As the new executive director of The Joint Commission’s Long Term Care Accreditation Program, I wanted to get a feel for what our customers were saying about us. So, I sat down and read through feedback we have received from long term care organizations over the past three years. After reviewing these comments, I identified three major areas of focus:
- Cost versus the value of accreditation
- Relevance of the standards
- Benefits of Joint Commission accreditation
These results were no surprise to me. In my previous positions as the CEO and CFO of a long term care facility, I watched Medicare and Medicaid reimbursement shrink while more resources were needed to care for an increasingly complex resident population. I plan to solicit input from stakeholders such as yourself in order to improve accreditation and make it more relevant to today’s long term care providers. I also think we can do a better job of quantifying the benefits of Joint Commission accreditation to your residents and to your organization’s bottom line.
One concrete benefit of accreditation is our talented and dedicated staff. The next several issues of LTC Update will highlight members of the Long Term Care Accreditation Team. Associate Director Peggy Lavin is featured in the first spotlight. Also, we will conduct a readership survey of LTC Update readers in August. Stay tuned for more details on this and other projects.
Meanwhile, if you have any thoughts on these issues, I would be happy to discuss them with you. Contact me at (630) 792-5722 or djohnson@jointcommission.org.
Dale Johnson
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John Herringer, associate director, Standards Interpretation Group, answers these Frequently Asked Questions about the Periodic Performance Review (PPR). Organizations which choose the Medicare/Medicaid certification-based accreditation option have access to the PPR, but are not required to submit it for review.
What is the PPR?
The PPR is a self-evaluation that gauges an organization’s compliance with accreditation participation requirements, National Patient Safety Goals, standards and elements of performance. If the organization finds areas out of compliance, it develops a plan of action. The organization will also identify measures of success for validating the resolution of the problem areas for those elements of performance which require a measure.
What are the benefits?
It makes organizations much more aware of the requirements, so they can take appropriate action before a survey.
How often is it completed?
Organizations are required to update and submit the PPR annually. The accreditation date is the due date.
Are there options for completing the PPR?
You can choose to do a full PPR with or without a follow-up call to SIG; or choose among three other options.
How do I begin?
The PPR is available anytime on the Joint Commission Connect extranet. Once your organization has completed it, the information will be there next year. You don’t have to start from scratch every time.
What’s the best way to get it done?
Organizations usually divide the work among different staff members to conduct the assessment. Then they submit the completed PPR to The Joint Commission. After this, they can choose to have a conference call with SIG to discuss the findings. If they choose to have a phone call, we go over the plan of action for standards out of compliance and check their responses to each.
If the organization chooses not to have a call, Joint Commission staff review the PPR and notify the organization if there are problems, e.g., if they’ve set a compliance date too far out.
What are the common problems and misconceptions?
Organizations think that the PPR is punitive. It’s not. Surveyors do not have access to the PPR; however, they will ask about the measures of success related to the findings of the plan of action, but they never see the actual PPR.
Tips for making the most of the phone call?
- Be prepared, have questions ready that you want addressed.
- View the time as a consultation opportunity. The focus does not have to be exclusively on the noncompliance areas. We can help you brainstorm and give you feedback on how other organizations meet the standards.
For more information, see the Facts about the Periodic Performance Review.
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This new feature highlights people who are on the Long Term Care Team. This time, we talked with Peggy Lavin, LCSW, ACSW, DCSW, associate director, Business Development. She has been at The Joint Commission since 1998.
Peggy Lavin, LCSW, ACSW, DCSW
How do you interact with customers?
If you’re a long term care organization interested in accreditation, I’ll be your new best friend. I can help long term care organizations before or after they’re accredited, but I mainly work with not yet accredited organizations. I see myself as sort of a ‘case manager.’ If you have questions and you don’t know who to ask at The Joint Commission, I can connect you with the right person.
What is a common misconception about Joint Commission accreditation?
Many people don’t realize that there are options in long term care accreditation ― traditional accreditation and the Medicare/Medicaid certification-based option. I help organizations determine which best fits their needs. Also, many organizations aren’t aware that the periodic performance review is now available to all accredited long term care organizations. Even those that choose the Medicare/Medicaid option can use it for their quality improvement program.
What does accreditation offer long term care organizations?
Accreditation sets the bar higher and helps you do the right thing for your residents. As long term care organizations struggle with issues such as staffing, accreditation provides the framework to maintain quality and safety.
What are some changes you’ve seen in the field?
I’m amazed at the continuum of care available for the elderly. I’ve seen it with my own mother. She currently resides in an apartment for older adults managed by a social services agency. It provides her with the support necessary for her to remain independent.
How can people reach you?
If you have any questions about long term care accreditation, or if you need a new best friend, contact me at (630) 792-5411 or plavin@jointcommission.org.
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Unannounced surveys can be conducted anywhere from 18 months to 39 months from your last survey. If you were surveyed in January 2006, your next unannounced survey could conceivably come as early as July 2007. Check The Joint Commission Connect extranet by 7:30 a.m., local time, for information about Joint Commission scheduled events.
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The Joint Commission Connect extranet site ― the Joint Commission’s main electronic communication link with its customers ― will soon have a new look. To see what’s in store, go to the current extranet site, click on “What’s New” for a sample screen shot. One of the new features is that you will be able to directly access the site by going to www.jointcommissionconnect.org. Other features include:
- Enhanced security controls to enable organizations to apply security settings for individuals. An organization will be able to allow certain individuals to have access to all of the accreditation tools on the site, or it can limit access to other tools, for example, allow access only to the application for accreditation.
- A “What’s Due” section that provides an at-a-glance display of accreditation tasks, such as evidence of standards compliance, measures of success, the periodic performance review and the application for accreditation.
- A “New Reports” section that provides an at-a-glance display of recently posted organization reports, such as the accreditation report.
- For corporate and multi-organization systems, a drop down menu list will enable the user to switch from one organization site to another.
- A “Quicklink” to update extranet contacts and apply security settings.
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The importance of planning and testing response plans for emergencies during conditions when the local community cannot support your long term care organization are part of new revisions to the Emergency Management standards. The revisions reflect an “all-hazards” approach to emergency preparedness that encourages flexible and effective responses to manage the variety, intensity and duration of the disasters that can affect a long term care organization. For the full text of the changes, see the June 2007 issue of The Joint Commission Perspectives.
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The Joint Commission website has a new Google™ search engine to expedite searches and yield more relevant results. The new search engine allows for more targeted searches and includes an advanced search function for options such as language, file format, date and exact phrases.
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- Long Term Care Accreditation (630) 792-5277
- Standards Interpretation Group (630) 792-5900
- Long Term Care Account Rep (630) 792-3007
- Customer Service (630) 792-5800
- Pricing Unit (630) 792-5115
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For information or to order products from Joint Commission Resources, Inc., go to www.jcrinc.com/Infomart.htm or call (877) 223-6866, 8 a.m. to 8 p.m., CT.
Education
2007 Long Term Care Audio Conferences
Audio conferences, held from 11:30 to 1 p.m., CT, include a presentation and a Q&A session. The next one is:
You can also purchase tapes of previous conferences on:
- The 2007 NPSGs
- Challenging standards in long term care
Publications
NEW! Reducing the Risk of Falls in Your Health Care Organization
Provides a thorough discussion on patient and resident fall assessment and reassessment techniques, environmental issues and equipment use, and data measurement needs–all of which are associated with the National Patient Safety Goal on fall risk reduction.
Order code: PPF01SJ, $75
2007 Accreditation Process Guide for Long Term Care
Includes tips on writing plans of action and measures of success and conducting sample tracers to address priority focus areas and clinical service groups; and a handy compliance assessment checklist to help you get the most out of your periodic performance review, note corrective actions needed, and identify areas in which measures of success are necessary.
Order code: APLT07SJ, $119
Credentials Review and Privileging for Long Term Care eBook
Explains Joint Commission credentials review and privileging standards and expectations specific to long term care. It also describes problems surveyors commonly encounter and offers strategies for improvement.
Order code: EB05CRSJ, $20
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