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Saturday 7:37 CST, April 19, 2014

Joint Commission FAQ Page

E-dition

About The Joint Commission

How long does it take The Joint Commission to render an accreditation decision?

How long is an accreditation and certification award?

What can The Joint Commission release about accredited organizations?

Where can I find information about an accredited Health Care Organization?

Is accreditation or certification mandatory?

What is an accreditation survey? What happens during an accreditation survey?

What do standards focus on?

What is The Joint Commission?


Accreditation Publicity Kit

Accreditation Certificates

National Patient Safety Goals

Copy Approval

National Quality Improvement Goals

The Gold Seal of Approval®

Linking to the Joint Commission Website

Surveyor Quotes

Quality Reports


Certification Publicity Kit

Does the Joint Commission need to approve our advertisement or news release?

May we use the Joint Commission corporate logo in our publicity efforts?

May we use a quote from a Joint Commission reviewer?

May we hotlink to the Joint Commission’s Web site so our community can learn more about the importance of certification?

What is the Pantone Matching System (PMS) color of the Gold Seal®?

Does my organization have to reproduce the Gold Seal of Approval® in a four-color process in all its printed materials? That’s expensive.


FAQs about RSS

What is RSS?

What is a news reader?

What is a podcatcher?

Where do I get a news reader or podcatcher?

How do I get The Joint Commission RSS feeds into my reader?


FAQs Behavioral Health Accreditation

What can accreditation do for my organization?

How long does the process take?

What does it cost?

What kind of help can I expect?

What are the first steps?

How soon after I apply can I be surveyed?

What happens to my accreditation if there are changes in our organization?

How long must we be in compliance with the requirements before our first survey?

How do I register a complaint about an accredited organization?

Where can I get an accreditation manual?

How do I find out how other organizations rate with The Joint Commission?


Health Care Staffing Services FAQs

What types of organizations are eligible to be certified?

What types of organizations are not eligible for certification?

Are firms that place only independent contractors eligible for certification?

What are the benefits of health care staffing services certification for a staffing firm?

What are the benefits for health care organizations that utilize Joint Commission certified staffing firms?

Will certified health care staffing firms receive a Gold Seal of Approval™ for their businesses?

How long is the HCSS certification valid?

What are the main components of the certification process?

What is entailed in the on-site review process and how long will the review be?

Who will typically conduct the review?

How long does it take to become certified?

How long is the HCSS certification valid?

What should a supplemental staffing firm do to pursue certification?

What types of resources are available to help staffing firms become certified?

What are the Health Care Staffing Services certification fees?


Hospital - Accountability Measures

What are “Accountability Measures?”

Why is The Joint Commission reclassifying the core measures as accountability measures and how will this help hospitals?

When will The Joint Commission begin assessing performance on accountability measures?

Have both process and outcome measures been re-categorized?

Have all measures within the 10 core measure sets been re-categorized?

Why not remove non-accountability measures from use?

How will The Joint Commission utilize accountability measures in future accreditation activities?

Will accountability measures impact current Joint Commission data uses?

Will The Joint Commission continue to categorize measures as accountable and non-accountable measures?

How many accountability measures are there?

Where can I locate additional information on accountability measures?

Of the 28 measures, how did you arrive at the list of 22?


Sentinel Event - Radiation Overdose

How do we go about monitoring fluoroscopy doses?

Is "cumulative" defined as a life-time dose?

The parameters that specify when these events are reviewable seem very high; in fact, much higher than are specified by the relevant practice guidelines and regulations. Why is that?

Does the term “single field” refer to the location on the skin through which the radiation is directed or the target internal organ, or both?

Does “delivery of radiotherapy” apply to radioisotope therapy or radiation producing machines, or both?

What, exactly, is intended by “any delivery of radiotherapy to the wrong region”? Are even minor variations in the field considered sentinel events?

Does the phrase “>25% above the planned dose” refer to the total planned dose or a single (fractionated) dose?

Are we now required to keep track of the cumulative fluoroscopy dose for all patients having fluoroscopy exams and report when they have a cumulative dose of 1500 rads?


Sentinel Event - Retained foreign object after surgery

Sometimes a needle or screw will break leaving a fragment behind. Is this a reviewable sentinel event?

What about a retained sponge following vaginal delivery?

When, exactly, is “after surgery?"

Why was this particular point in the process selected as the definition of “after surgery?"


Strategic Surveillance System (S3)

Is there an additional cost involved with S3?

Will the concept of S3 be adapted for organizations other than hospitals?

What is S3?

Why was S3 developed?

What are some of the benefits of S3?

Do we need to provide The Joint Commission with more data for S3?

How do we access these reports? How often do we receive them?

Will this data be made available to the public?

Is S3 available for all hospitals?

What is the source of the data provided by S3?

What is included in S3?


Subscription Billing

How often will I receive invoices?

When is payment due?

Is there a payment plan?

What is the cost of accreditation or certification?

How much is the deposit I need to send with my application?

I received my invoice invoice today. Has my deposit been deducted from the amount of my invoice?

Do I need to send full payment with my application?

Can I pay my deposit, annual fee or on-site fee by credit card?

Whom should we list as the payee on the check and what is the mailing address?

How are fees determined?

What if I should decide to withdraw from the process?

If I do not pay my annual fee, will my accreditation or certification expire when I am due for my next on-site survey or review?

How can I access my extranet to download billing information?


Top Performer on Joint Commission Key Quality Measures

What is the Joint Commission's Top Performer on Key Quality Measures® program?

Why did The Joint Commission launch this program?

When did The Joint Commission launch its Top Performer recognition program?

What eligibility criteria are used to determine if an organization is a Top Performer?

How does the Top Performer on Key Quality Measures program work?

Do hospitals need to submit an application to be considered for the Top Performer on Key Quality Measures program?

My hospital collects additional core measure sets beyond those of the ORYX requirements; will the accountability measures in these additional sets be included in the calculation of my hospital’s composite score for potential Top Performer recognition?

What does it mean if a hospital is not on the list?

How many hospitals are being recognized on the Top Performer list and what are the demographics?

What is new for the Top Performer on Key Quality Measures program?

Why are you announcing Top Performer hospitals now, when the data are from care delivered in the previous calendar year?

My hospital was at 95 percent on all the measures in a particular set, yet we didn’t get recognized. How could that happen?

Who do I contact if I have a question about our organization’s data?

What determines if a hospital is “on track” to being a Top Performer?

How can those organizations that did not make the list improve their performance?

What is an accountability measure?

Psychiatric hospitals have been reporting inpatient psychiatric services measures for some time. Are these hospitals eligible for the Top Performer designation?

What about rehabilitation hospitals?

Are the multiple antipsychotic medications measures (HBIPS-4a and HBIPS-5a) included in the composite for the inpatient psychiatric services measure set?

Is PN-6a (antibiotics to ICU patients) included in the composite for the pneumonia measure set?

Why is the perinatal care measure set data not included in the composite rates for calendar year 2012 data?

What is the time frame covered for “seasonal” measures included in the calculations for Top Performer recognition?

Why are the HBIPS-2 and HBIPS-3 measures excluded from the Top Performer program?

Why are some well-known hospitals and academic medical centers recognized on other lists and not on the Top Performer list?


Nursing Care Center

How has the Nursing Care Center Accreditation program changed?

What are the eligibility requirements for accreditation and specialty certification?

How do you define Post-Acute Care services?

Why did The Joint Commission reinvent the Long Term Care accreditation program?

My facility is already accredited with The Joint Commission for LTC, what does mean to me?

I’m a current customer, and am interested in achieving the new certification--Can we add it at any point during the accreditation cycle?

If we achieve certification, will we receive a separate certificate along with our accreditation certificate?

Will there be performance measurement requirements for the new accreditation and certification?

Who did you involve in the redesign process?

What’s the cost?

Can I choose to pursue certification without accreditation?

What’s the benefit to my organization to achieve certification?

What happens if my organization doesn’t “pass” the certification, does it impact my accreditation status?


About The Joint Commission

Q: How long does it take The Joint Commission to render an accreditation decision?
A:

The Joint Commission renders accreditation decisions two weeks to two months after the survey.

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Q: How long is an accreditation and certification award?
A:

Accreditation is awarded for three years, except for laboratory accreditation, which is awarded for two years. Joint Commission Disease-Specific Care Certification, Primary Stroke Center Certification, and Health Care Staffing Services Certification are awarded for two years.

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Q: What can The Joint Commission release about accredited organizations?
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Q: Where can I find information about an accredited Health Care Organization?
A:

Joint Commission Quality Reports give the public information on the safety and quality of care at the more than 18,000 accredited health care organizations. Quality Reports are available online through Quality Check® at qualitycheck.org.  Quality Reports include:

  • Accreditation decision and date
  • Programs and services accredited by The Joint Commission and other bodies
  • National Patient Safety Goal performance
  • Hospital National Quality Improvement Goal performance
  • Special quality awards
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Q: Is accreditation or certification mandatory?
A:

No. Health care organizations, programs, and services voluntarily pursue accreditation and certification.

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Q: What is an accreditation survey? What happens during an accreditation survey?
A:

Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey.  All regular Joint Commission accreditation surveys are unannounced.  

Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other health care professionals. The Joint Commission is the only health care accrediting body that requires its surveyors be certified. 

During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves. 

Joint Commission accreditation does not begin and end with the on-site survey. It is a continuous process. Every time a nurse double-checks a patient’s identification before administering a medication, every time a surgical team calls a" time out" to verify they agree they’re about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process. Every three months, hospitals submit data to the Joint Commission on how they treat conditions such as heart attack care and pneumonia – data that is available to the public and updated quarterly on qualitycheck.org. Every year, organizations evaluate their ongoing standards compliance through a periodic performance review. Joint Commission accreditation is woven into the fabric of a health care organization’s operations.

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Q: What do standards focus on?
A:

The Joint Commission’s state-of-the-art standards focus on patient safety and quality of care. The Joint Commission standards are updated regularly to reflect the rapid advances in health care and medicine. The hospital accreditation standards number more than 250, and address everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects data on its performance and uses that data to improve itself.

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Q: What is The Joint Commission?
A:

Founded in 1951, The Joint Commission seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 20,000 health care organizations and programs in the United States, including more than 9,500 hospitals and home care organizations, and more than 6,300 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. In addition, The Joint Commission also provides certification of more than 1,000 disease-specific care programs, primary stroke centers, and health care staffing services. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.

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Accreditation Publicity Kit

Accreditation Certificates

Q. Who should our organization contact to obtain our certificate of accreditation? And what if we want to obtain additional copies?

A. Each organization receives one free certificate of accreditation. If you have questions about your certificate or wish to order additional copies contact Alicia Golden at 630-792-5840.

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National Patient Safety Goals

Q. What are National Patient Safety Goals and why are they important?

A. National Patient Safety Goals are a series of specific actions that accredited organizations are required to take in order to prevent medical errors such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups. A panel of national safety experts has determined that taking these simple, proven steps will reduce the frequency of devastating medical errors.

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Copy Approval

Q. Does the Joint Commission need to approve my organization’s advertisement or news release?

A. No. Your organization is not required to send its ad or news release to the Joint Commission. However, our Department of Communications will be happy to review your promotional materials and answer any questions you may have. If your organization has questions, please contact Speakers Bureau and Professional Relations Coordinator Denise Tucker at (630) 792-5633. 

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National Quality Improvement Goals

Q. Hospital X got a minus on a measure – what does that mean?
A.  A Minus is used to show that the hospital has performed below the target range/value.  Using statistical formulas, the individual hospital’s result is compared to the target range/value. If the hospital result for the measure/measure set was statistically below the target range/value, the hospital receives a Minus.

Q. Hospital X got a check mark on a measure – what does that mean?
A.  A Check is used to show that the hospital has performed the same as the target range/value. Using statistical formulas, the individual hospital’s result is compared to the target range/value. If the hospital result for the measure/measure set was statistically similar to the target range/value, the hospital receives a Check.

Q. Hospital X got a plus on a measure – what does that mean?
A.   A Plus is used to show that the hospital has performed better than the target range/value. Using statistical formulas, the individual hospital’s result is compared to the target range/value. If the hospital result for the measure/measure set was statistically better than the target range/value, the hospital receives a Plus.

Q. Hospital X got a star on a measure – what does that mean?
A. A star means that for that measure, the hospital achieved the best compliance possible with that measure.

Q. Is Hospital Y better than Hospital X because it got a plus on a measure and Hospital X did not?
A. Not necessarily. The measures are reported on one specific aspect of care. The care patients receive at a hospital depends on many different factors. The Quality Report is one tool to assist individuals in selecting health care services. Individuals should discuss the Quality Report and its contents with their health care providers to help them make informed choices.

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The Gold Seal of Approval®

Q. What is the Pantone Matching System (PMS) color of the Gold Seal of Approval® ?

A. The Gold Seal of Approval®  is reproduced using a four-color process. A one-color version of the Gold Seal of Approval®  is available in the online version of this publicity kit. The one-color version uses Pantone color 117.

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Linking to the Joint Commission Website

Q. May our organization hotlink to the Joint Commission’s Website so our community can learn more about the importance of accreditation?

A. Yes, your organization may link to the Joint Commission’s home page, www.jointcommission.org. If your organization has questions about this, please contact the Associate Director of Web Communications Frank Barancyk, at (630) 792-5182 .

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Surveyor Quotes

Q. May our organization use a quote from a Joint Commission surveyor?

A. No. Your organization may not use verbal or written quotes from a Joint Commission surveyor or survey team. Sample news releases are included in this publicity kit and quotes from Joint Commission Executive Directors are provided that may be used in your organization’s promotional materials. Your organization may talk about the survey process in general, such as the composition of the survey team, the number of days the surveyors were on-site, and the scope of the review.

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Quality Reports

Q. How often and under what circumstances will the Quality Report change?

A. The accreditation, demographic and National Patient Safety Goal information will be updated when there are changes. The National Quality Improvement Goal information for hospitals is updated quarterly.

Q. Can  my organization “hotlink” to Quality Report on the Quality Check Web site?

A. Yes. Each Quality Report has a unique URL that will display in your web browser’s address bar. If your organization has questions about this, please contact Internet/Intranet Communications Manager Frank Barancyk, at (630) 792-5182.

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Certification Publicity Kit

Q: Does the Joint Commission need to approve our advertisement or news release?
A:

No. Your organization is not required to send its ad or news release to The Joint Commission. However, the Joint Commission’s Department of Communications will be happy to review your organization’s promotional materials and answer any questions.  If your organization has questions, please contact Speakers Bureau and Professional Relations Coordinator Denise Tucker, at (630) 792-5633 or dtucker@jointcommission.org.  

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Q: May we use the Joint Commission corporate logo in our publicity efforts?
A:

No. Remind your organization’s key audiences to look for the Joint Commission’s Gold Seal of Approval®  when selecting Disease-Specific Care and Health Care Staffing Services.

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Q: May we use a quote from a Joint Commission reviewer?
A:

No. Your organization may not use verbal or written quotes from a Joint Commission reviewer. Sample news releases are included in this publicity kit that provide quotes from Joint Commission executive directors that may be used in your organization’s promotional materials. Your organization may talk about the on-site review process in general, such as the composition of the review team, the number of days the reviewers were on-site, and the scope of the review.

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Q: May we hotlink to the Joint Commission’s Web site so our community can learn more about the importance of certification?
A:

Yes, your organization may link to the Joint Commission’s home page, www.jointcommission.org.  If there are questions about this, please contact Internet/Intranet Communications Manager, Frank Barancyk, at (630) 792-5182 or fbarancyk@jointcommission.org.

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Q: What is the Pantone Matching System (PMS) color of the Gold Seal®?
A:

The Gold Seal of Approval®  is reproduced using a four-color process. A one-color version of the Gold Seal of Approval®  is available in the online version of this publicity kit. It uses PMS 117.

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Q: Does my organization have to reproduce the Gold Seal of Approval® in a four-color process in all its printed materials? That’s expensive.
A:

No. Your organization may use any color on printed materials (defined to include newspaper advertisements, Yellow Page listings, stationery, business cards, fliers, brochures, newsletters, posters, tent cards and promotional items such as coffee mugs and T-shirts). A special line-art version of the Gold Seal of Approval®  may be downloaded from The Joint Commission Web site.

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FAQs about RSS

Q: What is RSS?
A:

RSS, Rich Site Summary or Really Simple Syndication, is a method of distributing news headlines and other content on the Web.

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Q: What is a news reader?
A:

A news reader combines content from many Web sources and for display.

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Q: What is a podcatcher?
A:

A podcatcher is an application you can use to subscribe to podcasts; the podcatcher automatically downloads podcasts as they are posted to a site. Podcatchers can also transfer downloaded podcast files to a portable media player.

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Q: Where do I get a news reader or podcatcher?
A:

There are many free readers and podcatchers that display RSS available on the internet.

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Q: How do I get The Joint Commission RSS feeds into my reader?
A:

Simply  paste the RSS link into a news reader or podcatcher.

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FAQs Behavioral Health Accreditation

Q: What can accreditation do for my organization?
A:

Accreditation is a periodic external evaluation by recognized experts that provides impartial evidence of the quality of care, treatment or services delivered to the individuals you serve.

Preparing for accreditation affords your organization the opportunity for an in-depth review of safety and care delivery processes.  Achieving accreditation is a visible demonstration to those you serve, their families, your staff and community of your organization’s ongoing commitment to safe, high quality care, treatment or services.

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Q: How long does the process take?
A:

How long you take to get ready for accreditation is up to you.  You can move forward at your own pace.  Most Joint Commission accredited organizations take about 4-6 months to evaluate themselves and/or establish new policies and procedures before they are ready for their survey.  As the application for accreditation is good for 12 months, this gives you time to review the accreditation requirements and make sure your organization is ready before our surveyor(s) arrive.  Also, your first survey is a “scheduled” one, which means you’ll know the exact date we’ll be arriving – and that date will be based on when you tell us you think you’ll be ready.

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Q: What does it cost?
A:

A Joint Commission accreditation period is three years.  We divide your fees across this three year period using an annual fee.  There is also a survey fee in the first year, as that is when we incur the most costs to send surveyor(s) to visit you.  So you’ll pay about 60% of your total accreditation costs in the first year and about 20% each the next two years.  All costs are included in those fees, so there are no extra charges for surveyor travel, etc.  As an example, a small organization would pay about $1,689 in annual fees every year, plus a survey fee of around $2,835 in the year we do the on-site survey. 

Your actual cost will depend on several factors such as the number of locations you have and the volume of individuals you serve.  You can get an estimate by calling (630) 792-5115; or you can calculate it yourself by using our pricing worksheet available on this web page. 

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Q: What kind of help can I expect?
A:

We understand that the road to accreditation often has its challenges, but we also offer a wide variety of resources to assist you.  These include a Behavioral Health Accreditation Team for the early steps, such as helping you find a mentor organization to talk to; a dedicated Account Executive for your organization, who will help you through the application and pre-survey process; and a Standards Help Desk, just to help clarify and answer questions about the accreditation requirements.  You’ll find their contact information under “Quick Links,” or see the Resource Directory in our “Guide to Joint Commission Behavioral Health Accreditation,” also available on this web page.

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Q: What are the first steps?
A:

The first step for most organizations is to contact us to get free trial access to our accreditation requirements, and to use the sorting feature(s) to determine which of the requirements in the manual you’ll need to be in compliance with by the time of survey.  This will let you conduct an analysis to see how close you are to compliance with the requirements and give you an idea of how much preparation time you’ll need.  You may also wish to review our “Guide to Joint Commission Behavioral Health Accreditation,” available on this web page, which explains the accreditation process in depth. 

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Q: How soon after I apply can I be surveyed?
A:

The key issue is when you feel you will be ready for your survey.  A new organization will need to be surveyed within 12 months of submitting their application and deposit.  But we will do our best to schedule your survey on or after the month you indicate on the application as your “ready date”.  We also allow you to tell us specific dates when you don’t want us to come. Most organizations request to be surveyed 3-9 months after they have submitted their application, to give themselves time to prepare.  But we can also be responsive to short turn-around times for those who wish to be surveyed quickly.
 

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Q: What happens to my accreditation if there are changes in our organization?
A:

If there are major changes at your organization, such as a merger, acquisition, or other major change in services/programs provided, location(s), capacity, or corporate structure, you’ll need to contact us within 30 days.  We do not automatically transfer accreditation to new owners.  Usually, we will extend your accreditation until we can determine if the change is major enough to warrant a special extension survey.  Failure to notify us of major changes to your organization can result in a loss of accreditation.
 

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Q: How long must we be in compliance with the requirements before our first survey?
A:

The Joint Commission does not require a “track record” for Behavioral Health Care organizations.  We do expect that you will be in compliance with all the accreditation requirements by the time of your survey, but we will not review previous compliance.

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Q: How do I register a complaint about an accredited organization?
A:

If you or anyone else wishes to register a complaint about an accredited organization, complete our online “Quality Incident Report Form”, or call 800-994-6610.
 

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Q: Where can I get an accreditation manual?
A:

They are available for purchase on our sister-site, www.jcrinc.com.  A complimentary copy will also be sent to your organization upon receipt of your application and a deposit towards your accreditation fees, and we also offer a free trial of our online accreditation manual to anyone who is interested in reviewing the requirements prior to sending in their application.  If you are considering behavioral health accreditation and would like a free trial of our online accreditation manual, please call us at (630) 792-5771.

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Q: How do I find out how other organizations rate with The Joint Commission?
A:

Visit www.qualitycheck.org, where you can search our database for a complete listing of all Joint Commission accredited organizations, and review their latest quality reports.

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Health Care Staffing Services FAQs

Q: What types of organizations are eligible to be certified?
A:

Health care staffing services are eligible for Joint Commission certification if they:

  • Place temporary clinical staff in other organizations that direct or provide direct patient care. (1)
  • Place temporary clinical staff under the direct supervision of another organization's personnel.
  • Collect and present four months of data for each of the three standardized performance measures.
  • Place at least 10 individual clinical employees on assignments by the time of onsite review.
  1. This includes disciplines such as physicians, RNs, LPN/LVNs, nursing assistants, pharmacy personnel, radiology technicians, surgical assistants, respiratory therapists, laboratory staff, etc.  These settings include health care organizations, schools, occupational and community settings, etc.
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Q: What types of organizations are not eligible for certification?
A:

 

  • Permanent placement firms that do not provide temporary staffing services
  • Internal organization registry or “pool” programs
  • Contracted services for management of functions within existing organizations such as emergency department management, pharmacy management, and housekeeping management services
  • Non-clinical staff (e.g. housekeeping, medical records or coders, home companions)
  • Individual employees


 

 

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Q: Are firms that place only independent contractors eligible for certification?
A:

Yes, they are eligible.  Under the Human Resources standards, it is stated that the HCSS firm evaluates the performance of each staff member.  Staff are defined as “individuals such as employees or independent contractors who provide services provided by the HCSS firm.” 
 
Whether a firm places only independent contractors, or a few independent contractors, both the firm and the Human Resources files for the independent contractors are eligible for review, and as part of the review process, may be selected.

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Q: What are the benefits of health care staffing services certification for a staffing firm?
A:

Health Care Staffing Services Certification:

  • Establishes criteria for providing appropriate and competent staffing services
  • Provides a management framework for quality, safety and improving performance
  • Provides external validation of sound business practices
  • Increases credibility
  • Improves risk management and risk reduction
  • Enhances contracting opportunities
  • Provides a competitive edge in the marketplace
  • Can be a tool to attract and retain quality personnel
  • Can fulfill regulatory requirements in select states
  • Provides potential recognition by liability insurers
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Q: What are the benefits for health care organizations that utilize Joint Commission certified staffing firms?
A:

The benefits to health care organizations that utilize Joint Commission certified staffing firms include:

  • A greater level of confidence that the processes within the staffing firm support that supplemental staff working in their organizations have met the rigorous requirements set by the Joint Commission.
  • Health care staffing services certification would provide health care providers with a third party source of information to assist in making informed choices among staffing firms. 
  • HCSS certification supports and facilitates health care organizations’ efforts to improve quality and safety of care delivered to their patients. 
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Q: Will certified health care staffing firms receive a Gold Seal of Approval™ for their businesses?
A:

Every location that is certified will receive a gold seal that can be publicly displayed.  Certified staffing firms are also encouraged to publicize their achievement to both health care organizations and to prospective employees in an effort to affirm their commitment to quality care and service.

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Q: How long is the HCSS certification valid?
A:

Certification is awarded for two years.  The review will be based on:

  • An on-site review, which allows the Joint Commission to evaluate factors relevant to the certification process
  • An Intracycle Event, which includes an evaluation of the performance measurement activities and other certification topics of interest via conference call with a Joint Commission Reviewer.
     
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Q: What are the main components of the certification process?
A:

The certification process will consist primarily of two key elements – compliance with set standards and performance measurement. 

A standard is a statement that defines the performance expectations, structures, or processes that must be substantially in place in an organization or service to enhance quality of care.  For more information see Standard FAQs.


Performance measurement in health care represents what is done and how well it is done.  Performance measurement utilizes performance measures, which are quantitative tools (known as measures or indicators) that are reported as a rate, ratio or percentage.  A performance measure provides an indication of an organization’s or service’s performance in relation to a specified process or outcome. 

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Q: What is entailed in the on-site review process and how long will the review be?
A:

The length of the on-site visit is dependent upon a number of factors such as a staffing firm’s structure, number and types of placements and number of states to which staff are sent.

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Q: Who will typically conduct the review?
A:

A Joint Commission Health Care Staffing Services reviewer who has experience and training specific to the health care staffing services industry will conduct the on-site review.
 

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Q: How long does it take to become certified?
A:

After submission of your application and deposit for certification, typically 60-90 days are needed for application processing and scheduling of the review.  Approximately 30 days prior to the scheduled review date, the staffing firm will be notified of their scheduled date and reviewer information (initial applications only).  The staffing firm can expect to receive a final certification report from the Joint Commission within 45 days after the on-site review.
 

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Q: How long is the HCSS certification valid?
A:

Effective January 1, 2006, the Health Care Staffing Services certification shifted from an annual review cycle to a biennial review cycle.  Reviews conducted in 2006 will be valid for two years.  The review will be based on:

An on-site review, which allows the Joint Commission to evaluate factors relevant to the certification process

  • An Intracycle Event, beginning January 2009, which includes an evaluation of the performance measurement activities and other certification topics of interest via conference call with a Joint Commission Reviewer.

 

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Q: What should a supplemental staffing firm do to pursue certification?
A:

Organizations wishing to become certified should contact the Joint Commission at 630.792.5291 to request access to the electronic application for certification.

 

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Q: What types of resources are available to help staffing firms become certified?
A:

Support resources from Joint Commission Resources (JCR) include:

  • Audio Conferences:  These conferences are designed to provide an in-depth understanding of the Health Care Staffing Services Certification standards, as well as address key issues to help with preparation for the certification process.
  • Health Care Staffing Services Certification Manual:  The standards manual for Health Care Staffing Services certification is available at http://www.jcrinc.com/ or call 1-877-223-6866 to purchase a copy.
  • Consulting Services:  JCR will have consultants skilled in the HCSS certification process to provide customized support to organizations seeking certification.
  • Publications:  JCR offers publications on topics including performance measurement and contracted services.  Contracted Staff and Patient Safety discusses the Joint Commission’s new certification program for health care and offers practical tools and valuable lessons to effectively hire, orient, train, and work with contracted staff while maintaining high standards of patient safety!  Please visit http://www.jcrinc.com/ for more information.

The Joint Commission Business Development Staff works especially with organizations preparing for their first certification.  Resources available include HCSS certification handbook, Review Process Guide and corporate system addendum.  Any questions that you have about the overall certification process and your preparation efforts should be directed to (630) 792-5291.  

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Q: What are the Health Care Staffing Services certification fees?
A:

There are different pricing options for certification, depending on the composition and needs of your staffing firm.  For information on pricing for your organization, please email PricingUnit@jointcommission.org or contact 630.792.5115.

For further information on the HCSS certification program, visit the Joint Commission web site or contact Michele Sacco at msacco@jointcommission.org.

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Hospital - Accountability Measures

Q: What are “Accountability Measures?”
A:

Accountability measures are quality measures that meet four criteria that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement on them. 

The criteria for classifying accountability measures include:

  • Research:  Strong scientific evidence exists demonstrating that compliance with a given process of care improves health care outcomes (either directly or by reducing the risk of adverse outcomes).
  • Proximity:  The process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs.
  • Accuracy:  The measure accurately assesses whether the evidence-based process has actually been provided.  That is, the measure should be capable of judging whether the process has been delivered with sufficient effectiveness to make improved outcomes likely. If it is not, then the measure is a poor measure of quality, likely to be subject to workarounds that induce unproductive work instead of work that directly improves quality of care.
  • Adverse Effects:  The measure construct is designed to minimize or eliminate unintended adverse effects.

These criteria are based on The Joint Commission’s experience implementing and evaluating the outcomes of quality measures for more than a decade. The criteria provide a more rational approach to the process of collecting and reporting quality data. 


 

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Q: Why is The Joint Commission reclassifying the core measures as accountability measures and how will this help hospitals?
A:

The Joint Commission wants to help hospitals improve performance on accountability measures in an effort to promote excellence in the delivery of care and maximize health outcomes, and in anticipation of the Centers for Medicare & Medicaid Services incentive payments that become effective in 2013.  The Joint Commission will eliminate measures that do not work well, include performance on accountability measures in accreditation standards and include only accountability measures in the ORYX program.:

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Q: When will The Joint Commission begin assessing performance on accountability measures?
A:

The Joint Commission will actively engage the field to determine how performance on the accountability measures will be assessed.  Performance assessment on accountability measures will not begin before January 1, 2012.
 

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Q: Have both process and outcome measures been re-categorized?
A:

Based upon The Joint Commission’s experience with standardized hospital quality measures, the conceptual framework for the categorization of the current measures was limited.  It focused on process measures because they account for the majority of the measures currently in use.  Since outcome measures have additional scientific challenges surrounding the need for case mix adjustment, additional criteria for evaluation need to be established.
 

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Q: Have all measures within the 10 core measure sets been re-categorized?
A:

Evaluation of the measures currently used for public reporting purposes is complete.  The Joint Commission is now evaluating the remaining sets of hospital core measures that meet ORYX performance measure reporting requirements (e.g., perinatal care and hospital based inpatient psychiatric services).
 

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Q: Why not remove non-accountability measures from use?
A:

Measures that do not meet the accountability measures criteria can still prove to be a valuable source of information to hospitals.  These measures are also currently used by other initiatives as standardized performance measures for assessing and reporting on hospital performance.
 

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Q: How will The Joint Commission utilize accountability measures in future accreditation activities?
A:

The Joint Commission currently is considering a variety of innovative approaches to integrating hospital performance on the accountability measures into its survey and accreditation activities.  To promote improved performance on accountability measures, and help hospitals prepare for the increasing reliance on attaining high performance on quality measures.  The Joint Commission will be engaging accredited hospitals through focus groups and online surveys over the next few months.
 

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Q: Will accountability measures impact current Joint Commission data uses?
A:

As of March 2010, accountability measures have already been integrated into the information reported on Quality Check.™  Starting with the third quarter 2009 core measure data, only accountability measures are being used to calculate the overall performance rate for each measure set. However, the categorization of the measures into accountability and non-accountability measures will not affect individual measure information reported on Quality Check.  Accountability measures also will be integrated into the Priority Focus Process and The Joint Commission’s Strategic Surveillance System (S3) Performance Risk Assessment beginning with the July release of the S3 Performance Risk Assessment.  In these tools, accountability measures will be weighted differently (i.e., higher) than non-accountability measures. When a hospital’s performance on an accountability measure is determined to be unsatisfactory, one (1) point will continue to be assigned to each of the related Priority Focus Areas (PFAs) and Clinical/Service Groups (CSGs). When performance on a non-accountability measure is determined to be unsatisfactory, 0.33 point will be assigned to each of the related PFAs and CSGs.
 

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Q: Will The Joint Commission continue to categorize measures as accountable and non-accountable measures?
A:

In the future, The Joint Commission will only adopt accountability measures for use in its ORYX initiative.
 

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Q: How many accountability measures are there?
A:

The Joint Commission has classified 22 of its 28 hospital core measures as accountability measures.  These measures are aligned with the Centers for Medicare & Medicaid Services measures and include the children’s asthma care measures which are reported on the Centers for Medicare & Medicaid Services Hospital Compare Web site.  For a list of both the accountability and non-accountability measures see the June 23, 2010 special issue of Joint Commission Online.
 

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Q: Where can I locate additional information on accountability measures?
A:

Additional information on accountability measures can be found in the June 23, 2010 special issue of Joint Commission Online and the June 23, 2010 on-line issue of the New England Journal of Medicine, “Accountability Measures: Using Measurement to Promote Quality Improvement.”  Additional information will be posted on The Joint Commission’s Web site and in the August 2010 issue of Joint Commission Perspectives.
 

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Q: Of the 28 measures, how did you arrive at the list of 22?
A:

All 28 measures were vetted against the four evaluation criteria.  To learn more about the criteria and which of the six measures did not meet the criteria for accountability measures, see the June 23, 2010 online issue of the New England Journal of Medicine, “Accountability Measures:  Using Measurement to Promote Quality Improvement,” of which Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission, is the lead author. 
 

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Sentinel Event - Radiation Overdose

Q: How do we go about monitoring fluoroscopy doses?
A:

Most fluoroscopic x-ray equipment can provide an estimate of the total (cumulative) dose that would
have resulted to a point on the skin if the x-ray beam was stationary during the complete procedure.
Such an estimate is derived from the fluoroscopic technique factors and the total fluoroscopic
exposure time, including any image recording, or from built-in dosimetry systems found on some
newer equipment. However, these systems, known as dose-area-product meters (DAP meters) or
some similar term, do not directly provide skin dose information without further knowledge of the
sizes of the x-ray beam during the entire procedure. The relationship between cumulative skin dose
and peak skin dose is highly variable, as has been demonstrated in a number of publications.
However, for purposes of estimating peak dose, one could establish a “trigger” for reporting peak
skin dose based on a fraction, say 75%, of the cumulative skin dose. Further recommendations for
monitoring, recording and patient follow-up for high dose imaging procedures are available from the
FDA at http://www.fda.gov/cdrh/radhealth.html.

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Q: Is "cumulative" defined as a life-time dose?
A:

No; monitoring “life-time dose” is neither practical nor necessary with respect to fluoroscopic
procedures. While tissue damage from radiation is dependent on the total (cumulative) dose
delivered over time, we recognize that skin sensitivity is, to a degree, repairable and that monitoring
cumulative dose over a period of six months to a year would be reasonable.

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Q: The parameters that specify when these events are reviewable seem very high; in fact, much higher than are specified by the relevant practice guidelines and regulations. Why is that?
A:

It is important to recognize that the purpose of the Sentinel Event Policy is to promote improvement
in patient safety, not to regulate practice. The parameters defining these sentinel events were
intentionally selected to identify only the most extreme cases—those that should never occur. On
those rare occasions when these limits are reached, it is clear that a root cause analysis is appropriate
to identify the systems factors that allowed such a significant variation to occur. This is in contrast to
practice guidelines and regulations that set limits on the acceptable range of practice variation.

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Q: Does the term “single field” refer to the location on the skin through which the radiation is directed or the target internal organ, or both?
A:

As it relates to fluoroscopy, the specification of “1500 rads to a single field” refers to a location on
the skin through which the fluoroscopic beam is directed. The issue here is the magnitude of the dose
to that portion of the skin that receives the maximum or peak skin dose. This may be the situation
that results from using several different x-ray beam projections or fields-of-view whose beam areas
on the patient’s skin overlap in a specific location to produce a region of highest radiation dose. In
fluoroscopically-guided interventional procedures, many different projections or x-ray beam
directions are often used, with many overlapping fields-of-view or imaged areas.

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Q: Does “delivery of radiotherapy” apply to radioisotope therapy or radiation producing machines, or both?
A:

It applies to both.

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Q: What, exactly, is intended by “any delivery of radiotherapy to the wrong region”? Are even minor variations in the field considered sentinel events?
A:

The intent here is the same as requiring a root cause analysis for a wrong site surgery. The fact of a
wrong site delivery of radiotherapy carries implications of system problems that should be
understood and, as appropriate, redesigned. With regard to “minor variations,” it is recognized that
as with any process, there will be some degree of common cause variation, which is within the range
of acceptability for that procedure. Any variation from the intended field of treatment that is within
the range considered by the medical physics community as acceptable would not be considered by
the Joint Commission to be a reviewable sentinel event. A variation greater than that, i.e., a special
cause variation, should be managed as a sentinel event. Additional detail on this topic is available
from the NRC for radiopharmaceuticals and the FDA for radiation-generating equipment.

 

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Q: Does the phrase “>25% above the planned dose” refer to the total planned dose or a single (fractionated) dose?
A:

It refers to the total planned dose.

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Q: Are we now required to keep track of the cumulative fluoroscopy dose for all patients having fluoroscopy exams and report when they have a cumulative dose of 1500 rads?
A:

This new “reviewable sentinel event” does not mandate any measurement activities that are not
expected as part of the usual standard of practice for fluoroscopy and radiotherapy. One of the main
reasons for adding this event to the Joint Commission’s list of reviewable sentinel events was to
raise awareness of the severity of the associated outcomes—often overlooked or unrecognized
because of the delay in their appearance. That said, routine monitoring of the parameters identified
in this new sentinel event definition would be an appropriate patient safety precaution. edit
 

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Sentinel Event - Retained foreign object after surgery

Q: Sometimes a needle or screw will break leaving a fragment behind. Is this a reviewable sentinel event?
A:

In some cases, a broken needle or screw fragment is recognized at the time of surgery and
a clinical judgment is made to leave the fragment in the patient. That decision is based on
an assessment of the relative risks of leaving it in versus removing it. It would therefore
not be considered an unintentionally retained foreign object.

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Q: What about a retained sponge following vaginal delivery?
A:

A retained sponge after a vaginal delivery is a reviewable sentinel event. The new
language in the definition of reviewable sentinel events is, “Unintended retention of a
foreign object in a patient after surgery or other procedure.” Note that it says “other
procedure” not “other invasive procedure.” Vaginal delivery in the hospital is not an
“invasive” procedure, but it is a procedure. More to the point, a retained sponge in this
circumstance is indicative of the same underlying systemic problems that could cause
other “retained foreign body” situations.

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Q: When, exactly, is “after surgery?"
A:

“After surgery” is any time after completion of the skin closure; even if the patient is still
in the OR under anesthesia.
 

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Q: Why was this particular point in the process selected as the definition of “after surgery?"
A:

The decision to define “after surgery” as the completion of skin closure was based on the
premise that a failure to identify and correct an unintended retention of a foreign object
prior to that point in the procedure represents a significant system failure, which requires
analysis and redesign. It also places the patient at additional risk by virtue of extending
the surgical procedure and time under anesthesia.

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Strategic Surveillance System (S3)

Q: Is there an additional cost involved with S3?
A:

No. S3 is provided at no additional cost and serves as a value-added benefit for our accredited customers.

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Q: Will the concept of S3 be adapted for organizations other than hospitals?
A:

The goal is to eventually spread this concept of S3 to all of The Joint Commission’s accreditation programs

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Q: What is S3?
A:

S3 stands for The Strategic Surveillance System. The Strategic Surveillance System is a benefit provided exclusively to hospitals accredited by The Joint Commission.

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Q: Why was S3 developed?
A:

One of the most compelling needs in the health care environment is actionable data and information that can be used to prioritize and drive quality and safety improvement.  As performance expectations increase, so does the need to know how to use data to drive improvement.  S3 is a tool that provides a series of risk assessment and comparative performance measure reports to help hospitals improve their care processes. The reports also help hospitals prioritize the actions to take for improvement.

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Q: What are some of the benefits of S3?
A:

There are several benefits to S3.

  • Hospitals have access to national and state benchmarks as well as select groups, in order to compare themselves to others.
  • Hospitals with a common owner have the ability to compare S3 data among each hospital to identify trends or common areas for improvement.
  • S3 helps drive and monitor systems improvement throughout an organization by providing ongoing quantitative feedback.
  • S3 allows organizations to drill down to certain performance areas so they can compare themselves to others on a well-defined basis
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Q: Do we need to provide The Joint Commission with more data for S3?
A:

No.  S3 is built from all existing data that The Joint Commission currently has.  Future releases will include an option for an organization to include their own unique internal data though it will never be required.     

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Q: How do we access these reports? How often do we receive them?
A:

Reports are posted and updated quarterly on each organization’s secure Joint Commission extranet site, which requires a log-in and password.  The tool allows you to drill back up to eight previous quarters.

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Q: Will this data be made available to the public?
A:

No, this information is only available to authorized individuals of organizations accredited by The Joint Commission for their Hospital program.

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Q: Is S3 available for all hospitals?
A:

S3 is for all Joint Commission-accredited hospitals.  Hospitals are able to make use of the Performance Risk Assessment tool.  Currently, critical access hospitals do not have access. 

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Q: What is the source of the data provided by S3?
A:

S3 uses data The Joint Commission currently has, which includes past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data.

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Q: What is included in S3?
A:

S3 is a suite of information tools.  The first available tool within the S3 application is the Performance Risk Assessment (PRA) tool.  This tool assesses potential internal system opportunities by utilizing Priority Focus Process comparisons; rating comparative performance for all Priority Focus Areas and Clinical/Service Groups; and identifying specific data and findings that are contributing to specific results.  Organizations are able to analyze comparative performance against national, state and other comparative benchmarks by Priority Focus Area and Clinical/Service Groups and trend historical data to identify and undertake opportunities for improvement, set priorities for attention.

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Subscription Billing

Q: How often will I receive invoices?
A:

We will electronically invoice your organization’s fees. Annual fees will be sent to your extranet in January of each year. The on site survey/review billing will be posted to your extranet approximately 1-5 days following event completion.

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Q: When is payment due?
A:

Regardless of survey or review findings, payment is due upon receipt of your invoice.

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Q: Is there a payment plan?
A:

Please contact our Collections Coordinator at (630) 792-5192 for further details.

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Q: What is the cost of accreditation or certification?
A:

All organizations will be electronically billed an annual fee.  As a returning customer, you will be able to locate estimated fees on your extranet. New customers may call the Pricing Unit at (630) 792-5115 or send an e-mail message to:  Pricingunit@jointcommission.org to request a fee estimate.

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Q: How much is the deposit I need to send with my application?
A:

No deposit is required for current customers.  New customers must remit a $1,700 non-refundable, non-transferable deposit for all Accreditation and HCSS Certification Programs.  New customers seeking DSC certification that are already currently accredited by The Joint Commission are not required to submit a deposit. 
 

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Q: I received my invoice invoice today. Has my deposit been deducted from the amount of my invoice?
A:

The deposit is not deducted from the invoice amount you received.  All open deposits are reflected on the lower part of your invoice.  A deposit (credit) balance will be applied to your invoice within 72 hours of billing and will be reflected on your subscription billing site.  Please call us at 630-792-5662, if you have questions regarding your deposit.

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Q: Do I need to send full payment with my application?
A:

No. As an initial customer, only a deposit is required.  A new customer’s annual fee is based on the calendar quarter when the application is submitted.  Accreditation and Certification on-site fees are generally invoiced 1-5 days following event completion.

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Q: Can I pay my deposit, annual fee or on-site fee by credit card?
A:

Yes.  You may pay your deposit online by navigating to the “What’s Due” tab on the extranet, then select “Pay my Deposit”.  All billing may be paid directly from your extranet’s subscription billing site.  The Joint Commission accepts Visa, MasterCard, AMEX, Discover and electronic check payments.  Please call us at (630) 792-5662 if you need assistance or wish to make payment over the telephone.

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Q: Whom should we list as the payee on the check and what is the mailing address?
A:

Checks for deposits, annual and on site fees should be made payable to: The Joint Commission. Invoice and customer numbers are listed in the upper right portion of our invoice documents. Please write your invoice number on your remittance stub or on the memo line of your check. Mail your payments to:

The Joint Commission
P. O. Box 92775
Chicago, IL 60675-2775

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Q: How are fees determined?
A:

In general, accreditation annual fees are based on the programs/services/volumes and sites where you provide service.  Certification annual fees are based on the number of diseases and types of certification.  On-site fees are generally based on the number of surveyors or reviewers and total days spent at your site(s). We publish the upcoming year's pricing schedule on the extranet in December, each year.    
 

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Q: What if I should decide to withdraw from the process?
A:

Annual fees are non-refundable and non-transferable. On-site fees are billed for surveys or reviews performed. In addition, an organization will be assessed a 1-day per surveyor fee for each accreditation program if the organization refuses a survey or review when the team arrives on-site.

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Q: If I do not pay my annual fee, will my accreditation or certification expire when I am due for my next on-site survey or review?
A:

Payment for annual fees is due upon receipt of your invoice.  Failure to make payment will result in a denial of accreditation or certification.  Delinquent accounts may be forwarded to our collection agency and the accreditation denial status will appear on Quality Check.

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Q: How can I access my extranet to download billing information?
A:

Your CEO and Billing Contact will be provided with a login and password to your organization's extranet.  Copies of invoices prior to 2006 will not be available on your extranet site.  In addition, if you selected paper invoices for mailing, your invoices will also not display on the extranet.    

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Top Performer on Joint Commission Key Quality Measures

Q: What is the Joint Commission's Top Performer on Key Quality Measures® program?
A:

The Joint Commission’sTop Performer on Key Quality Measures program recognizes accredited hospitals that attain excellence in accountability measure performance. Recognition in the program is based on an aggregation of ORYX® accountability measure data reported to The Joint Commission during the previous calendar year. The data report on evidence-based interventions for heart attack, heart failure, pneumonia, surgical care, children’s asthma care, inpatient psychiatric services, venous thromboembolism (VTE), stroke, and immunization.
 

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Q: Why did The Joint Commission launch this program?
A:

Excellent care is something all patients expect and deserve and all hospitals work to achieve. It is not an easy goal to reach; it takes the knowledge, teamwork and dedication of the entire hospital staff. To help hospitals achieve this goal, improve their performance on key measures, and identify target areas for improvement, The Joint Commission launched the Top Performer on Key Quality Measures program. This program honors hospitals that demonstrate excellent performance on evidence-based process of care measures. Also, it is intended to encourage hospitals to consistently improve their performance on accountability measures by publicly recognizing those that ultimately achieve excellence in this arena. The ultimate goal is to improve the care provided to patients in all aspects addressed by these accountability measures.
 

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Q: When did The Joint Commission launch its Top Performer recognition program?
A:

The program launched in September 2011. Recognition of Top Performer hospitals occurs in the fall of each year and coincides with the publication of The Joint Commission’s “Improving America’s Hospitals” annual report.  
 
 

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Q: What eligibility criteria are used to determine if an organization is a Top Performer?
A:

The current eligibility criteria for the Top Performer program include a three step process: 1) achieving cumulative performance of 95 percent or above across all reported accountability measures; 2) achieving performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) having at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable accountability measures have a performance rate of 95 percent or above. See the eligibility criteria.
 

 

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Q: How does the Top Performer on Key Quality Measures program work?
A:
  • Inclusion on the list is based on an aggregation of ORYX® accountability measure data reported to The Joint Commission during the previous calendar year.
  • A Top Performer must meet the eligibility criteria (also see question above).
  • Top Performer hospitals receive a certificate of recognition, a notification letter from Joint Commission President and CEO, Dr. Mark R. Chassin, and are recognized on The Joint Commission’s Quality Check website and in the “Improving America’s Hospitals” annual report. (A copy of the certificate of recognition and notification letter are provided on the hospital’s Joint Commission Connect extranet.)
  • Top Performer hospitals are notified of their recognition approximately one week before the publication of The Joint Commission’s annual report.  
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Q: Do hospitals need to submit an application to be considered for the Top Performer on Key Quality Measures program?
A:

No, hospitals are not required to apply for the program; eligibility is determined using data that hospitals already transmit to The Joint Commission through the ORYX® program. Critical access hospitals that report accountability measure data to The Joint Commission are also eligible. Recognition as a Top Performer is based on the total number of accountability measures reported by each hospital, regardless of whether the hospital transmits data on one measure set or several measure sets. Also, each year’s recipients are identified using the previous calendar year’s ORYX data. 
 
 

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Q: My hospital collects additional core measure sets beyond those of the ORYX requirements; will the accountability measures in these additional sets be included in the calculation of my hospital’s composite score for potential Top Performer recognition?
A:

Yes, all accountability measures/measure sets that have been included as part of the Top Performer program for a given calendar year and that are reported by your organization for the full 12 months of that year will be included in determining if your hospital meets the three performance criteria for Top Performer hospitals. See the current list of accountability measures that were used for the Top Performer program.
 

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Q: What does it mean if a hospital is not on the list?
A:

Most hospitals not recognized as a Top Performer are still performing well on accountability measures, but there is still room for improvement. The Joint Commission provides various resources to help hospitals improve their accountability measure performance, including the Core Measure Solution Exchange® and the Leading Practices Library. Both of these resources are available to all accredited hospitals on The Joint Commission Connect extranet site. Since 2002, hospitals have been reporting data to The Joint Commission and have continuously shown improvement in performance on core measures. The Top Performer program supports organizations in their quest to do better.
  

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Q: How many hospitals are being recognized on the Top Performer list and what are the demographics?
A:

In 2013, 1,099 hospitals are being honored for their performance on 2012 calendar year discharge data as part of the Top Performer on Key Quality Measures program. Of that number, 22 percent were rural hospitals, 51 percent were non-profit hospitals, and 46 percent had between 100 and 300 beds. Major teaching hospitals accounted for 7 percent of the recipients, and 5 percent were critical access hospitals.

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Q: What is new for the Top Performer on Key Quality Measures program?
A:
  • The immunization measure set was added in the calculation for the 2013 program (based on data submitted in 2012). The immunization measure set was formed by taking two measures --   pneumococcal immunization and influenza vaccination – from the pneumonia care measure set to expand coverage beyond pneumonia patients. In addition, two inpatient psychiatric services (HBIPS) measures were excluded from the program (multiple antipsychotic medications and justification for multiple antipsychotic medications), as was the pneumonia measure, antibiotics to ICU patients. See the current list of accountability measures used for the Top Performer program. 
  • A Top Performer section was added to The Joint Commission Connect extranet site, located under the Performance Measurement section. The site includes tools and information for Top Performer hospitals to use to communicate their recognition.

 

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Q: Why are you announcing Top Performer hospitals now, when the data are from care delivered in the previous calendar year?
A:

There is approximately a four to six month delay between the time the hospital collects and submits their data to the performance measurement system to the time it is received by The Joint Commission.
 

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Q: My hospital was at 95 percent on all the measures in a particular set, yet we didn’t get recognized. How could that happen?
A:

There may be one or more reasons for this. Although your hospital may have 95 percent in a particular measure set, it may have:

  • Failed to achieve 95 percent on the composite score for all accountability measures.
  • Failed to achieve 95 percent on each and every reported accountability measure in that measure set.
  • Failed to collect data for four calendar quarters for all measures within that set (except for seasonal measures, which require only two quarters of collected data), or had fewer than 30 total cases for the measures associated with that particular set.

 

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Q: Who do I contact if I have a question about our organization’s data?
A:

First, we encourage hospitals to contact their ORYX vendor. You may also send an e-mail to topperformersprogram@jointcommission.org or call (630) 792-5085.
 

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Q: What determines if a hospital is “on track” to being a Top Performer?
A:

Hospitals that are “on track” to becoming a Top Performer have achieved the 95 percent composite score and 95 percent performance on all but one accountability measure for which it reports data. After Top Performer hospitals are announced, The Joint Commission notifies “on track” hospitals about the measure on which they need to improve performance should they wish to achieve Top Performer recognition in the future. This notification is made via the hospital’s Joint Commission Connect extranet.
 

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Q: How can those organizations that did not make the list improve their performance?
A:

In April 2011, The Joint Commission launched its Core Measure Solution Exchange®, a web-based platform where accredited organizations can share practices and proven tools related to improving performance on core measures. The Solution Exchange is an interactive forum designed to facilitate peer-to-peer communication. For organizations that have worked to improve their core measure performance, it is an opportunity to share their success and be recognized for their accomplishments. For organizations looking to improve, it is an opportunity to see what their peers have tried and what has actually worked. The Solution Exchange is available via your organization’s Joint Commission Connect extranet under Quality Improvement Tools. If you need access to your organization’s Connect extranet, talk to your organization’s account executive or accreditation liaison. The Joint Commission has also taken other steps to help hospitals improve their performance on accountability measures, including integrating accountability measures into the accreditation standards (effective January 1, 2012) and redesigning the ORYX performance measure reports. .
 

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Q: What is an accountability measure?
A:

In 2010, The Joint Commission began categorizing its process performance measures into accountability and non-accountability measures. The approach places more emphasis on an organization’s performance on accountability measures – quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: research, proximity, accuracy and adverse effects. Non-accountability measures are suitable for secondary uses, such as exploration or learning within individual health care organizations, and are good advice in terms of appropriate patient care. Going forward, The Joint Commission will have a primary focus on adopting accountability measures for its ORYX program. For more information, see Facts about accountability measures and the current list of accountability measures used for the Top Performer program.  
  
 

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Q: Psychiatric hospitals have been reporting inpatient psychiatric services measures for some time. Are these hospitals eligible for the Top Performer designation?
A:

In 2012, freestanding psychiatric hospitals or hospitals with inpatient psychiatric units were included in the Top Performer program for the first time, based on 2011 calendar year data. Reporting on the inpatient psychiatric services measure set was not required until January 2011, so 2011 was the first year that these data became available for the Top Performer program designation. 
 

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Q: What about rehabilitation hospitals?
A:

Rehabilitation hospitals are not eligible for Top Performer designation at this time. Currently, rehabilitation hospitals do not submit core accountability measure data. Effective January 1, 2013, The Joint Commission suspended ORYX performance measure reporting requirements for accredited inpatient rehabilitation facilities (IRFs). It is The Joint Commission’s intent to support and build upon the emerging national measurement priorities and the move to the use of standardized federally mandated performance measures for IRFs (when those measures are identified and implemented).
 

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Q: Are the multiple antipsychotic medications measures (HBIPS-4a and HBIPS-5a) included in the composite for the inpatient psychiatric services measure set?
A:

HBIPS-4a (multiple antipsychotic medications) will not be included in The Joint Commission’s calculation of composite rates for calendar year 2012 and going forward. However, HBIPS-5a (justification for multiple antipsychotic medications) will be included in The Joint Commission’s calculation of composite rates beginning with calendar year 2013.  
 

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Q: Is PN-6a (antibiotics to ICU patients) included in the composite for the pneumonia measure set?
A:

This measure has been temporarily inactivated for calendar year 2012 due to an algorithm error. The PN-6a measure will be reactivated effective with January 1, 2013 hospital discharges addressed by the algorithm correction,and will be included in The Joint Commission’s calculation of composite rates beginning with calendar year 2013. 
 

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Q: Why is the perinatal care measure set data not included in the composite rates for calendar year 2012 data?
A:

Two of the perinatal care process measures have new specifications effective with January 1, 2013 discharges and therefore none of the three perinatal process measures will be included in The Joint Commission’s calculation of composite rates for 2012. PC-05a (exclusive breast milk feeding) will be included in The Joint Commission’s calculation of composite rates beginning with calendar year 2013.

 

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Q: What is the time frame covered for “seasonal” measures included in the calculations for Top Performer recognition?
A:

Seasonal measures, such as immunizations, are included if two quarters of data exist for the calendar year under consideration. For example, for the influenza immunization measure (IMM-2), the denominator includes patients discharged during October, November, December, January, February or March. The quarters that would have to exist within the calendar year would be both the first quarter (January, February and March) and the fourth quarter (October, November and December).  
 

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Q: Why are the HBIPS-2 and HBIPS-3 measures excluded from the Top Performer program?
A:

Although the physical restraint (HBIPS-2) and seclusion (HBIPS-3) measures in the inpatient psychiatric services measure set are accountability measures, they have been excluded from the Top Performer calculation since they are both ratio measures (i.e., Top Performer calculations only include process measures reported as proportions). The current statistical model used to calculate the composite rate does not accommodate ratios. Ratio measures do not reflect the number of people (as for proportion measures), but rather the number of psychiatric inpatient days. The number of inpatient days in the denominator is usually a large number, so including it in the composite would unduly weight the composite toward ratio measures.

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Q: Why are some well-known hospitals and academic medical centers recognized on other lists and not on the Top Performer list?
A:

Other national recognition programs or hospital comparisons may use other measures, metrics, or data, or rely on a hospital’s reputation as a determination of achievement. The Top Performer program uses evidence-based performance measures that have undergone rigorous development and testing to ensure data integrity. This year, the number of academic medical centers recognized as Top Performer hospitals has increased significantly: in 2011 and 2012, there were five; in 2013, 26 academic medical centers were included in the list of Top Performer hospitals.


 

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Nursing Care Center

Q: How has the Nursing Care Center Accreditation program changed?
A:

One of the key program enhancements includes the ability to pursue additional certification of specialty services in addition to accreditation.

Other program enhancements include:

  • Standards: Reflect enhanced foundation requirements focused on key care processes that contribute to improved outcomes for all patients and residents in nursing facilities. New standards have been added to address person- and resident-centered care and the cultural transformation away from institutionalized care within the industry.

  • Certification of specialized services: These additional distinctions will allow organizations to validate and better distinguish the caliber of their post-acute care and memory care services to hospital referrers (such as those within the managed care community), and to the public.  Organizations will be required to meet core requirements in order to seek the new certification.

  • On-site survey: All surveys will include additional patient and system tracer time to better identify potential risk areas as well as high performing areas. There will also be increased learning opportunities for internal staff and leadership.  Surveys that include accreditation with Post-Acute Care certification will include a dedicated “Transition of Care” session.

  • Surveyors: Have been specially trained and have experience in the specialty certification area.

  • Accreditation manual: Redesigned as a workbook that includes the reinvented standards and additional features to support overall performance improvement including “tracer prompts” to help prepare internal staff for expected on-site activities, and documentation checklists to help organize and prioritize written materials.
     

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Q: What are the eligibility requirements for accreditation and specialty certification?
A:

We require that your organization has served at least 5 patients or residents (regardless of how long your facility has been in operation) and has at least two active patients or residents at the time of your survey. Call us for additional questions about the eligibility of your specific services or patients for certification at 630.792.5020.
 

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Q: How do you define Post-Acute Care services?
A:

A program or service that provides goal-directed, time-limited, medically complex care or rehabilitative services to patients recently hospitalized. The goal is to help transition the patient from an acute care setting to a lower level of care setting or a return to their home. Examples of care include post-operative care, orthopedic or cardiac rehabilitation, respiratory care, and wound care.  
 

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Q: Why did The Joint Commission reinvent the Long Term Care accreditation program?
A:

The Joint Commission recognizes that the industry has changed. Long term care organizations are providing more complex care to patients and residents and are being asked to demonstrate competency in these specialized areas.
 

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Q: My facility is already accredited with The Joint Commission for LTC, what does mean to me?
A:

Your dedicated Account Executive will work with you to discuss your options based upon your upcoming resurvey date. They can also talk to you about the benefits of the new products and how we will help make the overall transition easy for you.

For customers currently accredited under the LT2, Medicare-Medicaid based option, you will move from a one day survey to a two or three day on-site survey, depending on if you choose to pursue certification (and based upon the ADC of your facility). 

For providers accredited under the traditional model who choose to pursue certification, your survey length will increase by one day.

We encourage you to contact your Account Executive to discuss your specific needs.

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Q: I’m a current customer, and am interested in achieving the new certification--Can we add it at any point during the accreditation cycle?
A:

Please talk to your Account Executive to discuss your specific needs and learn the options for pursuing certification for your organization. 
 

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Q: If we achieve certification, will we receive a separate certificate along with our accreditation certificate?
A:

Yes, there will be an additional certificate and designation on Quality Check.
 

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Q: Will there be performance measurement requirements for the new accreditation and certification?
A:

Joint Commission standards currently require measuring the performance of processes that support care and using that data to make improvements. These standards require long term care organizations to collect data on performance improvements identified by leaders, the use of restraints, behavior management and treatment, quality control activities, significant medication errors, significant adverse drug reactions, and resident perception of the safety and quality of care treatment and services.

In addition, nursing facilities should consider collecting data on staff opinions and needs, staff perceptions of risk to individuals, staff suggestions for improving resident safety, and staff willingness to report adverse events. The certification standards require the organization to collect data relevant to the unanticipated outcomes in care, patient readmission to the hospital, emergency department or other post acute setting and data relevant to information reviewed with patients and family following the patients discharge from the organization. This information will be reviewed as part of the evaluation of the facilities performance improvement processes during the onsite survey.

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Q: Who did you involve in the redesign process?
A:

We involved our customers, unaccredited providers, payers, and hospital referral sources in the overall redesign process.  Customers provided feedback on standards through online surveys and participated in pilot on-site surveys.  Additionally, focused calls were conducted with select customers to gain in-depth perspective on proposed program enhancements. 

 

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Q: What’s the cost?
A:

Accreditation fees include an on-site survey fee and annual fee, both based upon your “average daily census” and services provided.

The average accreditation annual fee for an organization serving approximately 100 patients or residents each day is $2300. The average on-site survey fee for a nursing home of the same volume is $3315 (this is due in the year of the on-site survey).

Post-Acute Care Certification adds one day to your on-site survey length.  This fee is $970.  

Additionally, each certification adds $250 to your annual fee. 
 

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Q: Can I choose to pursue certification without accreditation?
A:

No. Certification builds upon the newly reinvented foundational accreditation framework and, therefore, is a required part of the process.
 

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Q: What’s the benefit to my organization to achieve certification?
A:

 Achieving accreditation with specialty certification can help your organization in many ways including:

  • Stand out as a quality provider. Be among the first in your competitive market to tangibly distinguish the quality of your specialized services.

  • Capture more business. Leverage your recognized competencies to stand out among discharge planners, physicians, payors, and consumers to grow your business.

  • Reduce risk. Identify vulnerabilities before they can become problems.  Reduce liability risk, severity of risk and gain possible discounts on insurance as you demonstrate competency in specialized care.

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Q: What happens if my organization doesn’t “pass” the certification, does it impact my accreditation status?
A:

No. If a provider does not meet certification standards, the accreditation status is not affected; however, certification would not be awarded.
 

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