It’s been an exciting year with our new president, Dr. Mark Chassin, at the helm. We have forged ahead with changes, innovations and revisions. You can read about some of these transformations in the article on this page.
I’m encouraged by these improvements and The Joint Commission’s new vision, “To collaborate with health care organizations to lead the transformation of health care into a high reliability industry.”
We have several critical activities in place to achieve this vision. First, we have internally launched Robust Process Improvement™, which is an integrated Lean Six Sigma approach. So far, we have trained 20 Green Belts and 20 Change Agents, who are working with employees throughout the enterprise to improve customer satisfaction, standards development and communication. In addition, we are re-designing all aspects of the accreditation process ― pre-survey, survey and post-survey sub-processes with the goals of simplification, standardization, consistency and transparency to the health care organizations we serve.
We’re improving our processes in the same way that we require that you continually improve yours. The result should be better care delivered to your residents. If you have suggestions regarding our improvements or any thoughts about how The Joint Commission can serve you better, please contact our Long Term Care staff at (630) 792-5411. We look forward to hearing from you.
Dale Johnson
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January 1, 2009, will ring in more than a new year for accredited long term care organizations. As a result of the Standards Improvement Initiative, many improvements will be implemented including newly revised standards chapters, a new scoring process and an E-dition (electronic version) of the accreditation manual. Here’s an overview of what you can expect.
Extensive work is ongoing to revise and reorganize the standards to make them clearer, eliminate redundancies and create a simpler, more logical order. The 2009 Comprehensive Accreditation Manual for Long Term Care contains revisions to the Accreditation Participation Requirements, National Patient Safety Goals, Leadership and Life Safety chapters. In addition:
- The standards in the new chapters have a different numbering system to enable electronic enhancements.
- The other chapters retain the previous numbering system until 2010, when they will be re-numbered.
- Icons have been added to provide a guide to the requirements (see icon key).
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The new scoring and decision processes, effective January 1, 2009, focus on how critical an issue is to resident care or safety, as identified by noncompliant standards. The more critical the issue, the shorter the time frame that an organization has to address it. Following are highlights of the revisions. For a complete description of the changes, see the December 2008 edition of Joint Commission Perspectives or the introduction to the 2009 Accreditation Manual for Long Term Care.
- Decisions of Conditional Accreditation and Preliminary Denial of Accreditation will be driven by those standards that have the most direct impact on patient care or safety.
- There is no longer a supplemental section in the Accreditation Report. All findings of less than full compliance require resolution via submission of Evidence of Standards Compliance.
- The use of “thresholds” to determine Conditional Accreditation and Preliminary Denial of Accreditation has been revamped. Program-specific thresholds will now serve only as “screens” for identifying organizations whose survey findings require more extensive review by Joint Commission Central Office staff. The screens are based on the number of Direct Impact standards (see icon key) that are noncompliant.
- As requested by the field, Category B elements of performance have been re-categorized to either A or C. Category A reflects presence, absence or consistency and Category C is frequency based.
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Icons will be used to identify the scoring category, measure of success designation, whether documentation is needed, and the criticality of certain elements of performance (EPs). The icons that will be used in the manuals and their meanings are defined below. An icon key is provided at the bottom of each requirement page. EPs that do not have a “2”or “3” icon are considered Indirect Impact requirements (level 4). No EP is tagged as an Immediate Threat to Life requirement; instead, an Immediate Threat to Life situation is usually the result of noncompliance with a combination of EPs at any or all of the Situational Decision Rules, Direct Impact and Indirect Impact levels.
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In response to feedback from accredited organizations, The Joint Commission has launched the E-dition, an electronic, searchable version of the accreditation manuals. All organizations receive one complimentary, single-user license E-dition. If an organization is accredited under more than one accreditation manual, it will receive one complimentary single-user license E-dition for each manual it is accredited under. This single-user license allows anyone in the organization to access E-dition on a one person at-a-time basis. The E-dition may be upgraded by purchasing a multi-use site license or additional single-user licenses.
In November, an e-mail was sent to accredited organization’s primary accreditation and Periodic Performance Review (PPR) contacts. Additionally, a link to the E-dition is posted on every organization’s Joint Commission Connect extranet. This link will be a single-user guest link specific to each organization and will provide staff with the convenience of accessing E-dition without providing a login and password. In addition to the standards, the 2009 E-dition contains many new features and navigational tools such as:
- Always current. Contains the same changes published in Perspectives.
- Search ability. Provides keyword search across all standards, rationales and elements of performance to help users quickly find what they’re looking for.
- Three clicks to most standards. E-dition puts The Joint Commission standards and National Patient Safety Goals at your fingertips.
- Related links. Links to Joint Commission FAQs, sentinel event communications and other valuable information to related chapters of standards.
For more information about the E-dition, visit the JCR website at www.jcrinc.com/e-dition, or contact a JCR customer service representative at (877) 223-6866. If you need help accessing the E-dition, contact JCR E-dition Tech Support at (630) 792-5420.
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The Periodic Performance Review will be off-line from December 1, 2008 until January 1, 2009 while the new standards and scoring methods are loaded into the system. Organizations with PPR due dates from October 1 through December 31, 2008 are not required to submit a 2008 PPR. For more information see the October 2008 issue of Joint Commission Perspectives.
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Joint Commission accreditation can be used as a management tool, provide outside verification of good practices and it may reduce liability insurance costs. These are just a few of the reasons offered for pursuing Long Term Care Accreditation in a free CD. To receive your own copy, go to www.jointcommission.org/LTCvalue.
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The Joint Commission is asking for your comments on the standards and the National Patient Safety Goals.
LTC Update, the free quarterly newsletter, is chock full of the latest news and information from the Long Term Care Accreditation Program. Be the first on the block to receive the newsletter by signing up to receive it automatically at www.jointcommission.org/Library/Newsletters/list_serve.htm.
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Education
Joint Commission Accreditation Summit
April 28-29, 2009, Rosemont, Ill.
Organizations will have an opportunity to discuss significant accreditation topics and receive the latest updates on Joint Commission standards and the accreditation process with Joint Commission executives and program leaders. Includes plenary lectures and breakout sessions.
Pre-conference Primer for Long Term Care
April 27, 2009
Rosemont, Ill.
Offers information for those new to the accreditation process or those who need to get basic questions answered before the Accreditation Summit.
Publications
2009 Comprehensive Accreditation Manual for Long Term Care
Contains the standards, rationales, elements of performance, scoring, decision rules, accreditation participation requirements, National Patient Safety Goals, and policies and procedures for the Long Term Care Accreditation field.
Order code: CLTC09, $265
2009 Accreditation Process Guide for Long Term Care
This easy-to-use, spiral-bound edition features updated self-assessment checklist questions for all elements of performance, including new chapters on Life Safety and Leadership. And, new scoring information is included for all self-assessment questions.
Order code: LTSP09, $119
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, choose more effective interventions to reduce risk factors, and educate patients and gain their cooperation to reduce falls.
Order code: RPR08, $199
For information or to order products from Joint Commission Resources, Inc., go to http://store.jcrinc.com/ or call (877) 223-6866.
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Long Term Care Accreditation
(630) 792-5411
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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