Long term care professionals throughout the country depend on accreditation to keep them at the top of their quality improvement game. This is what Voorhees Pediatric, a long term care facility for medically fragile, technology-dependent children, has found. While licensure keeps them in business, it’s Joint Commission accreditation that helps them provide better care for their residents. It has paid off on the bottom line, too. You can read their story on this page.
Improvement isn’t just for our customers. Nancy Gorman, the field director for the Long Term Care surveyors, wants to know what you think about your survey and surveyor. She is the second person featured in the Long Term Care Team Spotlight. Gorman talks about her efforts to improve the survey process in this issue.
Improvement is definitely the theme of this issue. We’re looking for your thoughts about how we could make LTC Update more useful for you. We’ve already made a number of changes as we transitioned to The Joint Commission’s new brand. So we’d like you to tell us: Are we getting better? Are we missing the mark? Are we providing you with the information you need from The Joint Commission?
To take the survey, click here. The survey is open until October 31, 2007. Your comments will help us continue to improve. We’ll share the results in an upcoming issue.
Dale Johnson
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Resident Alyssa Di Meo and staff member Zaire Wright, CNA
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Nurse Executive Nancy Lord, RN, and the staff and administration at Voorhees Pediatric Facility, operate under the motto of “Do the right thing, at the right time, in the right way.” This helps Voorhees provide the best specialized care for the medically fragile, technology-dependent children at the facility. And, as a bonus, it also helps them do well on unannounced surveys and inspections.
“We are constantly evaluating and re-evaluating the care we provide. This leads us to continuously make changes and improvements,” says Lord. “The Joint Commission is at the forefront of quality improvement concepts. We’ve found that the standards and National Patient Safety Goals help us to reach for the next level of care and to think about where we could improve next.” |
Involve the staff
Changes start at monthly meetings. “We ask everyone, ‘What’s new?’ ‘What is or isn’t working in your area?’ Anyone can make suggestions for improvements. Because we do problem solving together, we come up with unique solutions. I’ve found that if you don’t involve all of the staff, the changes won’t make it to the bedside,” Lord says.
Info at your fingertips
Survey preparation is a matter of having the information at your fingertips, according to Lord. “We are already doing what the standards require, so we just have to be able to show the surveyor. I keep a rolling cart with a hanging file folder for each chapter. Into those folders goes evidence of our compliance. If there’s a new standard, we add them in. Any improvements we’ve made, we put that in the folder. We also include a resident roster and an organization chart with photos. Everyone from administration knows where the cart is and what it contains, so if I’m not here, they can still get the information.”
Accreditation pays the bills
“Our board is committed to accreditation, but it also helps that a number of private insurers have said that if we’re not Joint Commission accredited the reimbursement rate would be less,” says Lord. “Our residents’ families generally aren’t aware of accreditation, but they do want a facility that’s going to take great care of their kid and involves them in their care, and that would be an accredited facility.
“I’m constantly talking about the importance of accreditation. A state inspection is about what you’ve done wrong. A Joint Commission survey is about what you’re doing right and where you can improve,” Lord says. “We need our licensure to stay in business, but we need the guidance of Joint Commission accreditation to help us provide better care for our kids.”
See photos from Voorhees Pediatric Facility.
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Mark R. Chassin, M.D., M.P.P., M.P.H., has been appointed to lead The Joint Commission as its next president, effective January 1, 2008.
Chassin is the Edmond A. Guggenheim professor of health policy and chairman of the Department of Health Policy at Mount Sinai School of Medicine, New York, and executive vice president for Excellence in Patient Care at The Mount Sinai Medical Center. Prior to joining Mount Sinai, he served as commissioner of the New York State Department of Health. He is a board-certified internist and practiced emergency medicine for 12 years.
Dennis S. O’Leary, M.D., who has led The Joint Commission for the past 21 years, will become President Emeritus on January 1, 2008.
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Nancy Gorman, MS, RN, NHA, Long Term Care field director, wants to know what you really think about the long term care surveyor who comes to your facility.
“Surveyor effectiveness and the quality of the survey experience directly affects our long term care customers,” says Gorman who oversees the long term care surveyors. “That’s why it’s important that organizations fill out the electronic evaluation after the survey. We want to know what went well and where we could improve.”
The whole truth and nothing but the truth
Some organizations are afraid to put their dissatisfaction in writing for fear it will reflect on their final accreditation decision. “Nothing could be further from the truth,” explains Gorman. “Survey report processing and evaluation processing are done separately. There is no connection between the two activities. In addition, surveyors want and need your feedback because they’re also looking to improve.”
Gorman works hard all year to improve the quality of your survey. “Fifty percent of my job consists of traveling to survey sites where I drop in unannounced to observe surveyors working. I collect data on surveyor performance and organization satisfaction; then I discuss it with surveyors throughout the year.”
Accreditation as a management tool
Gorman has been at The Joint Commission since 1998 and previously held several managerial and administrative positions in a variety of long term care and hospital settings. She started as an intermittent surveyor.
“I’ve seen accreditation from all sides and I believe it’s an excellent management tool. For example, the priority focus process gives your organization a view into systems within your organization that may need attention. Traditional long term care accreditation offers the annual periodic performance review and free consultation with the Standards Interpretation Group,” Gorman says. “Accreditation also offers you a competitive marketing edge in your community.”
The biggest change in the survey process has been the unannounced survey and the tracer methodology. “I think there was a lot of trepidation about unannounced surveys, but organizations have really embraced the new survey process,” says Gorman
If you want to discuss your survey experience with Gorman, you can contact her at (630) 792-5707 or ngorman@jointcommission.org.
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The Joint Commission’s Board of Commissioners has reappointed Mary K. Ousley, RN, as the Long Term Care representative on the board for an additional two-year term. Ousley was first appointed in 2004.
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Several new requirements were approved to the 2008 Long Term Care National Patient Safety Goals. Organizations will be required to:
- Take specific actions to reduce the risks of resident harm associated with the use of anticoagulant therapy. This requirement addresses a widely acknowledged resident safety problem and a key element of the goal: “Improve the safety of using medications.” This requirement will have a one-year phase-in period.
- Measure and assess, and, if appropriate, take action to improve the timeliness of receipt of critical test results and values by the responsible licensed caregiver. This requirement is a central expectation of the goal: “Improve the effectiveness of communication among caregivers.”
In addition, 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 guidelines.
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Beginning October 1, The Joint Commission’s Quality Check® website will include organizations that are not accredited by The Joint Commission as well as Joint Commission accredited organizations. Joint Commission accredited organizations are easily identified by The Joint Commission’s Gold Seal of Approval™. This is the first listing of its kind. Several thousand home care, long term care, and ambulatory care organizations will be added using publicly available lists of health care providers. After October 1, organizations not accredited by The Joint Commission can request to be added to Quality Check by accessing www.qualitycheck.org/qcdirectory. The addition of non-Joint Commission accredited organizations provides consumers with more information to help them make decisions about their health care. While Quality Check will display demographic and service information for non-Joint Commission accredited organizations on the Quality Check Search Results page, Quality Reports will only be available for organizations that are accredited by The Joint Commission.
In addition, Quality Check users can locate health care providers by the types of services they provide, for example, skilled nursing facility or dementia care. The new “Search by Service” feature is in addition to the existing search by name and type of provider. The inventory of services on the Application for Survey has been expanded to support the Search by Service feature. An organization can update their inventory of services at any time by accessing The Joint Commission extranet.
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Long term care professionals around the world will be able to collaborate to develop performance improvement solutions through The Joint Commission’s WikiHealthCare™ application. This free, internet-based forum launched in June. It can be accessed through a link on The Joint Commission’s home page, or directly at wikihealthcare.jointcommission.org.
Register on the site and you can discuss content, edit existing content, and create new content which is then available to the entire community. Use of the test site is available at no cost. The content developed on the site is non-proprietary, open source information (i.e., owned by the community of contributing users). All users participate as individuals, not as representatives of their organization. Participation has NO impact on an organization's accreditation status.
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Give us your feedback about LTC Update. The survey is open until Oct. 25, 2007.
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- Long Term Care Accreditation (630) 792-5722
- 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.
E-tools
Accreditation Manager Plus: An Interactive Toolkit for Continuous Compliance™
This electronic tool has everything your organization needs to maintain continuous compliance and prepare for the periodic performance review:
- View an electronic copy of the Comprehensive Accreditation Manual for Long Term Care.
- Enter scores, plans of action, measures of success and notes.
- View detailed examples of the elements of performance.
- View and print summary and status reports.
- Review and revise entered data before it is final.
- Submit your official PPR to the Joint Commission.
Choose from individual PC, network, web-based intranet, or web-based extranet versions.
Publications
NEW! 2008 Accreditation Process Guide for Long Term Care
Get tips on writing plans of action and measures of success and a handy compliance assessment checklist to help you get the most out of your periodic performance review. The guide also includes mock tracer questions and a step-by-step example of a tracer from the surveyor’s perspective.
Order code: APLT08SJ, $119
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
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