Spring is a time of growth, renewal and change, and that’s exactly what is happening at The Joint Commission. In this issue, you can read about how we are retooling and fine-tuning our products and services to ensure they meet your needs.
This is all happening under the leadership of our new president, Mark Chassin, M.D. The biggest challenge and opportunity he sees facing The Joint Commission are to build on the momentum of demands for major improvements to bring about real change that improves health outcomes for patients and residents.
In the process, we must be mindful of the “opportunity costs” in undertaking a given improvement activity, for it takes the organization’s resources away from other improvement activities in which it might otherwise be engaged. As Dr. Chassin stated, there is a need to “prune this garden” to ensure that scarce resources are deployed in the most beneficial interventions.
I will keep you apprised of our progress as we work toward these goals. In the meantime if you have any questions, I’d be happy to hear from you. Contact me at djohnson@jointcommission.org or (630) 792-5722.
Dale Johnson
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The Board of Commissioners has approved new, improved and simplified scoring and decision processes, effective January 1, 2009 for all accreditation and certification programs. The current decision process is primarily based on the volume of survey findings in relation to pre-established thresholds. The new processes:
- Are based on the “criticality” of survey findings. This means that accreditation decisions and the timing of follow-up requirements are judged in relation to the immediacy of the threat to health care quality and resident safety as the result of non-compliance with Joint Commission requirements.
- Reflect an organization’s performance respecting compliance with Joint Commission standards and elements of performance.
Please note that the proposed changes to the scoring and decision processes are still under review by The Joint Commission; final changes will be published by July 1, 2008, on The Joint Commission website.
Tell us what you think
The Joint Commission is looking for your input on the long term care standards and elements of performance. Comments will be gathered for six weeks beginning May 6, 2008. To participate, click here.
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Joint Commission accredited nursing homes will be required to notify The Joint Commission as soon as they are designated a “Special Focus Facility” by the Centers for Medicare & Medicaid Services, effective June 1, 2008.
SFF facilities are designated by CMS as having a history of serious quality issues. They are included in a special program to stimulate improvements in their quality of care. CMS lists SFFs on its website, which is updated quarterly.
A new Element of Performance will be added to Accreditation Participation Requirement 1: The organization notifies The Joint Commission when it is designated by the Centers for Medicare & Medicaid Services as a Special Focus Facility prior to its designation being publicly announced.
For more information contact your account rep at (630) 792-3007 or go to the CMS website.
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The Joint Commission is developing a new Health Care Services Certification Program that will capture specialty services that “fall between the cracks” of the current certification and accreditation program offerings. These specialty services include (but are not limited to) palliative care, subacute care, and physical rehabilitation services–any program organized around a care delivery system that treats residents regardless of diagnosis.
Development of the standards and review process has been guided by the Health Care Services Task Force, composed of experts in microsystems concepts and resident-centered care, palliative care, physical rehabilitation, clinical engineering, wound care, and other services.
For more information about the Health Care Services Certification Program, e-mail ServicesCertinfo@jointcommission.org or call (630) 792-5291.
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The 2009 accreditation program manuals will be available electronically as “E-ditions” beginning in November 2008. Along with the customary free print copy of the manual, organizations will receive a free E-dition (i.e., single-user license).
The E-ditions will be accessed on the Internet via log-in and password. Features will include key word search capability across one or more manuals, access to every standard in three “clicks,” and the new scoring categories. (Please note that for the long term care program, some features related to ongoing SII improvements will be available in the 2010 E-ditions.) More information, including how organizations will receive the E-ditions, will be available in September.
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Long term care organizations have more time to implement the requirements for some new emergency management standards that became effective in January 2008. These standards require organizations to involve the community in disaster planning and disaster response.
For surveys in 2008, the new requirements will be surveyed, non-compliance will be cited in an organization’s survey report, and the organization will need to address the non-compliant standards in its Evidence of Standards Compliance. However, non-compliance will not be included in the count of non-compliant standards contributing to either a Preliminary Denial of Accreditation or Conditional Accreditation decision.
For more information, contact your account rep at (630) 792-3007.
|
The following elements of performance in the Environment of Care
chapter will not count toward the accreditation decision in 2008: |
EC.4.11 EP 9, 10
EC.4.15 EP 2, 3, 5
EC.4.13 EP 7
EC.4.17 EP 4 |
EC.4.12 EP 6
EC.4.16 EP 2, 3
EC 4.14 EP 8, 10
EC.4.18 EP 4, 5, 6 |
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The Joint Commission has expanded the window for unannounced surveys to within 18 to 39 months (previously 24 to 39 months) after an organization’s previous survey, effective mid-2008. The Joint Commission’s Accreditation Committee recently approved the methodology for conducting these surveys.
The new methodology will take into account Priority Focus Process data across multiple quarters as well as trends in the performance of these data. The majority of organizations will still be surveyed in the year that their triennial survey would be due, and a minority of organizations will be surveyed earlier. These outliers represent circumstances where data suggest that resident safety and quality are potentially at risk. For more information, see the April 2008 issue of The Joint Commission Perspectives or contact your account representative at (630) 792-3007.
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This free Speak Up™ brochure offers residents questions and answers that will help them better understand the care they receive. See the brochure online.
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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:
May 15–Cost effective ways to use data to drive improvement
July 22–2009 NPSGs for Long Term Care
Publications
2008 CAMLTC Subscription Update
Keeps your organization current with the latest accreditation information. Update 1 (March) focuses on changes made as a result of the Standards Improvement Initiative that are effective January 2009. Update 1 is available online for free.
2008 Accreditation Process Guide for Long Term Care
Includes an updated compliance assessment checklist so you can track your organization’s progress towards 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
A downloadable PDF version of the 2008 Accreditation Process Guide for Long Term Care is also available.
Order code: EBAP-LB08, $545 (site license)
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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