(Darrell) Hello, everyone, and welcome to today's webinar:
Peer Insights on Industry Trends in Behavioral Health and Human Services
and the Value of Joint Commission Accreditation.
Before we get started,
I would like to go over a few items,
so you know how to participate in today's event.
We've taken a screenshot of an example of the attendee interface.
You should see something that looks like this
on your own computer desktop in the upper right corner.
You have joined the presentation,
listening, using your computer speaker system by default.
If you would prefer to join over the telephone,
just select Telephone in the audio pane,
and the dial-in information will be displayed.
You will also have the opportunity to submit questions to today's presenter
by typing your questions
into the Questions pane of the control panel.
You may send your questions in at any time during the presentation.
We will collect these and address them
during the Q&A session at the end of today's presentation.
If we do not have time to address your question during this call,
we will try to follow up with as many questions as we can
following the webinar.
My name is Darrell Andersen.
I will be the moderator for today's webinar.
My guest today is Jennifer Sujdak,
Director of Quality Management at Cumberland Heights Foundation.
Jennifer has worked in the healthcare industry
for nearly 25 years
and has been in the field of addiction treatment since 2020.
She obtained a Master's degree in Healthcare Administration
and has a passion for quality.
As the Director of Quality Management at Cumberland Heights,
she takes pride in ensuring patients receive top-notch care
in a facility that shares her focus on safety and quality of care.
Welcome, Jennifer.
We appreciate you joining us today
and sharing your insight and experiences with us.
To start off, would you tell us something
about yourself and your organization?
(Jennifer) Thanks, Darrell.
Thanks, everybody, for letting me speak to you guys today.
Today, I want to talk to you guys
about some trends that are impacting the industry,
in my opinion, anyway.
Also, about how Joint Commission accreditation
affects continuous quality improvement and compliance,
and some tips for managing multiple locations.
You may go to the next slide.
We'll go ahead and get started talking about some of those.
And I can tell you a little bit about our organization.
Our mission is to transform lives,
giving hope and healing to those
that are affected by alcohol and drug addiction.
We have about 350 employees at Cumberland Heights
and serve about 2,500 individuals per year.
We have 20 locations throughout Tennessee.
As far as our treatments,
we see patients for detox;
residential, both adults and adolescents;
extended care;
intensive outpatient;
and regular outpatient-- that's both in-person and telehealth.
We do MAT, family care, and more.
That's a little bit about Cumberland Heights.
If you want to go to the next slide, we can go ahead and get started.
(Darrell) Cumberland Heights is a well-known and respected
SUD treatment organization based in Tennessee.
With all the locations of Cumberland Heights
being Joint Commission accredited,
I would like to invite Ms. Sujdak to share her insights
on a few key industry issues,
and how their Joint Commission accreditation journey
has helped some of these efforts,
influence their quality and safety initiatives,
and also share some results of those efforts with us.
(Jennifer) Thanks.
Much research has focused on quality improvement in medicine,
but I feel there's a gap in our knowledge about programs
that treat individuals with drug or alcohol use.
Pay-for-performance contracts,
they're also known as performance-based contracts
or value-based purchasing,
have been identified as a tool to improve healthcare quality
by providing economic incentives to meet benchmark goals.
HEDIS measures are an example of benchmarks created
to measure effectiveness of care,
access and availability of care,
and utilization in the hospital or ambulatory setting.
But my question is,
how do we measure quality in substance use disorder?
At Cumberland Heights,
we measure our quality by reporting compliance
with policies and procedures,
such as chart audits,
random drug screens, and room searches.
But we also measure patient outcomes,
including access to care, like wait times,
including the time from the first call to the time that the patient admits.
We measure treatment completion rates--
those are the discharge types,
treatment dosage,
which is our length of stay in care coordination efforts,
and measurement-based care symptomology changes,
like depression, anxiety, impulsivity.
We also measure patient satisfaction
with surveys given to patients and families
during and at the end of their treatment stay.
Also, talking about risk management strategies,
we have an Incident Report dashboard,
which trends incidents and allows filtering
by program, incident type,
date, time of day, and other demographic data.
If we see something trending in a certain direction,
we can look closer and see
if there's an increased risk in that area
and if there is an intervention warranted.
One of the most important features, the suicide risk management,
which is a National Patient Safety Goal, of course.
We try to mitigate the risk of suicide
with stratification and continuous monitoring.
Cumberland Heights has a protocol
for screening and assessing individuals for risk of suicide,
and a risk stratification criteria for monitoring and following up
with patients who are identified being at risk.
We have leveraged technology to assist counselors
with automatic reminders,
reassessment need alerts,
and effectiveness reports.
If you want to go to the next slide.
Here's a look at the SAFER Matrix.
Because during our 2021 Joint Commission survey,
we had a Suicide Risk Assessment protocol in place.
We call it our SRA.
However, we still received a moderate, limited RFI
for the National Patient Safety Goal.
During a tracer,
it was found that one of our counselors
did not complete an assessment with their signature.
We were double-checking our work
with spot checks and random open chart audits,
but for something as serious as suicide risk,
we wanted to make sure that every patient was being assessed
and receiving appropriate follow-up per our policy.
Following our 2021 survey
as part of our Evidence of Standards Compliance,
we revamped that SRA protocol.
This included broadening our compliance checks with full reports,
adding alerts when reassessment was indicated,
and tracking outcomes of our patients
as part of our Performance Improvement Plan.
I'm going to go over our Suicide Risk Assessment protocol
to let you know what we did after our 2021 survey.
Every patient is screened for suicide by the admissions nurse
with the C-SSRS Screening Tool before admission
to determine risk and appropriateness for admission.
Risk is identified as Low, Moderate, or High Risk,
depending on any affirmative answers.
If a patient is identified as High Risk,
they are immediately given the Standard Lifetime C-SSRS Assessment
for a more thorough assessment of risk.
We have our Program Director and Admitting Physician
use the information gathered from the Lifetime Assessment
to determine if the patient is appropriate for admission
and provide a plan for next steps.
All patients are fully assessed with the Lifetime C-SSRS Assessment
within 24 hours of admission.
We also assign risk stratification
and have a Decision Tree for reassessment and notification
when completing the full Lifetime Assessment.
If the patient endorses "no" on all questions,
they are considered Minimal Risk.
We'll continue to monitor and assess the patient as clinically indicated.
If the patient endorses SI
without method, plan, or intent with their lifetime,
they are considered Low Risk.
They will be reassessed and clinically indicated before discharge,
and we'll have a Crisis Plan and resources reviewed for each patient,
regardless of their risk.
If the patient endorses SI within the past month
or a suicide attempt within their lifetime,
they're considered Moderate Risk.
If the patient endorses SI
with method, plan, or intent within the past month,
or they've had an attempt within the past three months,
they're considered High Risk.
The medical director and program director are notified,
and the MD will determine if the patient needs to be on one-on-one,
or if an admission or referral to a higher level of care is needed.
The patient will also get a psychiatric eval as soon as possible.
They'll be reassessed the next day, as clinically indicated,
and before discharge.
They'll also get a wellness call after they discharge.
In addition to the C-SSRS,
patients are screened for depression and anxiety symptoms
with standardized assessments at admission and weekly thereafter.
If a patient endorses positive responses
more than half the days or nearly every day
on these highlighted questions:
"Thoughts that you would be better off dead or hurting yourself,"
or "Feeling afraid as if something awful might happen,"
they are reassessed for suicide risk with a C-SSRS.
If the total score indicates severe or moderately severe depression
or anxiety symptoms,
an alert is also sent
to have the counselor assess the patient for risk.
Total scores are used in treatment planning
and continuous patient monitoring throughout the treatment stay.
I'll go over a timeline of our patients in residential treatment.
When they come in,
they get assessments before the patient is admitted.
They get a PHQ-9 and a GAD-7.
They'll get the nursing screen,
which is the C-SSRS screen.
If they are high-risk,
they'll go ahead and get the Lifetime Assessment completed.
If they're not high-risk,
they'll get the Lifetime Assessment
the next day along with their BPS.
During their treatment stay,
they will complete screeners every week,
and if they answer
more than half the days or nearly every day
to those questions:
number seven on the GAD-7 or number nine on the PHQ-9,
they'll get reassessed for suicide risk.
Also, while they are here,
they'll be followed on a patient roster,
and the Program Director and the programs
will be monitoring those patients throughout their treatment stay
every day during a meeting
to make sure that they are getting follow-up as needed.
When the patient discharges,
if they were high risk or moderate risk,
they'll also get a C-SSRS
upon their discharge.
Any high-risk patients will also get a follow-up call.
This timeline shows our tracking points
and when the clinician will receive automatic alerts for follow-ups.
As part of our Performance Improvement Plan,
the Joint Commission Standard PI.01.01,
we collect data on our patients
and will adjust treatment programs if necessary.
This is a snapshot of our patients here.
Our female demographic information
has an average age of about 42 years old,
average length of stay of about 36 days.
Most of our female patients are married.
Primary SUD is alcohol followed by opiates.
The female co-occurring diagnoses that we see the most
are depressive disorder, anxiety disorder, and PTSD.
Most of our female patients get a regular discharge,
about 65% of them.
Most of our female patients are in residential treatment.
23% of those patients will go to IOP,
and about 25% of our patients are in IOP only.
For the males,
we have an average age of 37.
The average length of stay-- 38 days.
Most of our male patients are single.
The primary SUD diagnosis for our male patients
is alcohol followed by opiates.
The male co-occurring diagnosis that we see the most
is depressive disorder followed by anxiety disorder,
and then ADHD at 11%.
We do have an adolescent program for males,
so we're seeing more ADHD.
Male discharge type:
71% of our males get a regular discharge.
64% of our males are in residential treatment.
15% of those go to IOP following residential treatment,
and then 21% of our males do IOP only.
As part of our evidence of compliance following the 2021 survey,
like I was talking about before,
and as our continuous compliance,
we track the patient risk status and their reassessment.
We set a goal of 90% of our patients to be reassessed
for risk of suicide with a C-SSRS since last contact
within that expected time frame.
Patients identified as moderate or high risk
are reassessed for suicide within 36 hours
as part of our protocol.
Right now, we are about at 96% of those.
When patients come into our residential program,
we see about 61% of them being minimal risk,
but 20% at moderate risk,
and 8% of our patients come in at high risk.
I don't know if any of you guys went to Chicago recently
for the Joint Commission Conference,
but we had a talk about suicide risk,
and I learned that a person
is 300 times more likely to die by suicide
in the first week after discharge.
That was a big thing.
30% of patients do not attend an outpatient appointment
in the first 30 days.
Just for Tennessee,
our suicide rate is 29% higher than the national average rate
in the last published report, which was 2021.
Of course, recommendations for best practices
encourage a transition from inpatient to outpatient care
for individuals with a history of suicide risk.
So, for that reason,
we're going to track successful transitions.
We want our patients to go from residential care
to outpatient care, whatever that may be.
Because not only do successful transitions to outpatient care
support best practices and suicide risk management,
but our Research Institute has also shown
that treatment stays of 90 days or longer
is recommended for maintaining overall positive outcomes.
You can go to the next slide, if you like.
We have several stepdown options
for patients after residential care
to continue their treatment for 90 days or more.
We have intensive outpatient, extended care,
individual psychotherapy for outpatient.
We also have a 12-step immersion camp,
where patients can go to if that works better for them.
But we'll track those referrals and successful stepdowns
to those places
as part of our Performance Improvement Plan
and our compliance with the PI.01.01 Joint Commission standard.
As of now, to a year of the date,
we have almost 38% of our patients in Tennessee
going to one of our stepdown locations.
Then just following with our compliance effectiveness
of our quality initiatives
and looking at patient outcomes.
This is just a female patient who admitted as high risk for suicide
in our residential program.
She was reassessed several times during her treatment stay
per our protocol
due to concerning answers on our PHQ-9.
She successfully completed treatment with a regular discharge
and then transitioned to IOP in her hometown.
It's now 60 days post-discharge,
and she's being followed by our peer support recovery team.
She's still sober.
She reported getting a job.
She attends meetings regularly.
You can see in these graphs where she came in at admission.
She was in that severe depression;
and then leaving, she was in mild depression.
So that was a good thing for us to see.
With her GAD-7 anxiety scores,
she was moderately anxious when she came in.
And then upon admission, she was in that mild range.
It kind of ticked up a little bit right when she was discharging,
which is not uncommon for our patients
to get a little anxious right before they discharge.
And also her impulsivity went down as well.
That is something that they like to track.
Our clinicians like to track impulsivity
for patients that are high risk of suicide.
We also like to see how our patients respond to treatment as a whole.
This is part of our Performance Improvement Plan.
We'll track our outcomes
using measurement-based care standardized assessments.
Our Research Institute will publish an Annual Report
which will display the outcomes.
This is just a four-year trend
that will show a 67% decrease in depression,
63% decrease in anxiety,
88% decrease in craving symptoms,
and a 12% increase in recovery capital resources.
All this supports sustained recovery.
We're proud of these outcomes that we can see here.
Over three years post-discharge results,
we saw patient-reported symptomology sustained significant reductions
through the first year post-discharge.
You can see depression, anxiety,
both going down and staying that way for a year post-discharge
in this visual here.
And then, also,
recovery capital increasing and staying higher.
We also saw decreased readmission
with an increased treatment dosage.
So the longer a person stays in treatment,
the better their outcomes are and decreased readmission,
and also, increased abstinence for our patients.
Patients that successfully completed our programs
are more likely to report sustained recovery.
We have a lot of locations, like we do,
about 20 different locations.
Leveraging technology is the best thing that we have done
to be able to keep us in compliance
with our quality goals and our PI plan.
If a patient is moderate or high risk for suicide
and requires a follow-up assessment,
we have an email that will automatically go out
to the Primary Counselor, Program Director, and clinical leadership.
We want our clinicians to focus on the patient.
So if there is somebody who is moderate risk, high risk,
they're automatically going to get an email
to make sure that they're reassessing that patient
when they need to.
Also, if a patient endorses an answer that causes concern
when they're completing that PHQ-9 or GAD-7,
we're going to send a text alert and an email alert
to the Primary Counselor and Program Director.
And that way they know
that it's time to reassess that patient for risk of suicide.
Also, we have the daily roster
that those program directors and counselors can look at,
which tracks that risk stratification
that lets them know,
"Hey, my patient is about to discharge.
I need to go ahead and reassess them before they leave treatment."
I showed you some of our graphs that we have
that show our patients,
their PHQ-9 and GAD-7 scores
against the aggregate and trends, changes in symptomology over time.
Then those reports that track our outcomes
display the aggregate trends,
ensure compliance with our protocols.
It allows us to filter by program,
by time, by demographic data,
and it's kept in our staff portals for all our stakeholders
to be able to get to and access in real time.
(Darrell) Jennifer, thank you very much.
You've been extraordinarily generous with us
and with the audience today,
sharing your experiences,
as you've operated your business there at Cumberland Heights,
and I do deeply appreciate it.
As I mentioned before, we have questions
that the audience can send to us here.
But a couple of things struck me,
or I'd like to ask you if you don't mind
me asking you these questions, okay?
(Jennifer) Sure.
(Darrell) Thank you.
One is about the suicide issue.
I was struck by extraordinarily robust...
Cumberland Heights has put together
their Suicide Program there.
As you saw last week
when you were in for the training here in Chicago,
that an NPSG, National Patient Safety Goal 15.01.01
is the suicide standard
that's most cited in the past year on surveys.
It appears that providers are having a challenging time
meeting that level of monitoring, screening,
and following up on those red flags
on the suicide issue.
I wondered if maybe you could share a little bit about,
was this a recent improvement,
a program you recently put in at Cumberland Heights?
Or was it in response to the Tennessee report from 2021,
coming out of COVID, I guess?
(Jennifer) It was actually in response
to our Joint Commission survey that we had in 2021.
We were doing open chart audits
and doing spot checks
to make sure we were following that protocol.
We realized that we were not gathering as much information as we could
with just spot checks and open chart audits
because during our survey, we realized
we were cited, like many of the other facilities,
on that standard,
because one of our counselors,
although she did the assessment, she didn't sign it.
So that was an incomplete survey.
And leadership and I got together,
and we decided, you know what, this is very important.
We need to check every one.
Spot checks are not going to work.
So that's when we revamped this entire protocol.
And there are just little check marks
at every interval that we can have.
We make sure that the first assessment is done
by running a report through the EMR.
We make sure that every follow-up that needs to be done
is done by running a report through the EMR.
Then we also have daily meetings in each program to make sure
that every patient that needs to be assessed or reassessed is done.
Then we'll have our daily census meeting,
which includes program directors, QM, leadership,
and we'll go over those safety issues during that meeting.
We're making sure that every patient
that needs to be assessed or reassessed for suicide
is reassessed or assessed for suicide at that time.
(Darrell) Thank you very much for that insight.
Was that a heavy lift to put that in place for you?
Did the EMR help that?
(Jennifer) The EMR helped greatly.
We are very lucky to have a director of information technology
that's very good at pulling information from the EMR.
I am able to use Microsoft Power BI to create those reports.
We're able to put them on our staff portal in real time.
Being a large facility, we're able to do that.
I know a smaller facility
probably will not have that kind of infrastructure,
and people to be able to do that kind of thing.
But, yes, having an EMR that we're able to pull that data from
and put on the portal,
so people can see, "Oh, gosh, I missed one."
It was a big deal.
It included leadership,
and it included quality management,
and it included clinical directors.
It was a long time coming
because now we realized, "Wow, we missed more than we realized
by doing just spot checks when we started checking each one."
And it was a little scary to think that one could be missed.
Because what if it's that one patient
who is a high-risk patient,
and-- I can't even say it out loud-- they might try something?
(Darrell) Oh yeah, yeah, yeah.
Wonderful. Thank you for sharing that.
That's a great insight to see about that.
Would that be easier for the smaller organizations,
maybe even just starting out
in the substance use disorder industry,
I can call it, I guess.
Paper files.
Would that strike you as being a challenge,
or do you have any insight into that?
(Jennifer) I would think paper would be a challenge.
It's been a long time since I've used paper.
I'm sorry to say that I am old enough to be those paper chart people.
But to have to track something
as serious as suicide risk on paper,
I can just see where something may get lost.
Now, if it's a very, very small facility,
it may be okay.
I don't want to speak on something I'm not familiar with.
I'm sure someone can find a way.
But the EMR is just a blessing
to be able to see things in real time,
and for everybody to be able to see things in real time.
(Darrell) Thank you very much for sharing that insight
into what's really a vexing problem for most people now, I think.
How about some other critical areas
that maybe the accreditation process is assisted in?
One that came to mind is the high turnover rates
many people in the industry are going through right now.
Is there any way in which you're either attracting new talent,
or are you finding your educational efforts
for new people on board,
does that help at all?
(Jennifer) Sure. We are doing a lot with training.
Every time we see a new standard come out,
the new standard,
it was...
part of Leadership.
Now I believe you just moved it
to the National Patient Safety Goal,
but a lot with the DEI.
It's funny that you should say something.
We are doing a training now
based on this new standard.
Today, actually, I'm missing it because I am talking to you guys,
but that's okay.
I would much rather talk to you guys.
But we're doing a DEI training today, talking about how important it is
to know your patients and what they are going through.
So just keeping our staff informed
and giving them trainings that they need
and that are very important to us
and to our industry,
I think is very helpful.
(Darrell) The DEI standard
is the Diversity, and Equity, and Inclusion standard
that was more recently added to address that whole issue.
But you're actually finding it sensitizing perhaps your therapists
and their ongoing work with your clients,
actually enhancing maybe the clinical experience?
Is that what you're saying?
(Jennifer) You said it much better than I did, but yes.
(Darrell) Alright.
- Okay, thank you. - (Jennifer) Thank you! (both laughing)
(Darrell) That's happening today, huh? Good, good.
That's encouraging to hear.
That's great. That's great.
The other thing I was wondering about here
to maybe share with the audience,
the surveyors, they're our face
when they come out and they do these surveys.
I do most of my work on Zoom,
and the rest of us here do too.
But these are the people who are actually your peers, so to speak.
They live in the community, and they come out.
They're all behavioral health specialists
and people usually with a great degree of background.
Do you feel you develop peer relationships with most of the surveyors?
Are they inspiring or helpful to your staff as well on these surveys?
Could you share a little insight about that maybe?
(Jennifer) Oh, absolutely.
I still have Paige's number in my phone.
Don't tell her, but when she... (both laughing)
Our last survey was during COVID,
so it was really, really weird,
I guess is the best way to describe it.
And I was actually...
I had COVID while we had it.
So I had to be at home.
Our surveyors were doing it through Zoom,
and I was trying to communicate
with my team from my house.
It was just crazy, but the surveyors were wonderful.
They were very understanding of what was happening
and everything that was going on.
You see on social media the Joint Commission jokes or whatever,
"Joint Commission's coming, hide your water bottles,"
but that's none of what it is.
It's, like you said, our peers,
and we all have the same goal.
We want our facilities and our patients to be safe.
If we had any questions, they were very helpful,
very understanding of the questions.
If they could not answer the questions,
they would bring someone in who could answer questions.
I can't speak anymore about Paige
and whoever else came.
I cannot remember his name, but he was wonderful as well.
Answered everything to the best of their ability.
If anything needed to be cited, they would let us know why,
what we could do to correct it, that kind of thing.
It was a great experience.
(Darrel) Thank you very much for sharing that with us here.
I do appreciate that.
Maybe another question I have here would be about the standardization.
Are standards helping a more complex organization,
like Cumberland Heights,
become more efficient?
Do you have any insights into that whole process,
the use of the standards to enhance your own efficiency?
(Jennifer) Absolutely.
The way I interpret the standards, obviously,
the way that I think they're written,
and correct me if I'm wrong,
but they allow for the facility
to write our policies the best way for us,
as long as we are following the rules.
And that's very helpful
because what's good for something of our size
may not be appropriate for something very small
with only five clinicians.
We are able to, like you said,
standardize everything across the board,
being that we have detox residential IOP
and then have little specialty areas
for each of those different levels of care.
But somebody as big as us-- we have 300 and something policies.
Being able to have one standardized policy
for everybody here,
all 350 employees,
is very helpful in being able to follow the standards
in Joint Commission,
that they have it written out for us to be able to follow that.
Okay, as long as we are following this policy, we're good.
(Darrell) Thank you very much for sharing that insight into it.
I think we have some questions from the audience now,
and Melinda Lehman, our Executive Director here,
will be speaking here
and presenting these questions to you, if you don't mind.
Thank you.
(Melinda) Just a reminder that you can continue
to ask questions in the Questions pane of your control panel.
Our first question, and I can take this one, is:
"Does the Joint Commission require that we have electronic health records?"
And the answer to that is no,
we can still do it the old-school way,
but we're finding more and more organizations
do have electronic health records.
The second question is,
it says: "Thank you for sharing with great data and trend lines,
but what words of advice do you have for organizations
just starting the accreditation process?"
(Jennifer) Read those standards would be my advice.
Go through those standards,
and if you are starting policies,
write your policies to follow those standards,
and then whatever is in your policy,
be sure to follow that policy,
if that makes sense.
I love to start anew
because, like I said, we have over 300 policies now,
and I'm finding things from
2001.
I'm like, "Do we still do this? I don't remember. Do we do this?
We need to update this," that kind of thing.
Just be sure that you are following those standards
with your policies,
and if it's in the policy, be sure you're doing it.
So don't put it in a policy if you can't do it.
Does that make sense?
Thank you.
(laughing)
(Melinda) The next question is,
"Could you describe the level and amount of education/training
and clinical supervision
to monitor staff and client performance."
(Jennifer) We have LADCs,
which are licensed addiction specialists.
I'm not sure if that's across all of the US
or if that's a Tennessee thing.
We also have master's level clinicians.
Then we also provide supervision
to LADCs and master's level clinicians.
We have licensed clinical social workers
and then mental health providers.
(Melinda) Thank you.
The next question is,
"How long do you typically have to fix any issues found during survey?"
(Jennifer) Does the Joint Commission want to answer that question or...
(Melinda) We can certainly do that, yes.
For most organizations, for most issues, it's 60 days.
(Jennifer) I did know the answer, though, if that helps.
(everybody laughing)
From experience.
(Melinda) Good.
Our next question is,
"What technology are you using that allows you to issue email alerts
for elevated score/high-risk clients?
Is this leveraged through your electronic health record?"
(Jennifer) It is.
Our great Director of IT is able to pull that information
from our electronic health record
and then send that through our email system.
And if you guys want to know what electronic health record we use,
it is Sunwave.
(Melinda) Thank you.
The next question is, "Can you provide some insight
on the requirement to track compliance with handwashing by staff?"
(Jennifer) What we use here at Cumberland Heights
is actually our Director of Nursing
is our Infection Control Coordinator as well.
What she will do is visual checks.
She will stand in the lunch line
and also in our medical area
and do visual checks with a little notebook.
That may work for us.
I'm not sure how that will work for other people,
but that's what she does--
just kind of take a check if you use the sanitizer.
(Darrell) Sounds good.
(Jennifer) And yell at you, if you don't.
(laughing)
(Melinda) Our next question is, "We are a smaller organization.
What are one or two top reasons you think an organization like ours
would benefit from Joint Commission accreditation?"
(Jennifer) In my opinion, it's the gold standard.
You know you're safe if you're Joint Commission accredited.
That's my opinion.
It's not the opinion of Cumberland Heights Foundation,
but I actually think it is the opinion of Cumberland Heights Foundation,
now that I think about it.
But, if you have that Gold Seal, you know you're safe.
And anybody that comes to your facility
will know that you're also a safe organization,
and you put patient quality and safety before all else.
That's all I can say about that.
You have that--
it's the gold standard.
(Melinda) Fantastic. Thank you.
(Jennifer) Yeah.
(Melinda) Our next question is,
"Is the C-SSRS built into your electronic record?"
(Jennifer) It is, yeah.
It's part of the electronic medical record,
and that's how we can pull that information
to ensure that it was actually completed in its entirety.
Also, make sure that that follow-up assessment
was done in its entirety as well.
(Melinda) Great.
Our next one might require some thought.
"Was there ever a point that QM was not fully integrated
into the fabric of the company?
And if so, how did you leverage QI frameworks
to put forth a change management process
that's respected and adhered to across your organization?"
(Jennifer) Someone ate their Wheaties this morning.
(laughter)
It wasn't me.
Now, here is a great question,
and honestly, I've only been here for three years.
From my understanding,
QM has always been part of the organization,
but we've been here for 63 years, I think--
almost 60 years--
so it may not have been here from the beginning.
Cumberland Heights started out as a mom-and-pop kind of place
for people who drank too much,
and it's grown since then.
But once we became a facility
that focused on health care quality and safety,
I'm pretty sure quality management
has been part of the organization.
There are times where I will bang my head against the wall
because I think something is important,
but leadership may think something else is important.
And it's not that at any point in time that they will think--
they will not put safety first.
We just might have different priorities.
When I think, "Well, we need to focus on treatment completion."
And they said, "Well, no. We need to focus on AMAs."
It's the same thing,
but it's just "tomayto, tomahto" kind of thing.
(Melinda) Thank you for answering that one.
Our next question is,
"Can you comment on the Joint Commission survey
and what kind of insights you've received from them?"
(Jennifer) It's been a minute since we have been surveyed.
Yes.
But you will receive--
I think I showed you a picture of the SAFER Matrix.
So you will receive your SAFER Matrix.
If there is anything that you need to improve on,
it will be in the SAFER Matrix.
I don't know if you want to go back to that slide
while we're talking about it.
And Joint Commission might want to jump in here as well.
But you can see where Low, Moderate, High,
Limited, Pattern, Widespread.
(Melinda) Yeah, this is a chart that you will receive
after your survey.
It's going to take every one of your findings,
and it's going to put them in this grid by the scope,
whether they were an isolated incident
or widespread.
And then by the risk to harm of individuals,
staff, or people in your organization
between Low and High.
So that way you can prioritize what you need to work on
and see it all right in front of you.
It also allows you to benchmark these findings against...
For instance, an organization like Cumberland
can look at their various locations against each other,
or you can actually see some data
about other organizations like yours,
and how they scored.
(Jennifer) Yeah. Then you can check your SAFER Dashboard,
where, like she said,
you can benchmark against other places.
So we're able to benchmark against all other organizations
and see where we stack up against others.
It's really great to be able to see how you're doing
against the aggregate.
To see if, "Oh, wow, I had a lot more RFIs than they did."
Or, "Okay, we're doing okay. We're right with the aggregate."
(Melinda) Okay, our next question is,
"Our agency works with the homeless,
and it is difficult to track accurately the discharge status
other than discharge against staff advice or with staff approval.
Unfortunately, we have very few AS planning discharges
due to the ambulatory nature of the clients we work with.
What is The Joint Commission's thoughts on this?"
(Melinda) I don't know that The Joint Commission
can answer that for you right now.
We'd have to talk to our standards experts.
(Darrell) Within the E-dition, there is a Housing component
on the right side of the filters in the Service Profile.
Frankly, I only work with new people and new applicants,
and I don't see that many homeless housing programs
come through.
I can't remember the last time
somebody was offering that service.
But I would go there first,
and I would look at that linkage in E-dition
under the Housing
on the lower right side of the filter page Service Profile.
It's called Housing.
(Melinda) We do have a group of individuals here,
kind of our standards Help Desk
that we call the Standards Interpretation Group, or SIG,
and this is a perfect question for them as well.
So we're happy to connect you with them.
(Melinda) That looks like about it for the questions,
but I did want to comment on additional resources that we provide.
If you go to jointcommission.org and either search for Quick Safety,
or you can find it under
News & Multimedia > Newsletters > Quick Safety.
We do have a Quick Safety on validated tools
for suicide risk screening.
And we also have an entire web page devoted to suicide prevention.
You can find that under the Resources tab as well.
And that's under Patient Safety topics and Suicide Prevention page.
And there's a number of resources on that as well.
So let's see.
No additional questions are in the queue.
I think we're all set.
(Darrell) I'd like to thank everyone
for attending today's webinar presentation.
This concludes our presentation.
You will receive a follow-up email within one to two days
with a link to view and listen to a recording of today's webinar.
We have a survey at the end of the webinar.
We do appreciate your feedback.
On behalf of Joint Commission,
Ms. Sujdak, we want to thank you for your generosity of time.
It was a pleasure to have you with us and appreciate your insight
and sharing your experiences with our audience today.
And thank you to our audience for joining us today.
Please be safe and well, and have a great rest of your day.
(Jennifer) Thank you.
(Darrell) Thank you.