I’m Accredited Now What? - Joint Commission · I’m Accredited Now What? ... Accountability...

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I’m Accredited Now What?

A Guide to Supportive Resources for the Newly Accredited Organization

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Presenters

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From The Joint Commission:

Julia Finken BSN, MBA, CPHQ, CSSBB, Associate Director, Home CareKathryn Zaba, MA, CRC, Senior Account Executive, Home Care

Joe Misenko, Associate Director, Intra-cycle MonitoringDea Greathouse RN, MSHA, Associate Director, Standards Interpretation Group

Guest Presenter

Patti Atteberry, RN, MSN, Director of Professional Practice, OSF Home Care Services

.

May 21, 2015

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Key Milestones* in the Accreditation Process

27

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Resources to Promote your TJC Accreditation

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Publicity Kit

Gold Seal DownloadSample News ReleasesFact Sheets About TJC AccreditationSearch for Local Media to Promote

Your TJC AccreditationBrochure: “We Received the Gold Seal

of Approval from the Joint Commission”Other

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Continuous Compliance Infrastructure

Team ApproachAssign Key Responsibilities to Key Job Positions

– Consider Assigning by TJC ChapterDefine Clear Expectations

– Maintenance of Ongoing Compliance with evidence

– Periodic Reporting to Quality CommitteeReporting CalendarAccountability Embedded in Performance

Appraisal

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Role of the Account Executive The Joint Commission assigns an Account

Executive to an organization after receiving its E-App.

This person serves as the primary contact between the organization and The Joint Commission. He or she coordinates survey planning and handles policies, procedures, accreditation issues or services, and inquiries throughout the accreditation cycle.

An organization can find contact information for its account executive on its Joint Commission Connect

site or by calling 630-792-3007.

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Contacting the Account Executive

The Account Executive can be contacted via phone, email, fax, or USPS. – Most communication is done via phone and

email. Account Executives respond to both email and phone messages in a timely manner. – Please note your HCO ID number in all correspondence.

– If an Account Executive is not available, a back-up is assigned. Organizations may also speak to an operator to find an Account Executive who can help with general questions.

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Milestone One – 9 Month Application Submission

The General Application/Update Contacts link will appear under the What’s Due section 30 days before the submission due date.

The link will look similar to the picture below:

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9 Month Application Submission

The organization will review the General Application by clicking the ‘Next’ button, allowing the organization to view each section of information.

The organization should review the entire General Application, starting at TAB 1 – Your Organization.

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The organization can make changes to the application as needed.– Special importance should be focused on

the following:– Accuracy of Unduplicated Admissions and

Average Daily Census– Address and Phone Number– Branch Locations or Additional Sites– Services Provided– Ownership Information

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The Security Admin link on the extranet allows for contact updates. – An update will be automatically prompted

upon most submissions. If the organization closes this, it can always be reach via the Security Admin link on the extranet.

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Milestones Post Survey

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Identify key staff that will be responsible for follow up of any 45 or 60 day evidence of standards compliance for non compliant standards post survey

ESC 45 and 60 day Clarification submission Deemed status – For Condition Level

Deficiency’s

Evidence of Standard Compliance (ESC)

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Measure of Success

Identify key staff that will be responsible for creating and monitoring standards that require a Measure of Success– MOS icon – Appropriate Sample Size– Sampling method– 90% or higher compliance over four months– Based on patient population– Considered minimal requirements– Numerator (total number of compliant records/visits– Denominator (total number of records/visits)– Submission reviewed by Central Office

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Continuous Compliance

Maintain Documents, Policies and Procedure

Regularly Access the E-dition, Extranet Site Resources and ICM tool

Maintain Budgets and Capital Expense plans

Maintain Human Resource files

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Maintain an updated organizational chart

Review the previous ESC submission to ensure implementation was successful and ongoing

Ensure all meetings have:– Documented detailed minutes– Appropriate membership of staff– Are following policy

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Maintain Policy and Procedure Review

Perform identified data collection

Perform analysis on collected data

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Record of Care,

Treatment, and Services

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Record of Care

Perform random audits on patient records

– Review for complete orders– Review for care plans– Review for following the physician orders – Review for accuracy, legibility, and

completion on time– Assists you in identifying improvement

areas

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Clinical – Individual Tracers

Perform Individual Tracers with all disciplines to determine compliance and gaps where the organization may be vulnerable

Ensure staff have supplies and equipment that are to be provided by the organization

Complete supervisory visits as per policy/regulation

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Clinical – Individual Tracers

Home health, Hospice or Personal Care aide tracers

Care plan is current and specific with duties on frequency or type

Visit notes reflect what is ordered on the plan of care

Perform supervisory visits as required by law and regulation or policy

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Clinical – Durable Medical Equipment

Maintain equipment maintenance up to date and documentation of that maintenance. EQ.01.03.01

Maintain equipment storage clearly marked and equipment stored in the appropriate section. EQ.01.05.01

Continue to monitor the State law/Respiratory Practice Act to determine what equipment can be delivered and set up by non-licensed personnel. LD.04.01.01.

Maintain required licenses per State regulations. (DME license)Maintain competencies for staff at appropriate intervals.Comply with DOT regulations for transport of oxygen (shipping

papers, vehicle placarded if required) at all times.

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Clinical – Pharmacy

Maintain pharmacy license and individual pharmacist license

Maintain a formulary and update at least annuallyMaintain documentation of destroyed or returned

drugsContinue to monitor high alert and hazardous drugs

for addition to the list of current drugsMonitor care plans and medication profiles

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Human Resources

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Human Resources

Verification of Staff qualifications/licensureOrientation of StaffStaff trainingStaff competency upon hire and at least once

every three yearsStaff performance evaluations

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Organizational - Resources

Free Webinars and Webinar ReplaysStandards Interpretation Group (SIG)Dedicated Account Executive (AE)FSA Tool –Focused Standard

AssessmentPerspectives (Top 10 Standards)Home Care Bulletin

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Intracycle Monitoring

Using the ICM Profile

and

FSA Tool(Focused Standards Self-Assessment)

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Extranet Site

TJC Home Care Agency

One Renaissance Boulevard

Oakbrook Terrace, IL 61036

HCO ID 999999

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Organization Preparation

and Assessment Methods and Styles Vary

Time and ResourcesStaff InvolvementOrganization is Key

Focus Assessment on Most Important Processes (Use FSA)

Prioritize, Prioritize, Prioritize

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The 27 Month General Application submission is unique as it will drive the survey complement for the triennial event.– The organization should take special note to add

the following:– Avoid dates– Accurate Unduplicated Annual Admissions and

Average Daily Census– Volumes are one key factor in determining

survey length

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The Account Executive will review the application, as well as make contact with the organization. – The contact may be by phone or email.

The Account Executive will discuss current operations at the organization briefly to confirm no additional changes are needed in the application prior to scheduling.

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The Account Executive will encourage the organization use Resources and Tools– E-dition– Survey Agenda– Survey Activity Guide– Leading Practice Library– Standards Interpretation Group

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Key Strategies to Achieve Ongoing Compliance – A

Providers Perspective

Patti Atteberry, RN, MSN, Director of Professional Practice, OSF Home Care Services

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Account Executive

Standards Interpretation Help Desk: 630-792-5900Joint Commission Resources: 877-223-6866 or www.jcrinc.com

Brenda Lamberti, BSSenior Business Development Specialist 630-792-5252 or [email protected]

Home Care Team ContactsJoint Commission Home Care Program

Help Desk: 630-792-5070 or [email protected]/accreditation/home_care.aspx

Margherita Labson

BSN, MSHSA, CPHQ, CCM, CGBExecutive Director 630-792-5284 [email protected]

Julia Finken

BSN, MBA, CPHQ, CSSBBAssociate Director630-792-5283 [email protected]

Monnette Geronimo

Business Development Specialist 630-792-5251 or [email protected]

http://www.jcrinc.com/

mailto:[email protected]





I’m Accredited Now What? - Joint Commission · I’m Accredited Now What? ... Accountability...

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Transcript of I’m Accredited Now What? - Joint Commission · I’m Accredited Now What? ... Accountability...