I truly believe in the saying, “We work best when we work together.” I have taken this wisdom to heart in my personal and professional life. If we all work together, we can ensure that every nursing home resident in the country has safe, high quality care.
To further this goal, I have been meeting with representatives from the Centers for Medicare & Medicaid Services to discuss drafting a crosswalk between The Joint Commission’s Long Term Care Accreditation survey and CMS’ Quality Indicator Survey (QIS). The goal of this collaboration is to reduce the review burden on long term care organizations.
The two survey processes are remarkably similar; both:
- Gather pre-survey information to guide survey activities
- Strive to consistently and accurate identify problem areas
- Use laptop technology to provide timely and effective feedback
- Provide tools for continuous improvement
I am positive that this collaboration will benefit Joint Commission accredited long term care organizations, and ultimately, nursing home residents. I’ll keep you apprised of our progress. Meanwhile, if you have ideas on other ways in which we might collaborate with federal and state governments, please forward them to me at djohnson@jointcommission.org. I look forward to hearing from you.
Dale Johnson
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Long term care organizations ― those already accredited and those thinking about accreditation ― are invited to a free breakfast meeting September 22, 2008 from 8:30 to 11:30 a.m., at The Joint Commission in Oakbrook Terrace, Ill. The meeting will cover a variety of topics, including:
- Overview of the Long Term Care Accreditation Program
- The value of accreditation
- How to prepare for survey: Your first or next
- Joint Commission program updates for 2009: SII; E-dition standards manual; 2009 National Patient Safety Goals
- Discussion with Joint Commission accredited long term care organizations and accreditation experts from The Joint Commission
Attendees will also receive complimentary copies of:
- Long Term Care accreditation answer book
- The value of accreditation interactive CD
- 10 steps to accreditation
- Accreditation readiness checklist
Space is limited and registration will be closed 48 hours prior to the event or when the program reaches capacity. To register, visit the website, or call us at (630) 792-5866.
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Life Care Centers of America believes in going for the gold ― The Joint Commission’s Gold Seal of Approval ― for all 226 of its facilities. It’s a win-win situation for the residents, staff and the bottom line.
“The Joint Commission’s Gold Seal of Approval is something worth working for,” says Beecher Hunter, LCCA president. “It takes a substantial investment in staff time and dollars, but it shows a compelling commitment to quality care. And people are searching for quality when they place a loved one in our care.”
The LCCA facilities span the country from coast to coast and four are even located in Hawaii. The company operates skilled nursing facilities, home care services and Alzheimer’s centers. A sister company, Century Park, manages 44 assisted and independent living centers.
Kathryn Berger, director of accreditation at Life Care, is a firm believer in Joint Commission accreditation. “The accreditation standards aren’t something you use once and then forget, they are the principles on which we run our business,” says Berger.
Berger explains that Life Care regularly uses Joint Commission resources including the survey preparation guide, seminars and publications to keep current on accreditation requirements. In addition, LCCA incorporates a quality improvement mindset into day-to-day business practices by:
- Reviewing Joint Commission requirements and performance improvement initiatives at staff meetings.
- Posting performance improvement initiatives in visible areas to help staff keep up with progress.
- Conducting mock surveys and mock tracer activities.
- Keeping Joint Commission requirements in one, easily accessible notebook (a template is kept on the corporation’s website).
- Holding webinar training, teleconferences and face-to-face training throughout the divisions on quality improvement techniques and practices.
Accreditation has been a good thing for LCCA facilities, says Berger. She notes that it can benefit any long term care organization by:
- Challenging the staff to continually review processes and make improvements.
- Showing commitment to quality.
- Improving staff morale, giving them a goal to work towards.
- Offering a marketing advantage over long term care facilities that don’t have the Gold Seal of Approval.
For more information on the benefits of accreditation and how to incorporate accreditation requirements into your day-to-day business practices, contact Berger at Kathryn_berger@lcca.com.
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The 2009 National Patient Safety Goals for accredited long term care organizations include a new requirement related to preventing PICC (peripherally inserted central catheters) line-associated bloodstream infections.
“This National Patient Safety Goal recognizes that long term care organizations are increasingly providing more acute care. It builds on an existing NPSG to reduce the risk of health care associated infections,” says Dale Johnson, executive director, Long Term Care Accreditation Program. The new infection-related requirement has a one-year phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.
The new requirements and other revisions are available online.
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Ed Smith, R.N, M.S.N, associate director
Standards Interpretation Group
Q: Can I use a Failure Mode and Effects Analysis to meet the requirements of standard PI.3.20?
A: Yes. The standard requires: An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to residents is defined and implemented. This is the definition of a Failure Mode and Effects Analysis. Using an FMEA avoids hindsight bias and the fear of disclosure, embarrassment, blame and punishment that can happen after an event.
The elements of performance for PI.3.20 provide a handy “how-to” guide for how to conduct an FMEA. In addition, ask yourself the following questions to verify compliance:
- Within the last year, was a new high-risk process selected for analysis?
- Was the process selected proactively (before there was a problem)?
- Could we demonstrate how each EP was addressed?
- What method was used to monitor the effectiveness of the redesigned process?
If you have questions regarding this or any other standard, please contact the Standards Interpretation Group at (630) 792-5900 or submit via the online form.
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The 2009 Long Term Care Leadership and Life Safety Code standards are available for free online. These were the first chapters revised under the Standards Improvement Initiative for long term care organizations. The standards will take effect January 1, 2009 and have been placed online to give organizations time to become familiar with the new language, ordering and numbering.
Other developments to look for in the coming months:
- Single-user license, electronic E-ditions of the accreditation manuals in late 2008.
- Color-coded tabs added to 2009 print manuals to distinguish standards and requirements from accreditation policies and procedures.
- Changes in the scoring and decision process effective January 1, 2009 for all accreditation and certification programs.
In 2010, Phase II programs will see further improvements including:
- Program-specific language in all manuals.
- With E-ditions, the ability to sort relevant standards and elements of performance applicable to the services provided by an individual organization.
- Links from certain elements of performance to associated requirements in other chapters.
- Standards and EPs related to a focused area of improvement placed in relevant chapters.
New infection control field review
The Joint Commission is asking for feedback on the proposed revisions to the Infection Prevention and Control chapter for the Behavioral Health Care, Laboratory and Long Term Care programs. The survey closes Sept. 24, 2008. You can participate online.
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The Joint Commission is developing a new Health Care Services Certification product that will capture specialty services that “fall between the cracks” of the current certification and accreditation program offerings. These specialty services include any program organized around a care delivery system that treats patients regardless of diagnosis, such as palliative care, cardiac services and subacute care, among others. The survey will take approximately 7 to 10 minutes to complete. To participate, click to open the survey.
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The Joint Commission wants to know your opinion about its Speak Up patient safety program. Since its launch in 2002, the program has grown to include 10 brochures and four posters, as well as Spanish language versions of all brochures. Please take a few moments to take the short survey, which has a maximum of 18 questions. To participate, To participate, click to open the survey. For more information about Speak Up, please visit the website.
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New standards addressing rude language and hostile behavior among health care professionals go into effect January 1, 2009. The standards require organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. In addition, the new Sentinel Event Alert focuses on this topic. Research quoted in the newsletter states that this behavior goes beyond being unpleasant and poses a serious threat to resident safety and the overall quality of care. See the full Alert online.
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Publications
Reducing the Risk of Patient Harm Resulting from Falls
This toolkit for implementing National Patient Safety Goal 9 includes a guide to help organizations:
- Improve assessment and reassessment techniques to identify at-risk residents
- Choose more effective interventions to reduce fall risk factors
- Educate residents and gain their cooperation to reduce falls
- Train new staff members or provide additional training for veteran staff
- Consistently evaluate and use organizationwide data to make changes
- Learn how five health care organizations created programs to reduce falls
Order code: RPR08, $199
2009 Standards for Long Term Care
Contains the standards, rationales, elements of performance, scoring categories and measures of success designations. Also includes a chapter on the 2009 NPSGs.
Order code: LTCS-09, $110
2009 Accreditation Process Guide for Long Term Care
Includes an updated compliance assessment checklist to track organization progress, practice tracer questions and narratives.
Order code: APLT-09, $119
Click here for information or to order products from Joint Commission Resources, Inc., or if you prefer to speak to a customer service representativre, call (877) 223-6866.
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Long Term Care Accreditation
(630) 792-5286
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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