The Standards Improvement Initiative is the most ambitious undertaking I’ve experienced since my arrival at The Joint Commission in 2002, and I’m happy to report some exciting news.
The 2009 ambulatory and office-based surgery accreditation manuals will be available to all customers electronically as “E-ditions” this November. Along with a free copy of the comprehensive print manual, ambulatory care organizations and office-based surgery practices will receive a free E-dition (i.e., single user license). E-ditions will be accessible via the Internet with login and password. In response to field demand, key E-dition features include:
- Easy navigation of the standards
- Applicability filters to show only those standards that apply to a particular ambulatory care setting
- Easy navigation to history tracking, with links between the 2008 and 2009 standards
- Keyword search capability
More information about the E-ditions, including how organizations will receive them, will be available in September. Beginning in July, ambulatory and OBS customers will be able to review the revised standards on the website until the print manuals are published in September.
Our goal is to make the transition to the 2009 reorganized standards and scoring system as seamless as possible. (Read more about the standards and scoring in the next issue.) There is a free telephone conference call on SII for accredited ambulatory care organizations and OBS practices at 1 p.m. C.D.T. Thursday, July 31. Registration information will be sent via e-mail to all accredited organizations, and will be posted on The Joint Commission Connect extranet one week prior to the call. If you have questions, e-mail me at mkulczycki@jointcommission.org.
Michael Kulczycki, MBA, CAE
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As part of the Standards Improvement Initiative, mock surveys have been conducted in a variety of ambulatory care settings to test the usability of the revised standards and elements of performance. The organizations were chosen based on services, location and size.
Angelica Flores, Joint Commission ambulatory care surveyor, participated in the mock surveys and thinks the revised standards will be particularly helpful for organizations with minimal Joint Commission experience. “Organizations don’t need someone on board who ‘speaks’ Joint Commission to understand these standards.”
Prior to the mock survey, Flores was concerned about losing valuable survey time trying to understand the revised standards and to explain them to the organization. “That wasn’t the case at all. I also learned a valuable lesson—that it is possible to simplify the standards without diminishing them.”
“We participated in the mock survey because we are strongly committed to the concept of office-based surgery accreditation. The survey was an excellent tool to gauge our performance,” says Mark Zajkowski, D.D.S., M.D., Oral and Maxillofacial Surgery Associates, South Portland, Maine. “We hardly knew the surveyors were there. They seamlessly integrated into the practice and observed at multiple points, always ensuring they were not in the way, and only asked questions away from patients in non-patient care areas. We felt the mock survey was a great tool to prepare for our next unannounced survey, and a great way to show our staff why accreditation is a vital tool that sets us apart from other offices in our community.”
Note: For more information on SII and the future release of the E-dition—the new electronic manual—see the executive director column.
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The 2009 National Patient Safety Goals and related requirements for accredited ambulatory care facilities and office-based surgery practices include two new requirements (with a phase-in period) related to preventing central line-associated bloodstream infections and surgical site infections. Other changes include a revision of the requirements for the existing medication reconciliation Goal, and a requirement to eliminate transfusion errors related to patient misidentification. In addition, the requirements associated with the existing Universal Protocol were also improved for 2009. These changes, which address the topics of procedure verification, marking the procedure site, and conducting a “time out” immediately prior to starting procedures, were based on feedback received at the 2007 Wrong Site Surgery Summit. For the 2009 Goals and Elements of Performance, click here. |
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As part of the transition to a more continuous accreditation process, The Joint Commission has expanded the window for unannounced surveys to 18-39 months (was 24-39 months) after an organization’s previous survey, effective July 1, 2008. The new methodology takes into account Priority Focus Process data across multiple quarters as well as trends in the performance of these data. Some ambulatory care organizations or OBS practices will be identified and scheduled for an earlier survey; however, it is expected that the majority of organizations will still be surveyed in the year that their triennial survey would be due. For more information, see the April issue of The Joint Commission Perspectives, or contact your account representative.
Effective January 1, 2008, The Joint Commission discontinued track record requirements for organizations undergoing initial surveys. These organizations will not need to demonstrate a four-month track record of compliance with the standards at the time of the initial survey or review. However, those office-based surgery practices and ambulatory surgery centers surveyed as an “ambulatory health care occupancy” that are new to accreditation must undergo a follow-up on-site survey one year after becoming accredited. The Joint Commission’s follow-up survey is limited in scope, focusing on only those areas that are most important to the provision of patient care in the identified high risk services. Please note that track record requirements remain in place for organizations undergoing re-surveys. For more information, see the September 2007 issue of The Joint Commission Perspectives. Also effective January 1, 2008 and related to this action is the elimination of Early Survey Policy—Option 2 for all programs (except the laboratory program).
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Joint Commission accredited ambulatory care clinics and office-based surgery practices want more information about complying with specific standards according to the recent readership survey. In addition, readers would like more articles about National Patient Safety Goals and the periodic performance review. Of the 455 survey respondents, 87 percent always or sometimes read Ambulatory Advisor.
Open-ended comments include:
- “More ‘from the field’ compliance pearls”
- “Keep standards compliance and future initiatives at the heart of the publication”
- “Would like to see more coverage of issues dealt with by hospital-based ambulatory clinics”
- “My facility is not Joint Commission-accredited, but I still love reading your articles—very informative”
“I am encouraged by the constructive comments we received,” says Michael Kulczycki, executive director. “Our goal is to make this newsletter a useful tool to assist our customers in their accreditation efforts.”
If you do not currently receive Ambulatory Advisor electronically, sign up here . View the newsletter online.
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Q: Would you please clarify the changes to Standard LD.3.50 which took effect this year?
A: The 2008 revised version of Standard LD.3.50, “Care, treatment and services provided through contractual agreement are provided safely and effectively,” applies only to contracted services (consultation or other agreements are not included). In addition, the standard is only relevant for care, treatment and services provided—no products—and must be provided directly to the organization’s patients. Also, the organization must represent this care as part of the services it offers.
The previous version of Standard LD.3.50, “Services provided by consultation, contractual arrangement, or other agreement are provided safely and effectively,” included all outsourced services provided through all vehicles. “The revised standard only applies to those services that directly impact patient care and treatment. For example, this standard would not apply to housekeeping or snow removal services,” says Ginny McCollum, associate director, Standards Interpretation Group. “Organizations should find the revised standard much easier to understand and apply.” For more information on Standard LD.3.50, see the July 2007 issue of The Joint Commission Perspectives or your accreditation manual or update, or call the Standards Interpretation Group, (630) 792-5900.
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To find out more about conducting a proper risk assessment, read the May 2008 issue of Environment of Care News. The article, “Assessing Risk,” includes a listing of Joint Commission requirements, as well as tips for establishing a topflight risk assessment process at your organization. To subscribe, go to the Joint Commission Resources website.
The 13th Annual Ambulatory Care Conference, “Quality and Safety—Passwords to Success,” will be held Thursday and Friday, October 2-3, in downtown Chicago. Sponsored by The Joint Commission and Joint Commission Resources, the conference will feature a keynote address by Joint Commission President Mark Chassin, M.D., M.P.P., M.P.H., and sessions on the Standards Improvement Initiative, medication reconciliation, emergency preparedness and more. The conference also includes moderated track sessions dedicated to ambulatory surgery centers, freestanding ambulatory care clinics, and hospital-based ambulatory settings. To find out more about the conference and its early bird and team discounts, call JCR Customer Service, (877) 223-6866, or visit the JCR website .
Everything you need to know about standards compliance has been combined into a nine-part web conference series sponsored by Joint Commission Resources. The series focuses on accreditation standards, SII updates, key changes and revisions for 2009, National Patient Safety Goals, as well as strategies for maintaining continuous compliance. The series of 75-minute web conferences will include a formal presentation and a question and answer session. Click here for details, or call JCR Customer Service, (877) 223-6866.
- GE Outpatient Imaging Centers, Washington, D.C., July 24-25
- American Healthcare Radiology Association, Denver, Colo., July 28-30, booth 513
- California Ambulatory Surgery Association, San Francisco, Calif., Sept. 4-5, booth 27
- National Association of Community Health Centers, New Orleans, La., Sept. 15-16, booth 324
- American Association of Oral and Maxillofacial Surgeons, Seattle, Wash., Sept. 18-20, booth 502
- Otolaryngology Expo, Chicago, Ill., Sept. 21-24
Michael Kulczycki, executive director, (630) 792-5290
Mike Dye, senior associate director, (630) 792-5259
Darrell Anderson, business development specialist, (630) 792-5292
Account representative, (630) 792-3007
Standards Interpretation Group, (630) 792-5900
JCR Customer Service, (877) 223-6866
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