The Joint Commission Leadership Preparation

May 17, 2010

Opening Conference

Opening Conference

Governing body, senior leaders, medical staff leadership

Approximately 15 minutes Introductions Agenda discussion with surveyors Priority Focus Process and System

Tracers described

Opening Conference

Discussion includes leadership’s responsibilities for planning, resource allocation, management, oversight, performance improvement, and support in carrying out our mission and strategic objectives

Orientation to our OrganizationSession

Orientation to our OrganizationSession

Occurs immediately after the Opening Conference

Interactive dialogue to learn about our organization to focus survey activities

Learn how we are governed and operated Leadership’s perception of our top Priority

Focus Areas and Clinical Service Groups Learn about our Performance Improvement

Process

Orientation to our OrganizationSession Topics

Mission, vision, goals and strategic initiatives

Organization structure Contract management process Health care error reduction Patient safety initiatives-Coumadin,

Falls, Restraints National Patient Safety Goals

Orientation to our OrganizationSession Topics

Community involvement Leadership’s role in emergency

management planning Cleaning, disinfection and sterilization Patient Flow Organ procurement and donation

Orientation to our OrganizationSession Topics

Priority Focus Area (PFA) and Clinical Service Groups (CSG) Leadership role in the top PFA and CSG Processes at the PFA level Leadership’s oversight

Orientation to our Organization Session Topics

Leadership’s role in Performance Improvement How leaders set expectations, plan,

assess, and measure initiatives to improve quality of services

Approach to safety and selection of proactive risk assessment topics, improvements and Board involvement

Provision of resources for Safety

Strategic Surveillance System

S3 is a suite of information tools with the first available tool being the Performance Risk Assessment (PRA) tool.

S3TM – PRA provides a series of risk assessment and comparative performance measure reports to help hospitals improve their care processes and prioritize the actions to take for improvement.

The data within the S3 - PRA tool is updated on a quarterly basis

Customized Survey Focus Areas

PFAs are processes, systems or structures in an organization that significantly impact the quality and safety of care.

Our PFAs are Assessment and Care, Performance Improvement expertise and activities, Staffing, Communication, Credentialed Practitioners, Infection Control and Patient Safety

Clinical Service Groups (CSGs)

CSGs are services of a hospital for which data are collected

Surveyors select units based on our CSGs

Our CSGs are: Surgery, Medicine, Cardiology and Gastroenterology

Leadership Session

Leadership Session

Occurs on 4th day at 12:30 pm Board members, Medical staff leaders,

Senior Management, Clinical Managers Leaders should provide their view and

perspective on a topic being discussed Topics will include:

The planning process used How data is used once it is collected The approach used to change processes and

work flow

Leadership Session How information about new process is

communicated How leaders view the performance of the

PFA or function being discussed Leadership support, direction, planning

and resource allocation Relationship of the PFA to patient safety

and quality How the effectiveness of the PFA is

evaluated

Leadership Session

Leadership SessionQuestions asked at VHA Hospitals

Which of the five columns are your biggest challenge

How do you assess your priorities How do you encourage evidence based

medicine Board’s action on clinical information

provided by physician board members Are they Sentinel events, bad/ unexpected

outcomes, success stories

Leadership SessionQuestions asked at VHA Hospitals

What is your approach to bad outcomes Can you monitor to avoid bad outcomes How are individuals held accountable Talk about resource allocation Does the Board provide a plan Who sees the Strategic Plan How do you get information from the bottom

up

Leadership SessionQuestions asked at VHA Hospitals

What about patient satisfaction How do you account for the difference

between patient perception of quality and professional perception

How are priorities determined How is effectiveness of communication

assessed How is our culture communicated, how are

we changing it to a culture of safety

Leadership SessionQuestions asked at VHA Hospitals

How is community included in planning How does community communicate a need What is the largest challenge with medical

staff What drives employee retention How do you communicate and monitor

processes How do you ensure that you are not on the

front page of the newspaper

Survey Process

Scoring

Requirements for Improvement or RFIs have levels of severity based on the potential risk to patient care or safety.

The higher the risk the more immediately the issue of noncompliance needs to be resolved.

Criticality Levels

Immediate threat to health or safety Inoperable fire alarm Adult strength meds on pediatric crash cart Lack of master alarms for medical gas systems A patient with known antibodies received

transfusions without typing for the corresponding antigens.

Denial of Accreditation and requires Evidence of Standard Compliance in 45 days with a follow up survey

Criticality Levels

Situational Decision Rules Unlicensed facility Unlicensed individual who requires a license Failure to implement corrective action in

response to identified Life Safety deficiency

Denial or Conditional, Evidence of Standard Compliance in 45 days and a follow up survey

Criticality Levels

Direct Impact Requirements (no or few processes between noncompliance and the patient) Sedation/anesthesia – hospital has monitoring

equipment available Pain – hospital staff reassess and responds to

patient’s pain Emergency Meds – emergency meds are

accessible in patient care areasEvidence of Standard Compliance within 45 days

Criticality Levels

Indirect Impact Requirements Leadership standards compliance i.e. when

CEO is absent there is a designee HR – Orientation is completed prior to providing

care, treatment and services. Infection Control – An individual is identified to

perform Infection Control functions.

Evidence of Standard Compliance within 60 days

How are they scoring?

In 2010 RFI overall average is 12.13 per HCO. 2009 14.41 (1Q09 16.45)

Direct average 4.93 this year. 2009 5.76 (1Q09 7.09). 30% decrease

Indirect average 7.20 this year. 2009 8.66 (1Q09 9.36). 22% decrease

Source:15 VHA HCOs

Top Direct RFIs by Chapter

Provision of Care (PC) 20 Environment of Care (EC) 11 National Patient Safety Goals 10 Life Safety 7 Infection Control 7 Information Management 6 Medication Management 5