Despite your mounting responsibilities and diminishing discretionary budget as ambulatory care professionals, I urge you to attend the Annual Ambulatory Care Conference: Focus on Excellence on October 1-2, in Chicago.
This year’s conference will focus on areas that ambulatory leaders need to think about to ensure their success. You’ll learn more about performance measurement—which can help you drive change in your organization. You’ll also hear the latest on healthy design, systems approach and lean thinking.
There will also be sessions on the 2008 National Patient Safety Goals, the Environment of Care, Infection Control and Leadership standards. Attendees can sign up for a free 15-minute mini-session with a representative from our Standards Interpretation Group.
Plans are underway to link our conference with a community service project that benefits veterans using ambulatory and inpatient services at Hines VA Hospital, just west of Chicago. Stay tuned for details. For more information about the conference, go to www.jcrinc.com/14491.
I invite you to attend this year’s conference to learn, teach, share and play. In a room filled with 300+ like-minded ambulatory care professionals, great things are bound to happen.
Michael Kulczycki, MBA, CAE
Executive Director
-Top-
The Joint Commission recently announced the 2008 National Patient Safety Goals and related Requirements that will apply to accredited ambulatory are organizations and office-based surgery practices. Changes include:
- A new Requirement to take specific actions to reduce the risks of patient harm associated with the use of anticoagulant therapy. There will be a one-year phase-in period that includes defined milestones; full implementation is targeted for January 2009.
- The Requirement that addresses hand hygiene has been expanded to permit use of the World Health Organization Hand Hygiene Guidelines as an alternative to the Centers for Disease Control and Prevention hand hygiene guidelines.
- The Requirement to limit and standardize drug concentrations will be retired as a National Patient Safety Goal, but organization compliance will continue to be evaluated as part of the Medication Management standards.
Read the full text of the Goals, Requirements and implementation expectations. A free telephone conference call on the 2008 NPSGs will be held on September 13 for accredited organizations. Details will be posted on the extranet.
-Top-
An interview with Sophie Duco, R.N. and Ginny McCollum, R.N., associate directors with The Joint Commission Standards Interpretation Group.
What is the purpose of the periodic performance review?
Duco: The PPR provides ambulatory care organizations the opportunity to do a self-analysis of their processes against Joint Commission standards.
Why is the PPR a valuable tool for ambulatory organizations?
McCollum: Using the PPR, an organization can actually survey itself and get a good idea of how it measures up with respect to the standards. It’s also a great way to educate staff about The Joint Commission standards.
How can the PPR be used most effectively?
Duco: The organizations that get the most out of the PPR use it as an ongoing performance management tool whose byproduct is providing safe, quality care.
What can organizations find out about themselves by using the PPR?
Duco: They learn a lot about how well they communicate within their own organization. They also find out whether the right players, including leadership, are involved in the right processes.
Why should an organization take advantage of the SIG conference call?
McCollum: There’s an area in the PPR called “Topics for Discussion.” When an organization completes that section, we use the information provided to determine the focus of the call. For example, if an organization lists Environment of Care, we try to have an engineer on the call. Or, we pre-research the staff's questions. Most ambulatory organizations have the entire team present for the call—anywhere from one to 30 people. The important thing is to use the call to help your organization.
What are the benefits of having a SIG conference call?
McCullom: The organization can discuss issues and problems, and get approval for its Plan of Action, completion dates, and any related Measures of Success. With SIG’s approval for its plans, the organization can get a 45-day “safety umbrella.” If the organization gets surveyed during that time, it can’t be scored for those issues. Also, if the Plan of Action and Measures of Success are approved by SIG, the surveyor in a subsequent resurvey cannot question the organization’s audit.
Can a surveyor ask about the PPR?
Duco: While surveyors do not have access to an organization’s PPR, they can ask to see any Measures of Success that were identified during the PPR process and that the organization is working on or worked on previously.
What is one common misconception about the PPR and the SIG conference call?
McCollum: Organizations don’t understand that the PPR and the SIG telephone call are confidential. We do not share the information from the call with anyone. Also, SIG staff don’t know an organization’s survey date.
How can the PPR be used to prepare for an initial survey?
McCollum: While organizations undergoing a survey for the first time are not required to submit a PPR, they can complete the PPR to familiarize their staff with the standards and to develop plans for meeting compliance.
|
PPR tips |
- Read and follow the instructions that accompany the PPR.
- Don’t be afraid to call or e-mail The Joint Commission. No matter how many times you call SIG, you will not trigger a survey for your organization!
- If you are having difficulty with the technical aspects of the PPR, check with your internal IT staff before you contact The Joint Commission.
- If you are using The Joint Commission Resources’ Accreditation Manager Plus, make sure you have the most current version.
- If you have a question about the PPR, contact your account representative or call (630) 792-3007. For standards-related questions, call (630) 792-5900, or use the online form.
|
-Top-
The Joint Commission’s Standards Improvement Initiative is part of an effort to eliminate non-essential standards and to ensure that the remaining standards are understandable and relevant to the setting to which they apply.
Here’s the latest information:
- The Surveillance, Prevention and Control of Infection, Improving Organization Performance, and Management of Information chapters will be presented to the Professional and Technical Advisory Committee on July 30.
- Program teams are completing initial recommendations for the Human Resources, Environment of Care, and Medication Management chapters. In the next few months these chapters will be posted to the website for review and comment.
- Program teams are reviewing the Provision of Care and Rights chapters.
- Separate chapters or subsections of chapters are being planned for Emergency Management, Life Safety Code and Medical Records.
- A SII telephone conference call was held in May for ambulatory care organizations and office-based surgery practices. A transcript is available.
- The Ambulatory Accredited Customer Group continues to offer input on ambulatory-specific issues. See the members.
-Top-
To request an additional Joint Commission accreditation certificate for a separate site, send an e-mail to certificates@jointcommission.org with your organization’s HCO number and the name of the additional site. Or, contact your account representative. Additional charges apply.
-Top-
If you’re wondering how the Infection Control standards apply to interpretive reading (teleradiology) providers, check out the new FAQ.
-Top-
Joint Commission Requirements is a free listing of standards, policy revisions and requirements published in The Joint Commission Perspectives that have gone into effect since the accreditation manual was last issued. Visit www.jcrinc.com/2815/. Click on ambulatory care or office-based surgery in the left navigation bar.
-Top-
JCR publishes smaller-sized standards books for diagnostic imaging services, ambulatory surgical centers, and ambulatory care. See JCR's online catalog at www.jcrinc.com. Also, look for your 2007 CAMAC and CAMOBS updates in September.
-Top-
- National Association of Community
Health Centers, Dallas, Texas,
August 27-28
Booth no. 614
-Top-
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
-Top-