Patient-centered care means making the patient and his or her loved ones a key part of the decision-making process. National Patient Safety Goal #13 went into effect January 1 of this year and requires organizations to “encourage patients’ active involvement in their own care as a patient safety strategy.” Requirement 13A specifically calls for organizations to “define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.”
Just handing a brochure to your patient will not meet this goal’s intent. Requirement 13A emphasizes the active role that caregivers must take to encourage patients and their families to report their safety concerns. If your organization is complying with Standard PC.6.10 EP 3, you are already educating the patient about safe practices and you’re halfway there!
If you’d like to find out more about involving patients in their own care, read the Frequently Asked Questions. You’ll find links to a number of websites with information, tools and strategies.
Michael Kulczycki, MBA, CAE
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A new program-specific tracer addressing continuity of care was recently introduced for community health clinics and other medical settings accredited under the Ambulatory Care Program.
The continuity of care tracer evaluates the effectiveness of an organization’s processes from prescribing a diagnostic study through follow up with patients and other providers. Surveyors will select a patient with a known abnormal test result and review the communication, coordination and continuity of care in that situation.
“Many ambulatory care providers are concerned about missing a test value that they need to follow up on,” says Deb Ondeck, project director, Division of Standards and Survey Methods. “Using tracer methodology, organizations can identify problems and evaluate process flows to look for failure points. Once the staff understands the possible failure points, they can shore up their processes to alleviate their concerns and make care safer for their patients.”
During a survey of a medical or dental setting, a surveyor will conduct a continuity of care tracer when time permits, or if the surveyor finds possible delays in treatment related to adverse diagnostic results. Surveyors also evaluate continuity issues as part of the individual tracer activity. For more information, review the November 2006 issue of Joint Commission Perspectives.
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Joint Commission ambulatory care and office-based surgery surveyors have the skills and training to help take your quality improvement activities to the next level, according to Beverly Robins, field director, Surveyor Management and Development.
“Joint Commission surveyors are professionally certified,” says Robins. “They also receive ongoing training that results in consistency and reliability.”
The Joint Commission hires surveyors directly from clinical arenas—not just management—and places a priority on hiring those who are directly involved in the accreditation process at their organization. “This lends more credibility to the survey process,” Robins says.
Tom Long, M.D., has been a Joint Commission ambulatory care surveyor for three years. “When I learned about The Joint Commission’s new accreditation process, it sounded like The Joint Commission was walking its own talk with regard to quality improvement. Since I’d been a critic in the past, but recognized the importance of physician involvement, I thought I’d give it a try. I remain convinced of The Joint Commission’s commitment to the new approach.
“An organization that embraces the standards and the accreditation process as practice management tools can’t help but enhance its quality of care and safety for both patients and staff,” Long says.
A surveyor for 20 years, Charles Darke, D.D.S., continues working in this role “because I enjoy helping organizations understand and appreciate the possibilities that exist when improving health care delivery.”
According to Darke, “The biggest difference between an accredited organization and one that is not accredited is their lack of understanding their own organization.”
Fast facts about Joint Commission ambulatory and OBS surveyors:
- Currently, there are 42 total surveyors.
- The Ambulatory Care and OBS programs employ 24 physicians; two dentists; one podiatrist; six nurses; and nine administrative surveyors.
- Surveyors have at least five years of service in more than one clinical area.
- Tenure ranges from two to 30 years, with an average of 10 to 12 years.
- Surveyors conduct an average of 25 surveys annually, up to 50 per year.
- New surveyors complete a two-week training course, followed by several preceptorships prior to conducting surveys independently.
- All surveyors must pass a core certification exam and an ambulatory care- or OBS-specific exam.
- Continuing education is provided at the annual conference and via distance learning modules and weekly updates.
- Additional specialty training is provided for surveyors who conduct: Bureau of Prisons, Bureau of Primary Health Care, Office-Based Surgery, Department of Defense and Ambulatory Deemed Status (ASC) surveys.
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Q: What is an IC risk assessment and what should be included?
A: According to Louise Kuhny, R.N., M.P.H., associate director, Standards Interpretation Group, “A risk assessment (IC.2.10) is the cornerstone on which an infection control program is built. Ambulatory organizations should incorporate a formal process for determining their own risks at least annually, and more often if significant changes occur (EP 2). At a minimum, EP 1 requires these factors be considered:
- Geographic location and community environment
- Characteristics of the patient population
- Care, treatment and services provided
- Results of the analysis of the organization’s IC data
Joint Commission standards do not specify how to conduct a risk assessment. However, one common ranking system considers probability of occurrence, severity of impact and required response. The issues that are most likely to occur and have the greatest impact receive the highest score. Whatever method you use, be prepared to describe how you determined the level of risk.”
E-mail your Ask the expert question to abrown@jointcommission.org.
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The Joint Commission recently unveiled its new branding initiative with an abbreviated name and a redesigned logo. Specific changes include:
- A new name—The Joint Commission
- New logos for The Joint Commission, Joint Commission Resources, Joint Commission International and the International Center for Patient Safety
- Updated online Publicity Kit
- Extranet renamed “The Joint Commission Connect”
- Ambulatory Advisor redesign
- New e-mail extensions are "@jointcommission.org"
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The 12th Annual Ambulatory Care Conference, “Focus on Excellence,” will be held Monday and Tuesday, October 1-2, at the Westin River North Hotel in downtown Chicago. Optional pre- and post-workshop conferences will also be held. For details, visit The Joint Commission Resources website at www.jcrinc.com.
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A free telephone conference call for Joint Commission-accredited ambulatory care organizations will be held from 1 to 2 p.m. C.T. Wednesday, May 9. The topic is the Standards Improvement Initiative. CEOs and survey coordinators of accredited ambulatory organizations will receive an e-mail with registration information approximately one week before the call.
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The Joint Commission will exhibit at the following conferences.
- American Society of Cataract and Refractive Surgery/American Society of Ophthalmic Administrators, San Diego, Calif., April 28-May 1, booth 353
- Radiology Business Management Association, St. Louis, Mo., May 5-9, booth 333
- American Association of Ambulatory Surgery Centers, Denver, Co., May 16-19, booth 205
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Michael Kulczycki, executive director
(630) 792-5290
Mike Dye, senior associate director
(630) 792-5259
Darrell Anderson, business development specialist
(630) 792-5292
Account representative
(630) 792-3007
Standards Interpretation Group
(630) 792-5900
JCR Customer Service
(877) 223-6866
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