As I watched the closing ceremonies of the Olympic Games I wondered what makes Olympic winners achieve their goals? What drives them to achieve above and beyond what everyone else has achieved?
The athletes showed the world they were eager to “go for the gold.” So it is with disease-specific care programs that choose to become certified by The Joint Commission. They have chosen to go above and beyond what other programs have accomplished. They are eager to go for the gold ― The Joint Commission’s Gold Seal of Approval. If your program is already certified, congratulations on your accomplishments! If not, it’s something you should seriously consider because certification offers a host of benefits:
- Provides a framework for program structure and management
- Strengthens community confidence in the quality and safety of care, treatment and services
- Improves risk management and risk reduction
- Validates compliance with nationally recognized standards by the preeminent health care evaluator
- Provides a competitive edge in the marketplace
- Provides education on good practices
- Can be a tool to attract and retain quality personnel
If certification is something you’re considering or want to know more about, give me or my staff a call. We’d be happy to help prepare you for medal contention. You can contact Caroline Isbey at (630) 792-5279; M.J. Hampel at (630) 792-5720; or me at (630) 792- 5256. We look forward to hearing from you.
Jean Range, RN, MS, CPHQ
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New requirements for Primary Stroke Centers regarding the use of IV thrombolytic therapy will be effective starting January 1, 2009.
“The new requirements evaluate whether a Primary Stroke Center has the necessary infrastructure to support the safe administration of this medication for ischemic stroke patients,” says Kelly Podgorny, RN, MS, CPHQ, project director, Standards and Survey Methods.
The six new requirements, summarized in the table below, are in the chapters for Program Management (PR), Delivering and Facilitating Care (DF), and Performance Measurement (PM). For more information, see the article in the July 2008 issue of The Joint Commission Perspectives. Questions should be directed to the Standards Interpretation Group through its online question form at http://www.jointcommission.org/Standards/OnlineQuestionForm/ or by phone at (630) 792-5900.
|
Standard |
Element of performance |
New requirements for IV thrombolytic therapy |
|
PR.8 |
1 |
The organization’s formulary or medication list must include a thrombolytic therapy (IV administered) medication for ischemic stroke. |
|
PR.8 |
1 |
Documentation indicates the reason eligible ischemic stroke patients did not receive an IV thrombolytic therapy. |
|
PR.9 |
1 |
Emergency department licensed independent practitioners have 24 hour access to a timely, informed consultation about the use of IV thrombolytic therapy, obtained from a physician, privileged in the diagnosis and treatment of ischemic stroke. |
|
DF.1 |
1 |
|
|
DF.2 |
5 |
Use of the protocol, including IV thrombolytic therapy when indicated by the treating licensed independent practitioner, is reflected in the order sets or pathways, and is documented in the patient’s medical record according to organizational procedure. |
|
PM.2 |
6 |
There is evidence that specific stroke performance measurement data, focused on use of IV thrombolytic therapy, are evaluated through the quality improvement process and by the stroke team. |
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The Certification Measure Information Process (CMIP) tool is a new application that allows Disease-Specific Care Programs to electronically submit monthly performance measurement data. Your organization’s CEO and primary certification contact will receive an e-mail when the information is due to be accessed, completed or submitted via CMIP for each disease program. Following are some frequently asked questions about using the tool.
Q: How do I obtain access to CMIP?
A. Your organization's security administrator can provide access by updating the organization contact information within the DSC tab of The Joint Commission Extranet site.
Q: Where can I find instructions on how to use the CMIP?
A: Once you access the CMIP, there is a link on the left hand navigation bar to the instructions. Choose the designation that applies to where your organization is in the review process ― initial, intracycle or recertification for Stage I or Stage II diseases. It’s a good idea to print the directions so you can follow along as you complete the steps.
Q: What is the difference between Stage I and Stage II diseases?
A: Stage I diseases use non-standardized measures for performance measurement activities. Non-standardized measures are those selected by the program or service. They should be evidence-based, relevant, valid and reliable.
Stage II diseases use standardized measures for performance measurement activities. Standardized measures have precisely defined specifications, standardized data collection protocols, meet established evaluation criteria and can be uniformly adopted for use. At this time, Primary Stroke Centers are the only certified programs using standardized measures.
Q: What information do I need to enter?
A. Primary Stroke Centers are required to submit monthly data on a quarterly basis. For others, it depends on the stage your program is in (initial certification, intracycle or re-certification). You need to enter the information for each disease program that is certified.
- Clinical practice guidelines
- Performance improvement plan
- Performance measures:
- Stage I programs should enter four performance measures and the corresponding measure data up to the point in time that the information is due. If re-certifying, the four measures should be the approved and agreed upon measures from the previous review. New measures can be requested at the time of the re-certification on-site visit.
- Stage II programs have 10 standardized performance measures pre-populated to CMIP. These programs should enter the corresponding measure data up to the point in time that the information is due.
- Performance Measure Data Report: Respond to questions for each measure (for intracycle and recertification events)
- Letter of attestation per each disease program (intracycle only)
- Intracycle conference call contact information
Q: How do I know if I have correctly submitted the necessary documents?
A: Complete all the steps as listed in the instructions. Once you click “Send to the Joint Commission,” the system will display the following message:
“Your documents have been submitted to The Joint Commission. The data submission tool and Intracycle Conference Call Information form is accessible at all times, all other documents are locked.”
For the quarterly submission of data for Primary Stroke Centers, clicking the “Save” button will transmit your monthly data points to The Joint Commission.
Q: Can I print information from CMIP?
A: Yes, Print Instructions are on the first screen displayed after you click on the Certification Measure Information Process screen.
Q: What if I have other questions about CMIP?
A. Your account representative is always happy to answer any of your questions. Their direct extension is listed on the Extranet or they can be reached at (630) 792-3007.
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Changes to the 2009 National Patient Safety Goals for Disease-Specific Care Programs include new language related to existing requirements for medication reconciliation. Other revisions also have been approved for the elements of performance for the Goals. See the full text of the goals.
The 2009 Franklin Award of Distinction application is now available. This national award of excellence recognizes those practices demonstrating commitment to collaboration, care coordination along the continuum, and the application of interdependency across disciplines in achieving patient outcomes. The Franklin Award of Distinction has been awarded annually since 2003 by The American Case Management Association and The Joint Commission. The application is due by November 28, 2008. Apply at www.acmaweb.org/section.asp?sID=20. Questions should be e-mailed to franklinaward@acmaweb.org.
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. Click here to participate. For more information about Speak Up, please visit the website .
The Joint Commission is developing a new Health Care Services Certification product for specialty services that transcend diagnosis. These specialty services include any program organized around a care delivery system that treats patients regardless of diagnosis, such as palliative care, cardiac services, subacute care, and others. The survey will take approximately seven to 10 minutes to complete. To participate click here.
Members of the DSC program staff will be at:
- American College of Chest Physicians, October 25-30, Philadelphia, Penn.
- American Association of Hip and Knee Surgeons, November 7-9, Dallas, Texas
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Education
Disease-Specific Care Certification Workshop
Covers the DSC certification process, standards, clinical practice guidelines, and performance measurement expectations.
October 21, Oakbrook Terrace, Ill.
Publications
Coming soon! 2009 Disease-Specific Care Certification Manual
New to this manual is the introduction of improved scoring categories based on The Joint Commission's Standards Improvement Initiative, as well as updates of the National Patient Safety Goals and the certification process chapters. Includes all six setting-specific modules for Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Inpatient Diabetes Care, Lung Volume Reduction, Primary Stroke Center and Ventricular Assist Devices.
Order code: DSCC09, $125
Clinical Improvement Action Guide
In microsystem thinking, the quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. This new edition explains how to integrate clinical microsystems and practice-based learning into your own organization.
Order code: AG200, $75
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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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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