I’ve heard it said that “None of us is as smart as all of us.” That’s why The Joint Commission makes it a point to seek feedback from a wide array of stakeholders when crafting our state-of-the-art standards and review processes. We want to set expectations for organization performance that are reasonable, achievable and reviewable. One of the ways we accomplish this is through online surveys sent to the field.
Your participation in these field reviews is critical. Input gathered from the surveys helps to identify best practices, anticipate concerns, and lets us know how revisions will affect your organization. It’s a way for us to tap into the collective knowledge or “smartness” of our certified programs.
We’re currently looking for input on a brand new certification program ― Health Care Services Certification (which is separate and distinct from Health Care Staffing Services Certification). You can read the details in the article below.
I hope you will take this opportunity to participate in the field review. Meanwhile, if there are other issues on your mind regarding certification, I would be happy to hear about them. Simply send me an e-mail me at jrange@jointcommission.org. I look forward to hearing from you.
Jean Range
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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 palliative care, cardiac services and subacute care ― any program organized around a care delivery system that treats patients regardless of diagnosis. The field review of the proposed standards is open until Tuesday, April 8, and can be found here .
“The new certification program is for those health care services that are not disease-specific,” says Jean Range, executive director. “We’re excited about this new program because it emphasizes patient-centered care and teamwork. We’ve written the standards to include patients and their families in the decision-making process.”
Other examples of programs that will fall under this new certification include geri-psychiatric care, physical rehabilitation, wound care, ventilator care and women’s health care.
Development of the standards and review process has been guided by the Health Care Services Task Force, composed of experts in microsystems concepts and patient-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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Beginning in April, certified programs will need to submit performance measurement data electronically to The Joint Commission. Here is some basic information to help you get started.
- The submission tool will be available on The Joint Commission Connect extranet site in late April. All certified programs will receive an e-mail message when the submission tool goes live.
- Certified programs should continue to keep manual data records until the tool is active and they can submit their data electronically. The data must be submitted electronically — no paper forms — via The Joint Commission Connect extranet site.
- Certified Primary Stroke Centers will be required to submit data for the 10 standardized measures to The Joint Commission within 45 days following the close of each calendar quarter. All other certified programs (Stage 1) will be required to submit the data for the four measures they have selected within 45 days following the close of the quarter.
- Data submission is retroactive to the first quarter of 2008; all certified programs must submit their monthly data points starting from January 2008.
- Monthly data points are the numerator and denominator values for each of the measures. The computer will calculate the rate/measure result.
- Click here to access the extranet site. If you do not have a log-in or password, contact your organization’s CEO or program director. (As a reminder, the submission tool will become available in April.)
- Once you’ve logged onto the extranet, under “Application for Certification,” click on “Certification Measure Information Process.”
For more information, contact your account representative at (630) 792-3007.
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Beginning in late April, Quality Reports® for Joint Commission certified disease-specific care programs will be available on the Quality Check™ website. Quality Reports will feature a user-friendly format with checks, pluses and minuses to help interested individuals compare disease-specific care programs in a number of key areas, and will include:
- Certification decision and effective date
- Last full review and last on-site review dates
- Demographic information
- Certified locations of care
- National Patient Safety Goal compliance
- Commentary (optional)
Searches can be conducted by name, zip code or state, and further refined by type of service or type of provider. For more information about Quality Reports, contact your account representative, (630) 792-3007.
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As part of The Joint Commission’s Standards Improvement Initiative (SII), the Board of Commissioners approved new, improved and simplified scoring and decision processes, effective January 1, 2009 for all accreditation and certification programs. The current accreditation and certification 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 certification decisions and the timing of follow-up requirements are judged in relation to the immediacy of the threat to health care quality and patient safety as the result of non-compliance with Joint Commission requirements.
- Reflect an organization’s 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.
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Carol Mooney, RN, MSN, associate director, Standards Interpretation Unit
Q: My stroke unit uses a patient satisfaction survey from an outside vendor. However, we were told that we didn’t get “pure” data. What does The Joint Commission require?
A: The Joint Commission requires programs to evaluate patient/participant satisfaction and the perception of quality of care, analyze the results and make improvements. You may use any tool as long as you can extract program-specific data, which would most likely be by diagnosis-related group (DRG). The problem may be that the survey tool extracts data only by unit. This means that all the data may not be specific to stroke patients; it may also include neurology patients with other diagnoses such as seizures, multiple sclerosis or Parkinson’s disease. If this is the case, you need to make sure that your vendor can supply program-specific data.
“This is a pretty simple request that shouldn’t cost extra money to produce,” says Deirdre Mylod, vice president, Press Ganey, a patient satisfaction survey vendor. Mylod explains that at Press Ganey this type of request is typically handled via an online account using data that has already been uploaded about the patient’s diagnosis.
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For information or to order products from Joint Commission Resources, Inc., go to http://store.jcrinc.com or call (877) 223-6866.
Education
Disease-Specific Care Certification Workshop
Covers the DSC certification process, standards, clinical practice guidelines, and performance measurement expectations.
- June 3, Oakbrook Terrace, Ill.
- October 21, Oakbrook Terrace, Ill.
Publications
NEW! 2008 Disease-Specific Care Certification Manual
Effective January 1, 2008, the new manual includes:
- Integration of the Advanced Disease-Specific Care Certification requirements with consensus-based national core requirements
- Revised language to clarify standards and EPs
- Re-ordered standards and EPs to follow a more logical flow
- A self-assessment scoring grid provided in the margins so certified programs can continuously identify program performance
Order code: DSCC-03, $100
The new manual can be customized with setting-specific advance program requirements. Available for $15 each, they include:
- Chronic Kidney Disease, CKD-07
- Chronic Obstructive Pulmonary Disease, COPD-07
- Inpatient Diabetes Care, IDC-07
- Lung Volume Reduction, LVR-07
- Primary Stroke Center, DPSC-07
Ventricular Assist Device, VAD-07
Or purchase the Deluxe Package that includes the base manual plus all six setting-specific components.
Order code: DCDLX-07, $175
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DSC Certification (630) 792-5291
Standards Interpretation Group (630) 792-5900
DSC Account Representative (630) 792-3007
Customer Service (630) 792-5800
Pricing Unit (630) 792-5115
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