We want you to tell us what’s on your mind in 2008. We’ll be asking for your input on several important projects. One of these is the Standards Improvement Initiative. The goal of this project is to review and refine the standards — making them clearer, more objective and more applicable to long term care organizations. In 2009, long term care organizations will see refinements to the scoring and decision process. The process will be revised to place greater emphasis on critical standards and elements of performance requiring more immediate attention. Look for notification of field reviews for this project in the coming weeks. Or check the website.
The LTC Update readership survey told us that you like the newsletter, but that there are some changes you’d like to see. We appreciate your comments and will be making revisions in the coming year. See the full story.
Meanwhile, if you have other thoughts, concerns or suggestions about improving long term care accreditation, please let me know at (630) 792-5722 or djohnson@jointcommission.org. I look forward to working with you.
Dale Johnson
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Sea View Hospital Rehabilitation Center and Home, Staten Island, N.Y., has won an Ernest Amory Codman Award. The award recognizes excellence in the use of outcomes measurement by health care organizations to achieve improvements in the quality and safety of health care.
A common problem at long term care facilities, incontinence often results in skin breakdown, falls and other injury, as well as injury to staff. Sea View’s incontinence rates were about 41 percent above the mean reported by the Centers for Medicare & Medicaid Services. The staff decided to implement an enhanced toileting program to help decrease their incontinence rates and improve their resident’s dignity and quality of life.
“We presented this toileting program to the Joint Commission surveyor during our 2006 survey and she recommended that we go for a Codman Award,” says Carole Morgan, RN, director of nursing. “So we researched how to apply for the award and we went for it.”
Over a three-year period, staff at Sea View implemented a number of performance improvements such as creation of a bowel and bladder incontinent assessment tool; integration of a new “lift” device to transfer residents to the toilet; and hospital-wide in-service on the relationship between incontinence and falls and pressure ulcers. The initiative resulted in reduced incontinence rates, a decrease in pressure injuries, reduced falls, improved quality of life for residents, and decreased staff injuries related to toileting.
Morgan urges other long term care organizations to apply for a Codman. “If you have a project that has had a strong impact on the quality of care you provide don't be afraid to try for the award, but make sure you have good quality data.”
Sea View is a 304-bed, long term care facility providing 24-hour nursing and medical care to the frail elderly, chronically ill and disabled. Sea View also offers specialty units for brain injury and Alzheimer’s patients.
New website
Visit the new Codman Award website to find out more information, to sign up for the Codman list serv, and to get the application.
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The Joint Commission has launched a project addressing how accreditation factors into liability insurers' underwriting practices.
“Liability insurance companies recognize that Joint Commission accredited long term care organizations fare better when it comes to risk assessment and risk management,” says Katie Goryl, associate director, Payer Relations. “Insurers reward these organizations in several ways, such as insurance premium discounts, credits and other benefits.”
The carrier offering benefits to long term care organizations is ACE American Insurance Company, New York, N.Y. Goryl has also documented rewards to Joint Commission accredited or certified ambulatory facilities, behavioral health care organizations, hospitals, laboratories, health care staffing services and home care organizations.
If you want your carrier reviewed for placement on this list, send the name of your liability insurer to Goryl (kgoryl@jointcommission.org). Meanwhile, keep checking for additional listings as they become available on the website.
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Evelyn E. Choi, accreditation specialist, is often the first person that staff at long term care organizations talk to at The Joint Commission. Her friendly voice and helpful advice will guide you through the accreditation process with ease.
“I help customers initiate the accreditation process and walk them through the steps,” says Choi. “I want to make sure they have a positive experience with The Joint Commission.”
A former lab associate, Choi knows the value of accreditation. “Accreditation gives long term care organizations a marketing edge, improves resident safety and enhances community confidence. How can you go wrong with that?” says Choi. “In addition, we support the organization's business operations, assist in staff education, and offer the expertise of our experienced health care professional's.”
Choi completed a bachelor of science degree in Biology at the University of Illinois at Chicago and a master’s degree in Clinical Laboratory Sciences at Rush University. Before coming to The Joint Commission, she worked two years as a clinical laboratory scientist.
If you have questions about becoming accredited, contact her at (630) 792-5866 or echoi@jointcommission.org.
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Expect to see more articles about complying with specific standards, survey preparation and best practices in upcoming issues of LTC Update, says Dale Johnson, executive director, Long Term Care Accreditation Program.
According to the results of the recent readership survey, 94 percent of respondents always or sometimes read each issue. The standards Q&A columns are generally the most well-read at 96 percent, followed by feature articles at 95 percent and the Newsline column with 93 percent of respondents reading it frequently or occasionally.
Article length was right on with 90 percent of respondents saying that feature articles were about right, 85 of respondents liking the length of Q&A articles, and 90 percent liking the length of the Newsline feature.
In the open response section, people said they would like to see more examples of how to meet the standards in innovative ways; case studies; and ways to prevent sentinel events.
“We’re pleased that LTC Update is well regarded by its readers,” says Johnson. “We are planning to implement improvements based on this feedback in upcoming issues.”
A long term care organization new to the accreditation process will no longer have track record requirements — the period of time that a new organization is expected to be in compliance with Joint Commission standards and elements of performance — before it can undergo survey.
“These requirements have been in place for more than 10 years, but were deemed unnecessary because of the unannounced survey, the tracer methodology, and the follow up validation surveys that are conducted,” explains Dale Johnson, executive director.
Even though the initial track record requirements have been eliminated, the Joint Commission does require a minimum number of residents/volume in order to conduct a survey. For long term care, that number is five residents served with two active residents at the time of survey.
For the full article see the January 2008 issue of Joint Commission Perspectives.
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Education
2008 audio conferences
Audio conferences are held from 11:30 to 1 p.m., CT, and include a presentation and a Q&A session. Sign up for one phone connection from your office or have multiple attendees in a conference room. Dates and topics for this year include:
- March 31: Challenging standards for Long Term Care
- May 15: Cost effective ways to use data to drive improvement
- July 22: 2009 NPSGs for Long Term Care
Publications
2008 CAMLTC Subscription Update Service
Update 1 (March) will be an overview that explains the Standards Improvement Initiative effective January 2010 for the Long Term Care accreditation program and the new scoring model that will take effect in January 2009.
Order Code: CLTC-08S1, $200
All accredited long term care organizations will receive one free copy of Update 1.
2008 Accreditation Process Guide for Long Term Care
Includes an updated compliance assessment checklist so you can track your organization’s progress toward continuous standards compliance, note correction actions needed, and identify areas in which measures of success are needed. Practice tracer questions and tracer narratives are also provided.
Order Code: APLT-08, $119
2008 Standards for Long Term Care
This compact, easy-to-use spiral-bound book contains the 2008 standards, rationales, elements of performance, as well as scoring categories and measures of success designations (as applicable). Also included is a chapter dedicated to the 2008 National Patient Safety Goals.
Order Code: LTCS-08, $110
Good Practices in Preventing Patient Falls: A Collection of Case Studies
Reviews the basics of fall risk assessment, how to consistently evaluate fall reduction efforts, and explains the essential components needed for a successful fall prevention initiative. Ten health care organizations share strategies that helped them reduce patient falls and fine-tune activities already in place.
Order Code: BPPPF-07, $65
Click here to order products from Joint Commission Resources, Inc., or call (877) 223-6866.
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Long Term Care Accreditation - (630) 792-5722
Standards Interpretation Group - (630) 792-5900
LTC Account Representative - (630) 792-3007
Customer Service - (630) 792-5800
Pricing Unit - (630) 792-5115
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