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Joint Commission UpdateNational Credentialing Forum

San Diego, CaliforniaFebruary 5, 2015

Paul Ziaya MD

Field Director

Accreditation and Certification Operations

The Joint Commission

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Objectives

1. Briefly discuss the most commonly cited medical staff standards

2.Discuss OPPE as a performance improvement process

3. Introduce the Patient Safety Systems Chapter

4.Share Initiatives in Physician Engagement

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Most Often Cited Standards

MS.01.01.01- Medical staff bylaws address self-governance and accountability to the governing body.– Relates to structure, function and activities of

the organized medical staff

Most commonly EP 5– The medical staff complies with the medical

staff bylaws, rules and regulations, and policies.

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Most Often Cited Standards

MS.08.01.03 - Ongoing Professional Practice Evaluation– All elements of performance among

the top 10 medical staff EP cited– Single most common related to lack of

effective use of the data in decision making

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Most Often Cited Standards

MS.03.01.01 - Organized medical staff oversees the quality of patient care, treatment, and services– Medical staff oversight of radiology

and nuclear medicine – Monitoring the quality of histories and

physicals– Practicing in scope of privileges

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Most Often Cited Standards

MS.08.01.01 – Focused Professional Practice Evaluation– Primarily lack of a process for all

initially requested privileges

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OPPE: A Performance Improvement Process

Selection of Metrics

Accuracy in Measurement

Departmental Review and

Analysis

Physicians Review

Performance Reports

Education, Simulation, Training,

Coaching

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Opportunities

From performance monitoring to performance improvement

Resolving problem areas for each specialty or department– OR first start times– Improving specific documentation– Adherence to order sets and practice guidelines, as

appropriate

Selected by the department/chair and approved by the MEC

Can be changed

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Challenges

Attribution Selecting appropriate measures for the

specialty Triggers Zero data is dataPhysicians seeing the data Frequency of assessment - < 12 monthsUse of the data

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New for 2015

Patient Safety Systems Chapter

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Overview

There are no new requirements The chapter serves as a road map for

hospital leaders to use existing requirements to improve patient safety.

The chapter is only included in the 2015 Comprehensive Accreditation Manual for Hospitals.

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The Chapter…

Describes the framework of an integrated patient safety system

Discusses how hospitals can develop into learning organizations

Describes how to evaluate status and progress

Focuses on prevention through proactive risk reduction activities

Identifies all standards and requirements that support a patient safety system

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Learning Organizations

People continuously learn, and thereby enhance their capabilities to create and innovate

Transparent, non-punitive approach to error reporting so that the organization can report to learn

Fair and just safety culture enriched by sharing lessons learned

Data driven improvement

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Role of Hospital Leaders

Promote learningMotivate staff to uphold a fair and just safety

cultureProvide a transparent environment in which

patient safety events are honestly reported Model professional behaviorRemove intimidating behavior that might

inhibit a culture of safetyProvide the resources and training

necessary to take on improvement initiatives

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Safety Culture

Valuing transparency, accountability and mutual respect

Safety as everyone’s first priorityUndermining behaviors not acceptable Collective mindfulness –close calls

mean improvements are neededReporting errors is valuedLearning from those reported errors

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Data Use and Analytics

Data use and reporting systemsProactive risk reduction strategies Statistical toolsResources and references

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It is about Patient Safety Systems and Safety as a

Core Competency

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The Joint Commission’s Physician Engagement Goal

Help physician leaders in our accredited organizations meet or preferably exceed their patient safety and performance improvement goals

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Aspiring Higher: Organizations will need to achieve optimal physician

engagement

Overall Physician Indifference

Some Physicians Participate Some of the

Time

Optimal Physician Engagement

Searching for Stability

Building for Success AchievingSuperior

Performance

Quality and Safety Continuum

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TJC Physician Engagement Strategies

CMO AcademyPhysician Leader ForumPhysician Leader E LetterSocial MediaFellowship Rotations at TJCIHI CMO Mini Course

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Questions?

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For Standards/NPSG question:– 630-792-5900, Option 6 or– http://www.jointcommission.org/Standards/

OnlineQuestionForm/Paul Ziaya

– 630-792-5749– pziaya@jointcommission.org

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The Joint Commission Disclaimer Statement

These slides are current as of February 3, 2015. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.