3.20PI.3.20 Process to identify and Process to identify and reduce safety risks – new in 2005reduce safety risks – new in 2005– EP 1 -EP 1 - Selecting high risk processSelecting high risk process– EP 2 -EP 2 - Describing processDescribing process– EP 3 -EP 3 - Identifying process Identifying process
breakdownsbreakdowns– EP 4 -EP 4 - Effects of breakdownsEffects of breakdowns– EP 5 -EP 5 - Prioritize breakdownsPrioritize breakdowns
Improving Organization Improving Organization PerformancePerformance
PI.3.20PI.3.20 Process to identify and Process to identify and reduce safety risks (cont’d)reduce safety risks (cont’d)– EP 6 – Determine why occurredEP 6 – Determine why occurred– EP 7 – RedesignEP 7 – Redesign– EP 8 – Test and implementEP 8 – Test and implement– EP 9 – Monitor effectiveness of redesignEP 9 – Monitor effectiveness of redesign
Improving Organization Improving Organization PerformancePerformance
LeadershipLeadership
LD.3.20 Issues regarding same LD.3.20 Issues regarding same level of carelevel of care
LD.3.50 Contracts and contract LD.3.50 Contracts and contract management management {Compliance {Compliance problem}problem}
LD.3.90 Written P&P requirement LD.3.90 Written P&P requirement for patient carefor patient care
LeadershipLeadership
LD.4.40 Integrated patient safety LD.4.40 Integrated patient safety program – not a new conceptprogram – not a new concept– EP 1 - EP 1 - Assignment to manageAssignment to manage– EP 2 - Definition of scopeEP 2 - Definition of scope– EP 3 - Incorporate organization wideEP 3 - Incorporate organization wide– EP 4 - Procedures to respondEP 4 - Procedures to respond
LeadershipLeadership
LD.4.40 (cont’d)LD.4.40 (cont’d)– EP 5 - Systems for reportingEP 5 - Systems for reporting– EP 6 -EP 6 - Responses to unanticipated Responses to unanticipated
adverse events and proactive risk adverse events and proactive risk assessment / reductionassessment / reduction
– EP 7 -EP 7 - Staff support systemStaff support system– EP 8 -EP 8 - Report to governanceReport to governance
Environmental Safety and Environmental Safety and Equipment ManagementEquipment Management
– EC.4.10 Emergency management EC.4.10 Emergency management addressed addressed {COMPLIANCE PROBLEM #1 {COMPLIANCE PROBLEM #1 FOR HME}FOR HME} EP 1 – Rewrite to exclude HVA languageEP 1 – Rewrite to exclude HVA language EP 2 - Eliminated link to county or region EP 2 - Eliminated link to county or region
command structurecommand structure
– EC.4.20 Regular drills to test EC.4.20 Regular drills to test emergency management emergency management
{COMPLIANCE PROBLEM #7 FOR HME}{COMPLIANCE PROBLEM #7 FOR HME}– EC.5.10 - Fire safetyEC.5.10 - Fire safety
New EPs 11 & 12 – Fire-safe environment New EPs 11 & 12 – Fire-safe environment in buildings - Applicable to HME all servicesin buildings - Applicable to HME all services
EC (cont.)EC (cont.)
Patient equipment management Patient equipment management – EC.6.30 Plans for selection, delivery, EC.6.30 Plans for selection, delivery,
setup, and maintenancesetup, and maintenance– EC.6.40 DeliveryEC.6.40 Delivery– EC.6.50 SetupEC.6.50 Setup– EC.6.60 Maintenance, testing, inspectionEC.6.60 Maintenance, testing, inspection
{COMPLIANCE PROBLEM #5 FOR HME}{COMPLIANCE PROBLEM #5 FOR HME}}}
EC (cont.)EC (cont.) Patient equipment management (cont.) Patient equipment management (cont.)
– EC.6.70 Emergency maintenanceEC.6.70 Emergency maintenance– EC.6.80 24 hr emergency servicesEC.6.80 24 hr emergency services– EC.6.90 BackupEC.6.90 Backup– EC.6.100 StorageEC.6.100 Storage– EC.6.110 TrackingEC.6.110 Tracking
Organization equipment management Organization equipment management – EC.6.120 to 6.130 Equipment used by staffEC.6.120 to 6.130 Equipment used by staff– EC.7.10 Not applicable for Clinical EC.7.10 Not applicable for Clinical
RespiratoryRespiratory
Management of Human Management of Human ResourcesResources
HR.1.10 Staffing adequacy – HR.1.10 Staffing adequacy – implementation and survey prep issueimplementation and survey prep issue
HR.1.20 Qualifications consistent with job HR.1.20 Qualifications consistent with job responsibilitiesresponsibilities
– EP 3 – Verification of licensure if only required EP 3 – Verification of licensure if only required by organizationby organization
– EP 4 – Primary Source verification if required by EP 4 – Primary Source verification if required by organization organization
HR.3.10 Competency programHR.3.10 Competency program {COMPLIANCE{COMPLIANCE PROBLEM #3 FOR HME} PROBLEM #3 FOR HME}
Management of InformationManagement of Information IM.2.10 Privacy and confidentiality of IM.2.10 Privacy and confidentiality of
information – addresses HIPAAinformation – addresses HIPAA– Major rewrite and numbering of EPsMajor rewrite and numbering of EPs
IM.2.30 IM.2.30 – New EP 4New EP 4 - Business continuity plan is - Business continuity plan is
implemented if systems are interrupted implemented if systems are interrupted
IM.6.20 Patient-specific information IM.6.20 Patient-specific information {COMPLIANCE PROBLEM #4 FOR HME} {COMPLIANCE PROBLEM #4 FOR HME} – New EP 9 - Individuals/organization (from EP New EP 9 - Individuals/organization (from EP
8)8)
Clinical Clinical Respiratory Respiratory
ServicesServices(CRS)(CRS)
12 Possible Additional Standards 12 Possible Additional Standards
Additional Interpretations in Additional Interpretations in OthersOthers
CRS StandardsCRS Standards
RI.2.80 – End of life decisionsRI.2.80 – End of life decisions PC.4.10 – POCPC.4.10 – POC PC.5.10 – Correct order and PC.5.10 – Correct order and
verificationverification MM.1.10 - Patient specific MM.1.10 - Patient specific
informationinformation MM.3.20 - Clear ordersMM.3.20 - Clear orders MM.5.10 – Safe administration MM.5.10 – Safe administration
CRS Standards (cont’d)CRS Standards (cont’d)
MM.6.10 – Monitoring meds MM.6.10 – Monitoring meds administeredadministered
MM.6.20 – Response to ADRsMM.6.20 – Response to ADRs MM.7.10 – High risk/high alert processMM.7.10 – High risk/high alert process MM.7.40 – Investigational medsMM.7.40 – Investigational meds MM.8.10 – Evaluate med management MM.8.10 – Evaluate med management
planplan PI.2.20 - Undesirable trends analyzedPI.2.20 - Undesirable trends analyzed
Accreditation Accreditation and Survey Processesand Survey Processes
New 2006
Extranet Application Extranet Application for Accreditationfor Accreditation
Available on a secure, password-Available on a secure, password-protected web spaceprotected web space
Improves quality & consistency of dataImproves quality & consistency of data– Pre-population and UpdatePre-population and Update– Same data used by surveyorSame data used by surveyor
Allows for efficiency in Joint Commission Allows for efficiency in Joint Commission analysis of organizational informationanalysis of organizational information
Priority Focus Process Priority Focus Process ProcessProcess
Logic brings consistency to Joint Logic brings consistency to Joint Commission review of pre-survey Commission review of pre-survey datadata
Shapes survey processShapes survey process
Rules-Driven Priority Focus ProcessRules-Driven Priority Focus Process
= Previous= Current
APS Rules
Priority
Focus Rules
Previous On-site Survey Data
Standards
Complement
Length
PFP Output: •PFA•CSG•Relevant Standards, •Survey Activity
E-App
External Data: PMS & publicly available data
Surveyor Feedback
Loop
Fee
APS = Application Processing System
Priority Focus AreasPriority Focus AreasTop 4 assignedTop 4 assigned
– Assessment and Assessment and Care/ServicesCare/Services
– CommunicationCommunication– Credentialed Credentialed
PractitionersPractitioners– Equipment UseEquipment Use– Infection ControlInfection Control– Information Information
ManagementManagement– Medication Medication
ManagementManagement
– Organization Organization StructureStructure
– Orientation and Orientation and TrainingTraining
– Rights and EthicsRights and Ethics– Physical Physical
EnvironmentEnvironment– Quality Quality
Improvement Improvement Expertise and Expertise and ActivityActivity
– Patient SafetyPatient Safety– StaffingStaffing
Clinical Service GroupsClinical Service GroupsAssigned as appropriateAssigned as appropriate
Home Medical EquipmentHome Medical Equipment HME with Clinical Respiratory HME with Clinical Respiratory
ServicesServices HME with Rehabilitation TechnologyHME with Rehabilitation Technology HME with CRS and RTHME with CRS and RT
Tracer MethodologyTracer Methodology ProcessProcess surveyors use during on-site surveyors use during on-site
surveysurvey
Follow Follow patientspatients through through organization’s processes and organization’s processes and services experienced by patientservices experienced by patient
Review Review systems systems that support carethat support care
Surveyed across programsSurveyed across programs
Unannounced SurveysUnannounced Surveysand Annualization Plansand Annualization Plans
New 2006
Unannounced Surveys in Unannounced Surveys in 20062006
Value: Value: – Organizations Organizations stop preparing to be surveyedstop preparing to be surveyed
and start preparing to embed qualityand start preparing to embed quality
– Organizations Organizations report periodicallyreport periodically as they as they conduct their own tracer activities - PPRconduct their own tracer activities - PPR
– Scores are eliminatedScores are eliminated
– Validation of Validation of continual standards compliancecontinual standards compliance
Unannounced Changes Unannounced Changes Advanced mailingAdvanced mailing of applications for 2006 of applications for 2006
12 month cycle for application 12 month cycle for application updatesupdates in future in future
New APRsNew APRs for prompt submission and informing for prompt submission and informing publicpublic
Advanced Advanced application processingapplication processing by Joint by Joint Commission staffCommission staff
Additional application questionsAdditional application questions refine refine organizational information organizational information
Unannounced Changes Unannounced Changes (cont.)(cont.)
Extranet postingExtranet posting of PFP, introductory letter, of PFP, introductory letter, bio’s, and surveyor photographs on morning of bio’s, and surveyor photographs on morning of surveysurvey
EliminationElimination of pre-survey billing, notification of pre-survey billing, notification letters, and surveyor phone callsletters, and surveyor phone calls
Window widensWindow widens for scheduling for scheduling
Initial, PPR, small organization, and ESO Initial, PPR, small organization, and ESO surveys will remain surveys will remain announcedannounced
Unannounced Changes Unannounced Changes (cont.)(cont.)
Initial, PPR, and ESP surveys will remain Initial, PPR, and ESP surveys will remain announcedannounced– Extension new program surveys are Extension new program surveys are unannouncedunannounced
Agenda change: Surveyor Agenda change: Surveyor planning session movedplanning session moved to first activity followed by opening conferenceto first activity followed by opening conference
Communicate Communicate special eventsspecial events (e.g. KY Derby, (e.g. KY Derby, Daytona 500, national political convention, etc.)Daytona 500, national political convention, etc.)
Use your 10 “Use your 10 “avoid datesavoid dates” wisely – skip federal ” wisely – skip federal holidaysholidays
Don’t assumeDon’t assume (due date +/- 45 days, same (due date +/- 45 days, same geography, etc)geography, etc)
Annualization PlansAnnualization PlansTimingTiming Events DueEvents Due
Survey end date + 12 Survey end date + 12 monthsmonths
Application Application updateupdateBBIBBIPPR updatePPR update
Survey end date + 24 Survey end date + 24 monthsmonths
Application Application updateupdateBBI updateBBI updatePPR updatePPR update
Survey end date + 36 Survey end date + 36 monthsmonths
Application Application updateupdateBBI updateBBI updatePPR updatePPR update
Subscription BillingSubscription Billing Supports annual activitiesSupports annual activities
Two componentsTwo components– Annual Fees – Billed every January – about 20% Annual Fees – Billed every January – about 20%
of current feesof current fees– Survey Fees – Billed every 3 years about 30 Survey Fees – Billed every 3 years about 30
days after survey – about 40% of current feesdays after survey – about 40% of current fees
Fees will be posted to extranetFees will be posted to extranet
Random Unannounced Random Unannounced SurveysSurveys
Continue in 2006 at 5% of annual Continue in 2006 at 5% of annual volumevolume
Eligibility remains at 9-30 monthsEligibility remains at 9-30 months Focus is on program Priority Focus Focus is on program Priority Focus
AreasAreas– Assessment and CareAssessment and Care– Infection ControlInfection Control– Patient safetyPatient safety– National Patient Safety GoalsNational Patient Safety Goals
Complex Organization Complex Organization SurveysSurveys
HCOs accredited under more than one HCOs accredited under more than one Joint Commission accreditation manualJoint Commission accreditation manual
Replaced “tailored survey”Replaced “tailored survey” Integrated and streamlined processIntegrated and streamlined process Customized, focused, efficient, educationalCustomized, focused, efficient, educational Common standards surveyed once across Common standards surveyed once across
HCOHCO Program-specific surveyors survey Program-specific surveyors survey
specialty standardsspecialty standards
Corporate Survey ProtocolCorporate Survey Protocol
Corporate Survey ProcessCorporate Survey Process– ““Orientation” approachOrientation” approach– One dayOne day– Multiple surveyorsMultiple surveyors– Multiple surveyor disciplinesMultiple surveyor disciplines– Variable servicesVariable services– Where and whenWhere and when– Sequencing of subsequent surveys Sequencing of subsequent surveys
““The success of Joint Commission The success of Joint Commission accreditation will be measured by our accreditation will be measured by our ability to assist HME organizations in ability to assist HME organizations in embracing embracing quality patient servicesquality patient services and and safe provision of caresafe provision of care as an as an integral element of their corporate integral element of their corporate and organizational culture.” and organizational culture.”
PhilosophyPhilosophy
Joint Commission Home Care Joint Commission Home Care Accreditation ProgramAccreditation Program
Central Office – 630-792-5000 (Central Office – 630-792-5000 (www.jcaho.orgwww.jcaho.org))
Program office – 630-792-7441Program office – 630-792-7441
Bob Floro – 630-792-5741 Bob Floro – 630-792-5741 (([email protected]@jcaho.org))
Account Representative – 630-792-3004Account Representative – 630-792-3004
Standards Interpretation – 630-792-5900Standards Interpretation – 630-792-5900