(Donna) ﻿Hello, and thank you for listening
to Check in with The Joint Commission
for Hospital and Critical Access Hospital Accreditation.
My name is Donna Rutkowski,
and we're delighted to be able to spend some time with you.
Today, we're going to let you know what you need to know
regarding standards updates,
information regarding the actual survey process,
current RFI, and Frequently Asked Question information.
Then we'll talk about AMP for hospitals,
which can be helpful with compliance
and tell you about some educational conferences and webinars
you may be interested in for your team
that are coming up in August and September.
We'll send you both the presentation slides
and the recording to you via email after the webinar,
most likely tomorrow morning.
Who you'll hear from today
is Laura Smith from our Department of Standards and Survey Process,
Theresa Hendricksen, Field Director for the Hospital program,
Field Director Tim Markijohn
who will provide information about Life Safety,
Nancy Leckowitz from Standards Interpretation Group,
and Bhavna Mishra from Joint Commission Resources
to tell you about AMP.
With that, I'm going to turn it over to Laura
who will help you learn what to expect regarding standards updates.
Laura?
(Laura) Thank you, Donna.
I'm going to run through some updates,
and I'm going to talk about some standards updates
and also how we engage our customers
and field review activity.
Next slide.
For the Emergency Management chapter,
those changes went into effect in July 1st.
There's been several education programs for Emergency Management.
I hope you had a chance to listen to some of those,
as we know that this is a significant change to the chapter,
so we wanted to provide as much education as possible.
One of the major changes
is the focus on a complete Emergency Management program,
and under that program, would be all of your policies and procedures,
communication plans and coordination,
education and training,
testing and evaluation of exercises
under that overarching program.
We also added an additional emphasis
on the use of the Hazard Vulnerability Analysis--
many times referred to as an HVA--
the importance of that,
and the impact it has
on all of your plans, policies, and procedures.
We also increased the emphasis on leadership accountability,
and support of the program,
and provision of resources for Emergency Management.
The chapter was streamlined so that redundancy was eliminated.
We removed all deemed program lead-ins
so that we have consistent requirements
for all hospitals
and critical access hospitals across the board.
Next slide, please.
We also have some new and revised requirements
for antibiotic stewardship,
and those will be effective January 1st, 2023
for hospitals and critical access hospitals.
These changes are at standard MM.09.01.01, EP 10-21.
They basically were updated to align with the regulations
as well as scientific and professional organizations.
The revisions include allocation of financial resources
to support your Antibiotic Stewardship program;
appointing a leader
and identifying their responsibilities;
establishment of a multidisciplinary committee
to oversee the program;
and having a hospital-wide program
to address the inappropriate antibiotic use;
also focused on the importance of evaluating adherence
to evidence-based guidelines for the most common indications;
collecting, analyzing, and reporting the data about your program;
and then identifying opportunities to improve the program as well.
There were also editorial revisions made to these requirements,
which relate to numbering of EPs, or Elements of Performance;
clarifying language; and the addition of notes.
Next slide, please.
We also have some new health equity requirements.
This can be found at standard LD.04.03.08,
and there are six new EPs--
and this is in the leadership chapter--
and this is also effective January 2023.
The standard focuses on addressing healthcare disparities
as a quality and safety priority.
Again, this applies to both hospitals and critical access hospitals.
The new Elements of Performance
require hospitals and critical access hospitals
to designate an individual or individuals
to lead the activities to reduce disparities;
to assess patients' health-related social needs
and provide information about community resources
and support services;
also to identify healthcare disparities in its patient population;
to develop an action plan
to address at least one identified healthcare disparity
and then act when the goals are not achieved or sustained;
and finally,
to annually inform key stakeholders
about the progress to reduce healthcare disparities.
There's one additional change for critical access hospitals
that already is applicable to hospitals,
and that is EP 25
that requires the medical record
to contain the patient's race and ethnicity.
Next slide.
We also have the new COVID vaccination standards requirement,
and this is for deemed hospitals and critical access hospitals.
We were evaluating compliance
with the regulations for COVID vaccination
prior to this new standard.
That was a process we used
while CMS was reviewing
our draft standard and the Elements of Performance.
This was then approved,
and the new standard went into effect July 1, 2022.
Some highlights are that all staff
who provide care treatment and services must be vaccinated,
regardless of their clinical responsibility
or patient contact.
There is an exception,
which is if someone is exclusively providing Telehealth services,
then this does not apply to them.
Also, support staff who have no patient contact
also, this would not be applicable.
You might have support staff who are at a different location.
There's also requirements about policies and procedures
that ensure that all staff received the COVID vaccination
prior to providing any care, treatment, or services.
You have to have a process for tracking and documenting
the vaccination status of all staff,
and that includes boosters and exemptions.
Any precautions for mitigating transmission and spread of COVID-19
for unvaccinated staff
who have exemptions
and contingency plans
for staff who are not fully vaccinated for COVID-19.
These requirements are posted on our website
under the Prepublication Standards page.
You can also refer to the May 2022 issue of Perspectives
for additional information.
Next slide.
We also have some revised Environment of Care requirements
that went into effect on July 1st.
These also apply to both hospitals and critical access hospitals.
We deleted two Elements of Performance:
Elements of Performance 7 and 8 at EC.02.03.05.
Those relate to water storage tanks.
Those were deleted
because most organizations no longer have water storage tanks.
We also have a revision that we made
to Environment of Care standard 02.03.03, EP 3,
and that clarifies that fire drills need to vary
by at least one hour
for each shift from quarter to quarter,
through four consecutive quarters.
We also have two additional new EPs,
which I'll talk about here at EC.02.03.03.
The first one is EP 7,
and that requires annual fire exit drills
for operating rooms or surgical suites,
and then EP 8,
which is annual fire training drills
for hospitals that have hyperbaric facilities.
We also made some additional revisions
that clarify requirements related to supervisory signal devices,
automatic sprinkler systems,
automatic fire extinguishing systems,
and newly engineered smoke control systems.
Next slide.
We also have a Patients Rights Chapter revision,
and that relates to standard RI.01.03.01, EP 1.
There was a new bullet added that requires
that your policy addresses who can conduct informed consent discussions,
and that relates to licensed practitioners
who can conduct that informed consent process.
EP 3 at the same standard was deleted,
and that EP was specific to informed consent
prior to making and using recordings, films, or other images of patients.
It was replaced with a new EP,
which is EP 37,
and it is located at RI.01.01.01
that more broadly addresses issues related to protecting patients' privacy.
This went into effect on July 1st.
For more information, you can refer to the January 2022 Perspectives article.
Next slide, please.
Here are some proposed requirements
that are in process.
I'll run through each of these and give you a little more information.
The first is Surge Management Planning.
We did have an expert panel that we've been working with
and getting feedback from on these requirements.
In addition,
we had a field review that just closed in July,
and we're working on analyzing the results
and finalizing some requirements related to that.
You can look for those requirements
to potentially be effective in July of next year.
Stay tuned for communication through Perspectives
coming up most likely around January.
We are also working on electronics health record safety
that's in development as well as cybersecurity.
We're having discussions with the experts in the field
and analyzing that information
to look at the potential development of standards related to these two areas.
Next slide, please.
How to stay in touch with updated standards information?
We post prepublication standards information
on our Joint Commission website,
and you can find that under the Standards tab
and Prepublications of Standards.
That's important to periodically check and stay abreast of those changes.
We also use Perspectives as our official communication,
and that is a monthly newsletter.
Finally,
on our website,
there's another helpful section.
If you go to Resources
and then select Patient Safety Topics,
there's some great information there.
There's Emergency Management and health equity.
There's many resources available, too.
I recommend going to those areas of our website.
For Emergency Management,
there's also been several webinars that have been posted,
and those are really helpful
as you're working on changes and implementing the new chapter.
Next slide, please.
Now, I'm going to turn this over to my colleague,
Theresa Hendricksen.
(Theresa) Thanks, Laura. Good afternoon, everyone.
I wanted to check in with you about survey process.
Moving forward, we understand
that the COVID pandemic has had a significant impact
on your staffing and hospital resources.
We want you to know that we want to partner with you,
our customers and colleagues,
to help you identify risks
and to recognize and celebrate all the things you do well.
We do have broad experience
and can help you on your journey to excellence and zero harm.
Next slide, please.
Some of the trends we're currently seeing
while we're out on survey
is COVID vaccination compliance.
It's not that hospitals aren't compliant;
it's how they're tracking and maintaining the data.
We are definitely seeing staffing challenges
among many roles within a hospital setting,
but we are working on decreasing large group meetings when we're on site
by combining some system tracers.
Next slide, please.
Just to touch base on COVID vaccination compliance.
This is still a CMS requirement for deemed organizations.
We will evaluate your compliance with the CMS mandate
by looking at your data,
and that will either take place during the competency system tracer
or independently at a mutually agreed-upon time
by the survey team leader
and your survey leader within your organization.
That will be determined on Day One during that first hour:
when we're going to look at that data.
Next slide, please.
"Staffing Challenges."
The Joint Commission recognizes the challenges
most healthcare organizations are having
recruiting and retaining staff.
We want to help with that
by, first and foremost, working to put your staff at ease
during the survey process.
If staff are not available to assist with survey process,
meaning we come on to a unit,
and we want to talk to somebody about a specific patient,
and your staffing is not ideal that day
or the staff are very busy at that time,
we are willing to talk to a leader of the unit and department
that can walk the surveyors through your care delivery
and documentation.
You don't have to pull a staff nurse away from a patient
if they're not available.
Next slide, please.
"Decreasing large group meetings."
We want to say we heard you.
We've got a lot of feedback over the past couple of years
about the system tracers
in the sit-down conversations we were having.
We have now permanently combined Infection Control,
Medication Management, and data into a single system tracer.
The evaluation of data related to each one of those topics
will happen outside of the group discussion
by the surveyor assigned to the tracer.
The group discussion will be more about process
and the surveyor in the work room you provide us.
We'll look at your Infection Control data, your Medication Management data,
and your Performance Improvement data.
Just one caveat that I'd like to mention is with Medication Management,
we will still do a pharmacy tour.
We will still evaluate your compliance
with our sterile compounding requirements,
but we are combining those three system tracers into one.
Next slide, please.
With that, I want to turn it over to my colleague,
Tim Markijohn, another Field Director. Tim?
(Tim) Thank you, Theresa, and good afternoon, everyone.
I just want to go over some tips for success
in the physical environment and Life Safety arena.
Let's get with it.
Please, when the Life Safety Code surveyors arrive with the team
on the first day,
please have someone available
to work with the Life Safety Code surveyor
right at 8:00 AM.
We'll arrive around 7:45,
gets settled into our room,
but when the Life Safety Code Surveyor arrives on the first day with a team,
they're going to go ahead and get started
on what we call the "facility orientation" at 8:00 AM.
The opening conference will begin at 9:00 AM,
so between 8:00 and 9:00,
the Life Safety Code Surveyor is going to need someone
from your Facilities Management department
to accompany them on some facility orientation task.
Another tip for success is please review your Life Safety Drawings.
We're seeing a trend
where Life Safety Drawings are not up to date and accurate,
barriers aren't identified as they should be.
Take another look at your Life Safety Drawings
and make sure they're up to date and accurate.
Also, on the first day for the Life Safety Code surveyor,
on their first day of survey,
after the opening conference,
let's say, around 9:30 AM,
the Life Safety Code surveyor's going to begin the document review session
where they review all the binders or electronic-- either one is acceptable--
all the inspection, testing, and maintenance documentation,
a tip for success is please have those documents organized
and readily available for that 9:30 session.
That session usually lasts about two hours.
The best way I could share with you to organize those documents
is to go ahead and use our document review checklist
because we fall that in chronological order
from the beginning to the end,
so if your documents are organized that way,
it will help you be more successful during that time.
In your critical pressure relationship areas--
this would be operating rooms, suites,
sterile processing departments,
your airborne isolation rooms--
you all are doing a great job
of making sure the temperature, humidity, pressures,
air exchange rates are meeting the ASHRAE guidelines,
but I would encourage you, as a tip for success,
is to be checking those...
When you know we're arriving,
when you get the notification that we're arriving,
go up and take a look at those areas
and make sure that they're in compliance
and nobody propped a damper open or left the door open somewhere
and everything is within the acceptable range.
Another area that we're noticing as a trend is that a few years ago,
we brought back LS.01.01.01, EP 7,
and that EP pertains to having an accurate and up-to-date SOC and BBI.
We brought that EP back
because organizations stop keeping those up to date, actually.
Please verify--
I'd like to get the quality and regulatory compliance folks together
with the facilities and management folks
and make sure that the data in square footage in the application
and the information on the SOC/BBI corresponds and is accurate.
Another tip for success,
as many of you know, that we discontinued our Environment Care session
and moved the work that we did in that session
to other areas in the document review session
on the building tour.
We no longer have that EC session.
We just transferred the activities to other areas.
But I wanted to make you aware of a new change
to the EM session compliment.
Life Safety Code surveyors will still lead the EM session on psych hospital surveys,
critical access hospitals surveys.
On the hospitals surveys,
the Life Safety Code surveyor will lead
and be the only surveyor in that session for hospitals
when there's less than six clinical surveyor days.
When there's more than six clinical surveyor days
and there's more than three Life Safety Code surveyor days,
we're now doing a joint session
with the clinician and the Life Safety Code surveyor
to give a broader spectrum from not only the clinical perspective,
but also the Life Safety physical environment.
That's a new change with the EM session
where we're doing a joint session
whenever you see three or more Life Safety Code surveyor days
on your survey.
Unfortunately, with the pandemic,
we have a backlog of surveys that we are catching up very rapidly,
but we still do have a small backlog.
What that's causing is infrequent--
I would say it's infrequent--
that we have to split the survey,
meaning typically, you will see the clinical survey team
ahead of the Life Safety Code team
or the Life Safety Code surveyor.
I wanted to bring that up that you may see that.
It won't impact the quality of the survey,
but there are some split surveys out there
in the hospital critical access.
Laura touched on some new requirements in EM.
I won't go too far into that,
but just some data points on EM.
We really streamlined the EM chapter, as Laura mentioned.
We streamlined it from 124 EPs down to 60.
22 of those are new, and 38 are revised.
Another specific data point is 49 out of the 60 EPs
require written documentation,
so be aware of that,
but the EM chapter is much more streamlined.
There are new tools out there.
There's a new EM document checklist
and an EM discussion checklist
that surveyors are using to guide that EM session.
Workplace violence.
This year, we kicked off four new EPs for workplace violence.
You'll find those at EC.02.01.01, EP 17,
EC.04.01.01, EP 1 and 6,
HR.01.05.03, EP 29,
and lastly, in the Leadership chapter at 03.01.01, EP 9.
This isn't new, came out in January,
but we're still seeing folks are coming up to speed
on workplace violence.
Last July, we introduced our new water management standard
at EC.02.05.02.
There's four new Elements of Performance there.
We added that standard in our manual last July.
We didn't start enforcing the standard until January of this year.
Some common trends we're seeing
is that we're seeing about twice as many observations
in water management than we did
in the previous EP we had for water management.
Where we'd like you to focus on is,
of course, ensuring that you have a water management plan,
but also that you have somebody or a committee--
a person or a committee--
who is assigned the responsibility for that plan.
One of the other finishing out the top three observations
of the new water management standard
would be making sure you have a basic diagram of your water system.
Those are some tips for success
in the Life Safety physical environment area.
I want to hand this over to my colleague, Nancy Lechowicz.
Nancy?
(Nancy) Thanks so much, Tim.
I'm from the Standards Interpretation Group.
Today, we'll be discussing
the top ten scored clinical Requirements for Improvement,
or RFIs as we call them,
for the Hospital and Critical Access programs;
a review of top questions sent to the SIG, or Standards Interpretation Group;
and sharing some insights.
Slide, please. Thank you.
The top RFIs scored
for both the Hospital and Critical Access programs
are divided into the following standards:
Infection Control, Medication Management,
Provision of Care, and Record of Care.
The Infection Control, or IC standards,
are related as they address implementation issues
for Infection Control activities.
In both programs, you will see the following scored:
IC.02.02.01, EP 2,
which is high level disinfection and sterilization.
This is where we see the highest number of RFIs scored,
and it also is the most common reason for declaring an immediate threat.
IC.02.01.01, EP 1
addresses implementation of infection prevention
and control activities.
As you can imagine, this can apply almost anywhere in a healthcare setting.
Implementation issues may include surgical or procedural attire
as well as skin prep prior to surgery,
failure to clean equipment between patients, and so on.
This is important to note.
Failure to follow your organization's policies
regarding these issues is also scorable.
IC.02.02.01, EP 4
speaks to storage of medical equipment, devices, and supplies
and can be cited for failure to follow
the manufacturer's instructions for storage,
or storage may not be consistent with items intended use,
for example, failure to protect sterilized items from contamination
during storage,
or items are not stored
in accordance with your organization's requirements or policy.
Moving on to the Medication Management standard,
the second highest score in both programs is MM.06.01.01, EP 3.
This standard discusses non-compliance
with the administration of medications
and administration of medications outside of a physician's order.
The RFIs scored note the following examples:
medication administered was not one ordered for the patient,
titrations were not administered at the correct time intervals,
the medication ordered IV and orally as needed
without information as which to give first.
In the Provision of Care, or PC, chapter,
there is some variance
between the Hospital and Critical Access program.
In the Hospital program,
PC scored
include PC.02.03.03, EP11
where scores typically reflect food storage,
including those items brought in by a patient or a family.
Often seen scored are refrigerator temperature monitoring issues
and lack of dating of food and expired food products.
PC.02.01.11, EP 2
is about resuscitation equipment readiness and availability,
adherence to both manufacturer's instructions for use
and organizational policy,
for example, not filling in organizational required logs
is often scored.
PC.01.03.01, EP 1
relates to the patients' plan of care based on identified needs.
Frequently scored in the Critical Access program hospital
includes:
PC.01.02.01, EP 1 addressing goals;
PC.03.01.03, EP 1,
which is the presedation or preanesthesia patient assessment;
and RC.02.01.01, EP 2.
In the Critical Access Hospital, also frequently scored--
it is also about the medical record and what is contained there.
It's a very large requirement in that EP,
so you will see a lot of things scored there.
Both programs have PC.01.02.07, EP 7,
which scores high, and it's regarding the pain evaluation,
documentation of responses to interventions,
and progress toward pain management goals.
RI.01.03.01, EP 1
is our consent standard,
consent and what is required in the consent,
exceptions to obtaining the consent,
how the consent is documented in the record,
and the organizational policy surrounding consents.
That is an overview of the most commonly scored standards.
Slide, please.
I want to discuss some questions that SIG is frequently asked.
These inquiries can be broken into several categories
and are usually around hot topics,
mandates, and a few specific standards.
Hot topics would usually be your new or updated standards,
and they draw a lot of attention.
As Laura had said earlier,
we do have, on our website,
a place where the standards that are being worked on are presented,
but in the meantime,
we get questions around upcoming standards
and why things were changed.
The Joint Commission publication, Perspectives,
and the information for standards and review
can be referenced on The Joint Commission website.
Perspectives is really helpful,
and I encourage you all to use it.
The data is usually very concise and to the point.
Other inquiries we have are around mandates,
for example, by CMS,
in any applicable law and regulation
and in very particular standards.
Some of those standards might be the Medical Staff chapter.
We get a lot of questions about credentialing and privileging
and Telemedicine as it became more popular.
In the PC chapter,
the history and physical requirements.
The National Patient Safety Goal 03.06.01
gets inquiries regarding medication reconciliation.
Frequently, we will be asked if this applies to a particular setting,
or who is responsible for the reconciliation.
There is also an FAQ page available
that addresses these and many other questions,
and, of course, you can always ask SIG by submitting your question.
Slide, please.
A few tips, finally, from me on what you can do
in your organization.
Remember that each and every individual that works there impacts the patient,
so involve your staff,
educate staff at the bedside level, at the front lines.
A good understanding of why is always important and helpful to staff.
Have the experts meet with the staff and discuss particular topics,
share their knowledge, for example, the Infection Control team.
Please do go ahead and use our Joint Commission Resources.
Now, I am handing the presentation over to my colleague from JCR,
Bhavna Mishra.
(Bhavna) Thank you, Nancy.
Next slide, please.
And the next one.
Thank you, Clara.
I'm here to walk you through our software platform
with which we are supporting your organizations
for your continuous accreditation readiness,
the digital tracing, and rounding.
Next slide, please.
We're supporting over 1,600 hospitals right now within United States
and over 50% of the critical access hospitals
in their journey of the innovation and improvement
via technology platform.
We support their accreditation readiness
and continuous compliance
with the data-driven journey,
risk assessment with high priorities identification,
improved performance with limited resources,
and then, last but not least,
the built-in business intelligence helps our users
for making informed decisions
based on the self-assessment data that has been collected in the platform.
As I said, both hospital and critical access hospitals standards
are available in the program.
Next slide, please.
The truth is AMP platform meets your goals
because we have provided you up-to-date hospital standards.
The standards are always available before they are effective,
which provides organizations opportunity to prepare for the upcoming--
and readiness for the upcoming standards.
In addition, it provides the visibility to all of their staff
who have access to the platform.
It provides unlimited user access,
which really helps organizations spread the access
to multiple users who need visibility to the standards.
If you are familiar with E-dition,
it automatically includes a site license of E-dition,
which can also be used for the staff members
who may not be responsible for data collection and scoring,
but may still need full visibility to the standards of The Joint Commission.
This helps not only identify the trends
as their organizations are collecting data into the platform,
achieve their regulatory compliance,
but on top of that is bridging the silos
as all of the departments within an organization,
all of the hospitals within a system,
are using the same platform and able to follow this standardized process
and communicate their priorities and risk areas.
Next slide, please.
How do we achieve this?
It's pretty simple to...
As we have automated your own journey
that you may be collecting information,
either using your own separate files, Excel spreadsheets, paper,
to centralize it into one location.
The number-one step is to start planning your tracer activity.
I will show you some examples of tracers templates
available within the product
that can be customized based on your own policies and procedures.
Once those are disseminated within the platform to the staff members
or those responsible in your team who conduct the tracers,
the data can start feeding in into one location.
This data then is used to identify the trends,
the risks,
by departments, by locations, by hospitals,
now it can be sliced and diced anyway needed,
can be used for developing other recommendations plan of action,
and then develop implementation and begin the cycle again
for this continuous compliance journey.
Next slide, please.
Here are some examples of some templates that are available in the platform.
There are thousands of questions built-in into the platform
that include not only the questions
that apply to that specific area or topic,
but also linking those questions to the EPs.
The CMS compliance readiness is also available,
so the questions are also linked to the CoPs.
There's a crosswalk available
between The Joint Commission EPs and the CMS CoPs,
which really helps organizations to have a view on both sides of the day.
As you see here, some of the examples of the topics.
These are continuously updated and monitored
for the current risks,
so you can see some examples of COVID-19 checklists
that were added into the platform over the last few years.
Then, in addition to that, as new standards or the updates come in,
these are updated to reflect the new changes from The Joint Commission.
Next slide, please.
Here's an example of how the data is...
This template is used by our administrators
within the organization.
It's pretty simple, too,
as they can just select a topic that they are focusing on.
One more click, please.
Then, you can see as the topic is selected from the various questions
based on the focus or the priority of your organization
and the administrator developing this questionnaire
can select the questions that they need to focus on.
They can customize these questions.
They can add additional questions that are not listed here
based on your own focus area
and then, also edit these questions into various types,
for example,
the question may be written for just compliance/noncompliance,
but you can have questions by a yes/no-answer type,
multiple choice,
to really give you those drill down for root cause areas if you needed to.
These questions, if edited and if the intent is changed--
as you see, they're linked to the EPs--
you also have flexibility to edit the EPs
that apply more to the question that you are looking into.
Next slide, please.
Once the tracers are developed
or customized based on your organization's need,
and also the questions when they are developed
can be built in from the top of a system
who may have multiple hospitals oversight
and can be disseminated to various hospitals or locations.
The data then can be collected by various staff members
who have been assigned to respond to these tracers.
The data can be collected via mobile app,
which really simplifies the usage.
It is very easy to use; easy to access on their mobile device;
can attach pictures while they are on the floor,
so it really gives the opportunity to collect real-time information;
can use voice text entry, so it makes it easier;
but, also, if there is a user who is not ready to use the mobile app,
there are printer-friendly forms available,
which they can print, collect data on paper,
and then enter it later.
I do want to point out that any pictures that you see here,
of course, this is your own self-assessment data,
so this data that you're collecting stays within your product.
It's a very secure access to the users who have access to this
and stays within the platform.
These pictures are not attached to the mobile app.
In case somebody is using their personal device,
these pictures are only attached once taken into the observation
and stays within the central location of the database.
Next slide, please.
What happens when all of this data comes together?
This is the value of the technology
where those responsible for scoring and documenting the compliance for EPs,
you can see here...
I do want to point out that you can see the July standards available,
which, of course, were available before the effective date,
so our user starts preparing for the new standards or the changes.
As they're assessing those,
the data that is collected,
because that is linked from the tracers to the EPs,
that data can be used to objectively determine the EP compliance
for each of these standards.
Next slide, please.
This is just a similar view.
I just wanted to show you
that critical access hospital on the right-hand corner
is also available for your view.
Next slide, please.
As the scoring is conducted into the platform,
the SAFER Matrix values can also be entered.
The traces data really helps in making that determination
if the likelihood to harm is moderate,
or if it's widespread based on the data.
As I said, the objective decision is made by their teams.
That's why it also becomes a great education tool
for the teams to really come together
to make the right decisions on the compliance.
Next slide, please.
After all, in today's world and the times,
it is all about the data-driven decisions,
and the business intelligence that the platform has built in
really helps the transparency for the leaders
to be able to see each location's current status,
each hospital's current status
if there are system leaders who have access to multiple hospitals.
Risk areas based on the SAFER Matrix, or by standards, or by tracers,
the data can be drilled down by various ways
to as the data is needed to be seen.
On top of that,
because the organizations also are using this data
to create their action plan,
within the platform, the action plan can be created.
The reports can be run to see
what are the high risk areas.
If there is an action plan, when is the plan to be completed,
and once that was completed,
were the improvements noticed in the future data collection.
One more important point,
as I heard Nancy talked about the top ten RFIs.
That's a great benchmarking tool for us,
for our users,
those are available here as well.
Organizations can also do a benchmarking of their self-assessment data
with those top ten RFIs that was scored in the last six months.
You can also download your RFIs from your previous survey
into the platform.
You can also download--
if you had a mock survey with JCR,
that data can also be downloaded here.
It really becomes that central intelligence
for all of the information in one place.
Some organizations also prefer to have data analysis of all this data collected
into their own warehouse.
We have APIs available
that is just set up once.
All of this data collected here can also be moved
into your own organization's data warehouse
to give you that 360 view of any other data sources
coming in into your organization.
You can also upload your RFSA when you are ready for that
during your intracycle monitoring
to The Joint Commission,
but that is a very controlled process
that only you have access to to upload that data.
Within your organization, those administrators have that capability.
Next slide, please.
Here's an example of one of the healthcare system
on how they have really enjoyed using the platform
to improve their performance and be ready for the next patient.
Really, they see the value
in that they can focus more on their action plan
then doing the groundwork to get ready with all the content that is available,
ready for your use.
The next slide, please.
You can see, with the data,
over 1,600 hospitals who are using it,
and as we are learning from them,
we continuously meet our customers to learn how they're using it,
what improvements they need,
and improve the platform,
but overall, because of that one central location,
continuous standardization of the process
for all the staff member's visibility,
they are really able to gain greater visibility to anticipate,
reduce, and report risks across the system.
The next slide, please.
If you want to learn more about the product,
and if you want to see a demo, please register here for a live demo
or send us an email.
One of our product managers
will be happy to walk you through more details on how the product works,
how other systems use it.
They can also do a customized demo for your teams based on your priorities
and get back to you with any questions that you have.
With that,
I'm going to hand it over to our moderator, Donna.
(Donna) Thank you, Bhavna.
A couple more things. We just need to go over some more things
that might be useful for your organizations.
We are doing one more COVID-19 webinar for hospitals.
That's the last one that we're doing.
It's on August 16th.
That's one of the webinars
where you can submit questions ahead of time,
and we will answer them live on that day.
That webinar is coming up later this month.
Next slide, please.
There's also a couple of other conferences coming up this month.
JCR's Hospital Accreditation Essentials is later this month
and also another very popular one that's coming up in September,
the Hospital Executive Briefings.
They're back with an in-person opportunity and also virtual as well.
You'll hear our new president, Dr. Perlin, will be speaking at that.
There's also another Hospital CMS Update.
Those links are on here
as well as the links
to the Hospital Breakfast Briefings webinar series,
which are available to you at all times.
Those are a couple other things that you may use
as you're going through the things that you need to help with your staff.
Next slide, please.
I also wanted to remind you that on your Joint Commission,
your private extranet site,
the core of Joint Commission Connect,
you have a lot of resources on here that were actually mentioned today.
Laura, Nancy, and Tim said references
to the Survey Activity Guide that's on there.
We also included the link to the SIG suggestion form.
Perspectives is on there.
But that's always a place to go where you can find resources.
Another one that's important and very interesting
on Joint Commission Connect is the Heads-Up Report.
Next slide, please.
The Heads-Up Report is interesting and important,
there's all the information is,
but the reason that I'm talking about this today for this split second is
these are quarterly reports that come out
that actually tell you what has been observed on surveys
that you can see what your peers are doing,
some things that went awry,
and how you can have solutions to help avoid that in your facility.
I just wanted to just talk about that for a split second.
Then, next slide, please.
That's it for today.
Thank you for joining us. Thank you for checking in with us.
Look for the presentation and the recording in your email
in a day or two.
Thank you for all you do,
and have a great rest of the day.