(Gina) Hello, everyone, and welcome to today's webinar,
Peer Perspectives: The Advantages of Joint Commission Accreditation
for Ambulatory Healthcare Organizations.
I am Gina Doruff, Associate Director,
Marketing for Ambulatory Healthcare at The Joint Commission,
and I'm honored to be your moderator for today's session.
Before we get started, I'd like to go over a few items
so you know how to participate in today's events.
Here's a screenshot of an example of the attendee interface.
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via phone call or computer audio.
If for any reason during the call you want to change to the other selection,
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You may send in your questions at any time
and, again, we'll address those at the end.
The deck used during today's call, along with the recording,
will be emailed to all attendees within 24 to 48 hours.
Now I'd like to introduce you to our panelists for today's discussion.
We're excited and honored to have with us
Kathryn Lilli Kaminski,
Director of Regulatory Services and Accreditation
at Azura Vascular Care and National Cardiovascular Partners.
We also have Dawn Ruiz, VP of Clinical Operations and Quality
at Regent Surgical Health.
And we have Karen Bewer, Administrator at Pain Physicians of Wisconsin.
Thank Karen, Dawn, and Kathryn for joining us today.
Rommie Johnson, Associate Director, Business Development
at The Joint Commission will also be joining us today.
Rommie has been with The Joint Commission for six years and he manages
the business development and strategic direction
for corporate segments for Ambulatory Care.
He focuses on large practices in surgery management firms.
So without further ado, let's get started.
I will hand the call over to Rommie to give you a quick rundown and the basics
of Joint Commission accreditation.
Rommie?
(Rommie) Thank you, Gina and hello, everyone
from wherever you may be joining from.
I'd like to-- before I get started, I'd like to echo my colleague's sentiment
and gratitude by thanking you for joining us today.
We're really excited to hear straight from our accredited organizations
and we hope that you will definitely learn a thing or two about our processes,
about why organizations,
such as the ones affiliated with our panelists,
choose The Joint Commission's Ambulatory Care Program.
But before we start that, I thought it might be a good place
to take a step back and discuss a little bit about the basics
of our Accreditation Program.
So in the next slide,
what you'll see is, of those on the call,
they may be going through this process for the first time.
Again, like I mentioned, we thought it might be worthwhile to review
the general intent of accreditation.
In a nutshell, facilities such as yours, that are exploring
or made the definitive decision to achieve Joint Commission accreditation
really do so because it's a distinction achieved through demonstrating
that your facility performs at or above a set of industry standards.
To ensure that the process is actually relevant
to your operations, staff, leadership, and patients,
this Ambulatory Accreditation process is developed in collaboration
with your industry peers.
We want to make sure that everything that we do,
from our standards, through the resources that we provide you,
actually make sense for the services that you provide
and the communities that you serve.
So if you were to zoom out and look at the entire process from above,
it really can be summarized in three steps: Application,
so after you've confirmed your eligibility;
the Survey Process, which is an on-site experience;
and then finally, achieving that Accreditation,
which is good for three years.
So moving on to the next step of high level overview,
in this equation where we analyze
the relationship between accreditation and excellence in patient care,
I really wanted to draw everyone's attention
to that middle section,
and that is the fact that our processes, our standards, and tools
really allow facilities to increase standardization,
thereby reducing variations in things, such as documentation,
instrument sterilization, disposal of hazardous waste,
and even entries in patient records, among other things.
When you reduce that variation, you inevitably reduce the risk
that something will be missed.
And this is ultimately what results in less sustainable quality
in patient safety in your facility.
This is not just a matter of getting a certificate
for three years.
This is a matter of really turning the culture within your organization
to make sure that even as leaders come and go,
as patients come and go, you have the sustainable culture
in patient safety and quality.
Moving on to the next slide,
so for those that on the call today on the webinar that is created by us,
this might be familiar to you,
but actually a lot of folks don't realize that
our Ambulatory Care Program has actually been around
for over 45 years.
A couple of years ago, we actually celebrated
our 45th year anniversary.
And really, the main takeaway from this slide here I wanted to get is
we wanted to focus on industry surveyor,
so folks that work in the ASC setting,
in the Ambulatory Surgery Center setting or outpatient setting,
we want to make sure that we have our manual
that's specific to your facility.
So usually, we will hear, contrary to what you may hear about--
especially if you have experience in the hospital,
really, this Ambulatory Care Program is specifically catered
to your type of facility and we want to make sure
that the process is comprehensive and collaborative.
Here at headquarters, at The Joint Commission headquarters,
there's really a strong emphasis on customer service
and especially having a mechanism
to ensure that by the time you apply and the time you achieve accreditation,
that turnaround time is as quick as possible.
We know that someone that called might be looking to be accredited
for their initiatives or to maybe meet state requirements.
So we really have a process and turnaround to make sure that it's timely as possible.
Now, last year, our program hosted another webinar
where we dove a little bit deeper as to what are the top five things
you should all look for in an accreditor.
What you can see here are some of the things
that we discussed in that webinar.
And as you'll get to hear today from our panelists,
these are five items that have been shown time and time again to be beneficial
to either returning or new organizations that are looking to earn that Gold Seal.
Later on, you'll hear a little bit more about the process--
how the process, rather, helps you all build a stronger business system,
helps in standardization, and even reimbursement,
expanding the reimbursement where applicable.
So for those that are doing orthopedic procedures,
perhaps this is something that Joint Commission's Accreditation Program
can definitely help.
Then finally, before I turn this presentation over
to the main stars of the show, the folks that you really came here for,
our panelists,
I wanted to close by reiterating, again, the value of that accreditation,
The Joint Commission accreditation beyond the certificate.
Again, as I mentioned, we wanted to make sure
that this process is collaborative,
that it makes sense for the setting that you have.
And that as you continue to grow, whether you're with the management company
or whether you're just a solo organization,
wanted to make sure that this is actually applicable
and useful to your facility.
Through our propriety tools, usually we have tools internally
that are really meant to help you meet and sustain compliance,
as well as having that focus on ensuring
that the experience that you're going to get
from our surveyors is collaborative.
We are seeing and hearing some positive feedback
as to the role Joint Commission plays in patient safety, and this here,
this slide just underlines what we are doing
from a multi-faceted perspective to make sure that our tools,
our processes, our surveyors, and our staff here at headquarters,
really meet or exceed your expectations
in what you're looking for in an accreditor.
So with that being said, I wanted to turn this over again
to the stars of the show, our panelists that are going to give insights
as to their Joint Commission experience and really what they saw as key
to ensuring a successful accreditation experience.
Thank you.
(Gina) Thanks, Rommie.
Now we are on to our panelists' discussion.
Today's panel will talk about Joint Commission Accreditation
and how it has made a positive impact on their organizations.
Next slide, please.
Our first panelist is Karen Bewer,
Administrator of Pain Physicians of Wisconsin.
Hi Karen, thanks for being part of the panel today.
How are you doing?
(Karen) I'm doing well here, thanks for asking.
(Gina) Alright.
Can you share a little bit about Pain Physicians of Wisconsin,
its relationship with The Joint Commission and your role within your organization?
(Karen) Certainly.
Pain Physicians of Wisconsin is a very small organization
owned by four physicians that used to be a part
of a larger corporate organization
that actually went out of business in 2020.
So the four physicians decided to open their own organization,
it's interventional pain management,
and in the last-- little over a year, we're onto our third small surgery center.
We have worked with, as a team, the physicians and myself,
has worked with The Joint Commission for many, many years
in the previous organization and now.
I think that was one of the first things we agreed upon, is that
we were going to stick with The Joint Commission
because we were great partners before.
In my organization, I'm the Administrator because, again, it's a small organization.
I also take care of the clinical education the patient safety, the risk management,
the quality improvement.
I wear lots of hats.
And hopefully as we grow, I'll be able to pass those hats
onto somebody else.
But one that I'll never pass on because I love working
with the standards and the accreditation process
for the surgery centers, both the initial accreditation
and then the triennial ones after that.
It's been a very great relationship.
(Gina) Great, thanks, Karen. So why did you decide
to stick with The Joint Commission when you started the new organization?
(Karen) Well, I looked at other organizations
and then I came back to Joint Commission and I explained it to the staff,
the clinical employees, in a way that they'll ask me a question like,
"Does Joint Commission make us do this?"
Whatever question they may have.
And I like that I can answer that question
to say that The Joint Commission lets us make our own decisions.
We have the standards and they do a very nice crosswalk
between The Joint Commission's standards
and the CMS Conditions for Coverage
because we're also a deemed status
surveys that we do.
We have Medicare credit hours certification also,
and so the framework is there.
But how we get there and what our policies say
are up to us, and how we make sure that our policies stay consistent,
and that our practice meets our policies.
We use the standards to guide our policies
and to guide our education and guide our practice.
But our policies are the real meat of what we have in our surgery center,
and that's how we're held accountable by the surveyors
is if we have a policy that says we're going to do something,
as I explained to the staff, then we need to do it.
We need to follow what we've said is important for our policy.
So I thought that was the most important.
It's not a-- it doesn't dictate certain very regimented ways
of approaching the standard that I saw for some of the other organizations.
I was just very-- I've always been very impressed with the way
the surveyor can sit down and in a very collegial way,
walk you through when maybe your policy doesn't meet the standards
or your practice doesn't meet the standards.
And how they can take you through that walk through and say,
"How else could we look at this?" or, "How else could you meet your needs?"
I think it's just the collegial nature of the surveyors
and the educational process that should go through.
I look forward to the surveys.
I absolutely love them.
I always laughed about some people who dread the survey process.
I really enjoy it.
(Gina) Thank you, Karen, we appreciate that enthusiasm for the surveys.
(laughter)
So as a new organization, is there anything
that Joint Commission has done to help you get started?
What kind of role did we play in helping you get up and running?
(Karen) Oh, my first organization,
they were such, such a help.
Because I had come onto an organization that had done this many times before,
and I only started a few sites at that organization.
So when I started up brand-new, with not really knowing
what's-- which way to go, and not having a lot of resources either,
The Joint Commission was there for me even before accreditation happened.
Knowing that we were in that journey towards accreditation,
I was able to pick up the phone and call what Rommie had started to throw me
and then move on to the account manager who was going to be working with me.
And they were just-- they were really, really helpful.
Little things like before that, the physicians were employed
or in a contracted situation with a larger organization.
And now I had a small organization, they were the owners.
And it was a completely different process.
We went through, "Who gets to approve what?
How do you get if there's only one physician?
He is the medical director.
Who approves his privileges?"
It was little questions like that like, "Oh, wait a minute.
How do I do this?"
So it was very, very helpful for just taking the standard,
walking it through and approaching it from either a small organization
or a large organization, that was really helpful.
(Gina) You had mentioned that your facility started as two
and you're moving on to three, so as your organization continues to grow
how do you see The Joint Commission as a tool to help your goals
of when you grow?
(Karen) I think it's standardization.
I think it's getting the same answer, no matter who you ask,
that the standard is explained
and it's surveyed the same way.
So if I have a policy on certain kind-- maybe, my OR attire
or the infection control surveillance process,
whatever part of the policy I may have,
how I can apply that to the next facility,
and I have to make a lot of changes because it's just common sense.
It doesn't have to be so very, very specific
to that moment in time.
It's a policy that guides practice, that guides your surgery center
as you grow.
And maybe as you don't grow and just stay where you are.
So I think that the consistency in the standardization
is really what's been positive.
(Gina) Yeah, Karen, I think you made an excellent point about our standards
on helping standardize processes and provides a reliable training protocols
for employees across the entire organization.
You said you worked with Joint Commission for some time.
Can you explain how it is working with our surveyors?
(Karen) It's actually fun.
With the other organizations that I was with--
I had, at one point, 23 surgery centers, that I...
made every attempt to be at every survey.
So there were times that I would attend between six and ten surveys a year
and facilitate them and learn from them.
And it was fun to see the same surveyors.
Perhaps I had seen them in March and I see them again in May.
And that was nice, it's just-- I think as the time has gone by,
the many years that have gone by I've worked with The Joint Commission,
both in a hospital setting and in an ambulatory setting,
the surveyors are certainly much more consistent
than ever before.
I think that--
It's never a punitive...
situation.
I remember being a new nurse and dreading the thought
that The Joint Commission was going to come into the hospital
and, "Oh, my goodness! I hope they don't catch me
and ask me a question."
But that's been very positive too
that the staff look forward to it.
I tell them, I model the behavior that there's nothing to be afraid of
and if you have a question,
ask them about it.
Ask them, they're the best...
resource right there, we can ask them what they think
and there's not going to be any punitive coming back,
"Oh, if you asked about this, then you must not be doing it right
so we better dig deeper and find the problem."
I have never had that experience or anything like that.
Any kind of survey, any kind of regulatory body
coming into your facility is frightening for those that aren't familiar with it.
But to have it where it's really a learning experience
and that the staff is thanking them as they're leaving
and laughing with them and really enjoying just the discussion with them,
hearing a little bit about their other experiences
or what it's like to survey in, maybe, a different state,
I think it's a very positive experience.
(Gina) Thanks, Karen, you did a good job explaining that we truly are there
to help our customers, support you, and get you better.
We want to be partners in your patient safety journey.
(Karen) Thank you.
(Gina) Well, Karen, thank you for joining us today.
I appreciate you taking the time to share your experiences
and for being a constant, long-standing cheerleader
for The Joint Commission.
(Karen) It's a pleasure.
(Gina) And now, I'd like to introduce Kathryn Lilli Kaminski.
She is the Director of Regulatory Services and Accreditation
at Azura, Vascular Care and National Cardiovascular Partners.
Hi, Kathryn, thanks for joining us today. How are you?
(Kathyrn) Hi, I'm good, thank you.
Good afternoon, I'm happy to be here.
(Gina) Great, thank you, thanks for being here.
I'm asking the first question that I also asked Karen:
can you share a little bit about your organization,
its relationship with The Joint Commission
and your role with National Cardiovascular Partners.
(Kathryn) Sure.
My organization operates and manages a national network
of outpatient vascular centers and cardiology ambulatory surgery centers.
We specialize in minimally invasive techniques
to treat a wide range of conditions.
We have over...
60 Joint Commission accounts
for a total of over 100, 110 different accredited centers.
We're continuously expanding our services to include new service lines
while working hard each day to achieve optimal outcomes
and of course, The Joint Commission helps us achieve our goals.
My role-- I have diverse healthcare experience
including hospital and ambulatory direct patient care,
which I did spend, probably almost 20 years
doing direct patient care.
Now I have administrative,
some operations management experience,
clinical support and education, and more recently
regulatory and accreditation compliance and clinical policy development.
I've coordinated and supervised
Joint Commission Survey Readiness activities
for centers to achieve first-time accreditation,
to help them maintain accreditation
in various settings across the United States,
from busy cities out to rural areas.
And in my current role, I do help manage those...
Joint Commission accounts for the centers
and continue to provide education and support
for all accreditation and regulatory activities.
And I do sit on The Joint Commission Ambulatory Care Accreditation Council
and try to participate in as many activities as I can
to be able to...
add that information
and bring it back to my organization to strengthen the centers.
- (Gina) Thanks, Kathryn. - (Karen) Mm-hmm.
Why did your organization choose The Joint Commission
as its accreditor?
(Kathryn) I'm so glad you asked that question.
I was part of the organization, it was a very, very--
a very, very long time ago.
We were a very small organization at the time.
We had several mergers since then, but way back when,
when we chose The Joint Commission,
The Joint Commission's goals of patient safety and quality
really align perfectly with our organization's mission.
And The Joint Commission is known for their high standards.
They do have a reputation for being the best.
They set the bar high
and they really are the gold standard in accreditation.
Joint Commission, we felt, was more organized,
had better resources,
a more user-friendly extranet,
and basically a more positive and educational survey experience.
I couldn't stop nodding my head
when the previous panelist was speaking about the surveyors
and how collaborative they are.
And I'm glad-- I'm really, to this day, I'm very grateful and glad
our CEO at the time
didn't choose the easiest route.
He chose the best route, the one with the highest standards.
And Joint Commission accreditation does instill a tremendous amount of pride
across the organization.
Because it's not the easiest route
but it is the best route, we feel.
(Gina) Thanks, Kathryn and thank you for touching upon a really great point,
it's really a collaborative relationship
between our surveyors and your staff.
We really want it to be educational and want the orgs that we accredit
to be successful.
So thanks for shedding some light on that.
Next question.
So how has Joint Commission accreditation helped improve your organization?
The Joint Commission has helped improve--
I mean I'm part of the organization
for 20 years.
The Joint Commission has helped improve our organization
in so many ways.
It's really hard to even narrow it down.
One way which has been really important recently
as we were growing larger and larger,
it does help us...
and make it easier for us to maintain compliance.
We've been recently converting
many of our office-based surgery centers to CMS accredited ASCs.
The Joint Commission has partnered with us
on this journey.
We utilized their deeming authority to achieve deemed status for these sites.
And they have been instrumental in achieving this organization goal
by providing an abundance of education and support along the way,
I can't tell you that it was really a scary undertaking,
many, many, many dozens of centers across the United States of America,
no experience in this previously.
I feel like we just all held hands and dove in together.
And the availability, the accounts executive,
for questions and the resources really helped us to achieve this goal.
Being accredited with The Joint Commission helps keep us focused on
and aligned with our mission of patient safety and good outcomes
by providing that structure and a framework.
And, like I said, the executive administrator,
very friendly, very helpful, very available.
And then my favorite-- I mean there are an abundance of resources,
but my favorite is the user-friendly electronic manual of standards,
which can be quickly and easily electronically searched.
So this has made it very easy for me over the years
and for our center staff to understand the standards better.
So I think that's a priceless tool
and as far as I know, that is not available
in other accredited organizations.
I have had the opportunity to...
two other accrediting bodies, I have...
had the privilege of...
participating in some of their accreditation activities
and I really was at a loss for the lack of...
available online information...
for use.
Even logging in as an accredited site, I was quite frustrated, and again,
went back to, as I always do, thanking that original CEO
for choosing The Joint Commission.
So one of the ways that it really has helped us
improve our organization is making it easy
to maintain compliance because we're all busy.
We know we have to maintain compliance but that's really only one of our jobs,
we have a lot of other jobs.
So I feel that The Joint Commission really helps in that.
And I think...
equally as important, if not more important,
and this is very important to me personally too
is the recruitment...
piece, I think that having Joint Commission accreditation
definitely positively helps in recruitment,
Good quality people want to work for an accredited organization.
Being Joint Commission accredited will help you attract
higher quality candidates and help you retain them.
I think generally people in healthcare want to do the right thing
and they want to feel safe and deliver safe patient care.
And when you deliver that care in an environment
with high standards,
they feel comfortable and supported in that environment.
The Joint Commission helps you achieve a positive safety culture
and that is how it helps in retaining those people as well.
So I think it's the high standards,
the consistency, the professionalism,
the safe environment,
knowing what to expect, being compliant,
people want to work in that environment.
So I think you're going to attract
better people.
I think that's been a big plus.
(Gina) Thanks, Kathryn.
Glad to hear that, thanks for your comprehensive answer.
And then how would you describe The Joint Commission
to an organization that is considering us
as an accreditor?
(Kathryn) The previous panelist really said a lot of things
that I had planned on saying, I think when you've been around
as long as we have, you do remember the days
when The Joint Commission was scary,
people thought they were mean.
When I worked in a hospital many, many moons ago,
I used to go in a patient room, hide behind a curtain,
get very involved in some wound care or something until they left.
I was afraid.
And it just makes me laugh now because as the previous panelist said,
the surveys are enjoyable.
We sit down most of the debriefing calls at the end of the surveys,
wherever they occur.
And people are laughing, people have shared stories.
The staff always says after the survey,
"Wow, that wasn't so bad at all!
That was fun," they do look forward to them coming back.
So I would say to try to...
come in with an open mind.
The Joint Commission of yesteryear is not The Joint Commission today.
Maybe I want to say this is not your father's Oldsmobile
maybe that's a bad example, I think Oldsmobile went out of business.
But The Joint Commission is very collaborative.
And that's very important for my organization
because we are not cookie cutter.
We're not like other organizations in what we do and how we do it.
And The Joint Commission has taken the time
to learn our organization and help us achieve accreditation
and maintain it wherever we are practicing.
They're very flexible and they work with you,
which is very important because we all have busy jobs.
Their surveyors are professional,
thorough, consistent,
very friendly, and very approachable.
They know your staff is nervous.
They speak to them
on a level that they can understand.
They don't speak above their heads,
they don't speak this Joint Commission lingo
that some of us in regulatory have now learned that lingo,
but we didn't always know that lingo.
So the surveyors are very in tune and aware of the centers.
When they come in, they're gracious, they understand they're in your space
and they are there to partner with you.
And they really have a great time and they learn a lot.
It is very educational.
And The Joint Commission basically just makes it easy.
They just make it easy.
You know what to expect,
there are no surprises.
And accreditation is a lot of work.
But it's hard work
but it's not because you have to figure out the accreditation process.
I mean that would just be--
make your work even harder,
accreditation and maintaining compliance is hard work across the board.
But not because you can't find resources,
not because you can't figure out the process.
Joint Commission is very easy to understand.
And I think that helps...
in that-- carry that load of becoming accredited.
I could go on and on, I'm going to cut myself off.
(chuckles)
(Gina) Thank you, Kathryn, thank you for mentioning
how we are no longer yesterday's Joint Commission.
I think as organizations start to work with us,
they're really understanding how we are very collaborative
and willing, flexible, willing to work with teams
to truly meet their goals.
I think you added a lot of great insights into what it's like working with us.
So thank you again for joining us.
(Kathryn) Thank you, it's been a pleasure.
(Gina) And our final panelist is Dawn Ruiz
VP of Clinical Operations and Quality at Regent Surgical Health.
Hi, Dawn, how are you today?
(Dawn) Great, thanks for having me today.
(Gina) Great, thank you for joining us.
Can you share a little bit about Regent Surgical Health,
its relationship with The Joint Commission
and your role.
(Dawn) Sure, I'm happy to.
Regent Surgical Health, lots of changes here for us--
a year ago, Regent went from a small company
of less than 20 ambulatory surgery centers
to partnering with TowerBrook and Ascension Capital.
And with that extra capital and the strategic investment,
we have become the exclusive partner
with Ascension
for their ambulatory center development.
My role-- I'm pretty new in this role.
Joined the team in October of last year
as a VP of Clinical Operations and Quality,
it's to oversee all the...
clinical aspects, regulatory patient safety risk
for the company.
So, really excited to be here and as with this growth,
we are acquiring and building new surgery centers
and just looking to have Joint Commission as our partner
as we're opening up new centers and development and grow.
(Gina) Thanks, Dawn.
So why did Regent decide to go with The Joint Commission
as their accreditor?
(Dawn) Yeah, well, a lot of reasons.
But just to name a few,
a lot of our joint ventures, I mentioned that
we have our largest partner Ascension,
we also have other joint venture hospital partners
and they're very familiar with The Joint Commission
and have that with the hospital relationships
so would like to see that gold standard continued
with the surgery centers.
With a rapid growth, obtaining deemed status
is really important.
That's an important aspect financially, obviously, to be able to start...
billing and being paid for our Medicare, Medicaid patients.
But also it's really important to be able to have safe standards
and be able to know that we're opening up our centers
and ready to operate and provide surgical care that's safe
for our patients.
So this was really important as Joint Commission,
in the last several years has been a good partner
for zero harm initiatives.
And our companies really, especially this year,
has embraced and established many zero harm initiatives
that were focused on.
And Joint Commission has a lot of different tools.
I love the targeted solutions tools.
You have tools for falls
and surgical safety, to name a couple,
that are very helpful in my career in the past,
being in hospital, surgery centers, surgical specialty hospitals,
have used these tools.
And it really helps us to focus on areas where we can improve
and know where the need is to keep those patients safe
from falling
and to do the right things for surgical safety.
(Gina) Dawn, I'd like to hear a little more
about your safety initiatives and zero harm initiatives.
Can you talk about how Joint Commission accreditation
has helped you meet your goals for these initiatives?
Just give a little more detail on that, please.
(Dawn) Sure, I'd love to.
Well, like everyone, all the other panelists has said
that the surveys, Joint Commission surveys
are very...
consultative and they provide evidence-based.
So they are all over the country and some surveyors I know
do other markets worldwide, right?
And they learned from best practice.
They get to speak to a lot of different surgery centers,
hospitals, whatever they're focused on doing.
And what I like is that they come in and they educate
and they share these practices.
This has changed.
I've been a nurse for almost 30 years and gone through the gamut
of different types of accrediting organizations
and seen the growth and changes that Joint Commission has had.
I really like the tracer methodology
because it helps us as they come in and survey,
it's not a checked list or just going through books
to make sure we have policies and procedures in place.
But they're actually taking a look at the care
for that individualized patient
and walking through the whole patient experience
for that surgery day.
So that's very helpful.
What I also like is the inter-cycle monitoring tool.
So on the off cycle years, Joint Commission has a tool
that you can go in and look at the standards,
that they've identified several standards with the R icon,
which are the higher risk icons.
And this gives you-- because there are so many standards
and it's hard to be able to...
focus, even though we try to focus on every standard
every day, right.
It really narrows down on the areas that you should be
paying particular attention to.
So that tool is electronic and you can go in
and score yourself to see how you're doing
and work towards making sure that you're always survey-ready.
And the other tool that I absolutely love is the SAFER Matrix.
And that tool is so helpful.
Because, like I said, there are so many standards
it really helps you to drill down and see there's this heat map.
So you know if you scored...
in a red zone, that that's something that you really need to pay attention to
and fix immediately because it's a higher risk
and could do more harm to a patient.
I think this is really helpful for the clinical,
as well as non-clinical team because it paints a picture
and really helps you understand as an organization
where your strengths are and where your challenges are
and where you need to improve.
(Gina) Thanks, Dawn.
You have a very large organization and you had mentioned
that you put a lot of focus on staying prepared.
Can you provide some examples of how your organization...
stays prepared?
(Dawn) Yes, so like I said, one way is to use the inter-cycle monitoring tool
and we've also created based on...
the standards...
checklist that we can review,
and the ambulatory surgery centers leaders
can look at these standards and it's broken down by chapters.
So with that, they could maybe focus for a month
if they're looking at things related to infection
or medication management.
We can build the programs and education around that.
We've been striving to do...
educational series to help where we find that
some of the centers are struggling with the standards,
maybe these come out with mock surveys.
We try to have a mock survey
the year prior to the survey being due,
so that gives them that ability, especially if they're new,
to understand how a survey goes,
just to give them a feel of...
we're looking at the standards, we're trying to do it
as best as we are a surveyor.
And being open to suggestion and a friendly source, right.
And the other thing that we are doing is just sharing lessons learned.
So if you had a survey, you're able to communicate
either in a monthly meeting or annually
where you have a Director of Nursing conference
that-- and ours is coming up in June, I'm really excited that
we're going to get to meet in person.
And then we share these opportunities and we use this time
to build upon areas that is as shown in need of education.
So we're always striving to be survey-ready.
Does that help?
(Gina) Yes, it does and I think other organizations appreciate
hearing examples of how organizations stay survey-ready.
So thank you for those answers.
Are there any last comments you'd like to add?
(Dawn) Sure.
I would just say that as a nurse leader,
especially over 20 years, I've worked in the quality regulatory space
in all types of, whether it be hospitals, surgery centers, specialty hospitals,
rehab hospitals,
I've seen a lot of changes that have been very positive
with Joint Commission.
I really like the fact that we get an account rep
and they listen and hear our needs.
And especially over the last two years with COVID, it's really changed.
I even had a survey that was...
by Tela Communication, which is really interesting.
It was at my last organization.
And just so helpful
as far as...
helping us really focus on the areas and being educated.
And that's what I hear a lot.
We just recently had a Joint Commission survey
at one of our surgery centers and they couldn't speak enough
about how the surveyors were so helpful.
As the other panelists said, it used to be a little frightening
for some people.
They just found that it was very helpful.
So I really like that.
I've been involved in the professional technical advisory committee
in the past with Joint Commission,
I currently sit on the Ambulatory Care Accreditation Advisory Council.
This provides leaders like myself to give a voice input on standards
and the challenges and things that aren't working.
So they listen and understand what our needs are
and I appreciate that and find Joint Commission
just to be a collaborative partner,
helping us on our zero harm and quality journey to--
overall is we want to keep our patients safe
and do the right things and it's great to have that partnership.
(Gina) Thanks, Dawn, that's great and I appreciate you touching on
our people again.
We consider our most valuable assets are people at The Joint Commission,
from the surveyors to our business development
to our account management team.
We're comprised of a deep bunch of experts
and all of our surveyors and reviewers are carefully trained
and fully employed by us.
So thank you again for mentioning that.
(Dawn) You're welcome.
(Gina) Sure and thanks for joining us.
We appreciate your knowledge and experience.
(Dawn) Happy to help and be a voice.
Thank you.
(Gina) And now I am going to turn it over to Rommie for questions.
As a reminder, you can still submit questions
through the Questions pane in you Control Panel.
Rommie?
(Rommie) Thank you and thank you again to all the speakers.
So as the panelists are going through their experience,
so far I only see two questions.
The first one is for Dawn.
Dawn, you mentioned that CMS and the ability of Joint Commission
to come on site quickly and provide the survey result quickly
is important for your organization in particular.
Could you expand a little bit on what the average turnaround time
after a survey is in your experience?
(Dawn) Yes.
We found with Joint Commission and the things that we like
with Joint Commission is the electronic ability.
So once a surveyor comes on,
and some of the other accrediting organizations,
they take the whole ten days and those are business days.
So they may come in and survey you,
give you ten business days to turn around the report
and then once you get that report, you have ten calendar days
to return it back.
So we found with The Joint Commission when they leave, you have the report.
You have your SAFER Matrix.
And you can start immediately on your plan of corrections.
And typically,
within the next day or two, I've never experienced in
it being more than a couple days
that that report is final.
And then once you put your plan of correction in
and submit that, they are quick in reviewing those
plan of corrections.
They're very collaborative as far as--
If they have questions or they're not sure if they need more information.
Whereas other organizations I've seen, they want proof...
that all the things have been completed,
not that Joint Commission doesn't either.
But they require-- other organizations require you to take pictures,
to give invoices.
Joint Commission shows more to trust that you are completing the work.
And then that once submitted, can get your letter
so then you can submit it to start
the process so you can bill for your Medicare, Medicaid.
Is that helpful?
(Rommie) Absolutely, thank you. Thank you.
There are two other questions, one is about the SAFER Matrix
and SAFER Dashboard.
I think this is for all three panelists, so whoever wants to jump in,
but the question is:
can we hear a little bit more about the SAFER Matrix
also SAFER Dashboard?
(Karen) Sure, I'd be happy to talk a little bit about that.
The SAFER Matrix is a wonderfully color-coded diagram,
just where the issues that have been identified
during the survey, where they fall.
Just in the light of a lot of diagrams where you look at things
that are going from increasing severity.
The higher up and the more towards the right
is a little higher severity.
(chuckles) We tend to talk about it during the survey
and with each other and things like, "Oh, I hope that's a yellow."
(chuckles) "I hope that's one of those pale yellows!"
And then it goes from yellow to the darker gold
to orange then to red.
And I remember someone just referring to it
as a "Ketchup Area", you don't ever want--
like you don't want to be in the ketchup area.
So it's just a way of looking at where is, as you go from there,
that lower left-hand corner, light yellow,
that means it's a problem, it's a citation something that you need to fix.
But it happened maybe once or a couple of times.
Not anything that was a pattern.
It was just a single issue.
If that same issue had happened and it was a pattern
throughout your organization, that would go,
even though it was a lower level, it would go over towards the right
and you'd see it on the lowest level but over to the right-hand quadrant.
I'm going to say 'quadrant' but I think it's actually three sections,
I don't have it in front of me right now.
And then if you had something a little higher,
if it's more related to safety infection prevention,
just patient safety, that's higher up you go.
Single issue is in the left-hand side and then if there's a pattern
that they're seeing, it goes over to the right-hand side up high.
So I tend to-- it's at a glance, and I love to use that phrase
because you can just take a glance at the SAFER Matrix
and you can either sigh a relief or you can say, "Ooh, goodness!
We have some work to do before we know that
we're going to be the safest place for our patients to go."
So that's what the SAFER Matrix has meant to myself,
to my staff.
And to the physicians who own the organization.
I'll tell them, "Just look at the colors."
Don't get too concerned about those little yellow.
Those are things that are easily fixed and that's-- it's--
we knew sometimes these things just happen.
But there's things to fix.
So I think the SAFER Matrix was a great visual tool
to use, to understand...
how you're doing in your journey towards accreditation and zero harm
as Dawn talked about.
(Kathryn) Yes, this is Kathy and I would have to agree
with everything you said.
I think our leadership is thrilled with the SAFER Matrix.
So years ago and as many other accrediting bodies,
the way they send out their survey findings,
it's in a paragraph form,
just a lot of words on a page
and pages and pages and pages of a lot of words.
So you really have to spend a bit of time to get a feel for...
how are these findings, how severe are they,
what is going to be the impact to patient care,
patient harm?
It required a lot of work and now with the SAFER Matrix,
it's a bird's eye view.
And immediately, you look at one page and you can see right away
if a center is in need of a lot of resources,
a lot of time.
You can just look at that page and say,
"Oh, this is going to be quick.
We only need to get a few people on this,
we need to get a lot of people on that."
So it saves a lot of time.
And it also helps, if there are many findings,
which happens sometimes,
it immediately, when you look at it, you know how to address them.
You know in what order they should go in
because the findings are laid out in regards to their ability
to cause harm to patients.
So you just start with those ones
that are at increased risk of creating harm
and you work your way down to the ones that are...
lower level.
I think it saves a lot of time and really, again,
helps you stay organized and provides that structure
for how to then tackle the plans of correction.
So we love it.
(Rommie) Great, thank you for that feedback.
As we come close to time, there's just one other question,
this is around price.
The question is, what factor did price play in your decision
to go with Joint Commission?
So I can see where this question is coming from,
we definitely-- we talked about quality, the tools and resources.
But this gentleman here specifically is asking
what factor did price, if at all--
I know a couple of you have experience with other accreditors.
But did price play a role, how did you look at that
as an organization?
If you could share a little bit about that.
(Karen) This is Karen, I can probably address that
because we're a new organization starting out.
Cost was a significant issue and it was something--
that's why I felt obligated to look into a couple
of other organizations.
At first, I thought it looked like there was a big difference
in a few of the organizations, how much it would cost.
And then I-- it's pretty simple with Joint Commission.
There's an application fee, there's a fee for the survey
for however many procedures you'll be doing in a year,
what the plan is.
And it was pretty straightforward.
When I saw another organization,
I thought, "Ooh, that's a lot less expensive,
perhaps I should look into that.
Maybe I should see what that's--"
But then when I asked a few more questions
that it wasn't true, it was going to be just about the same exact price.
And I thought, "Now I know what I'm buying,
why not get The Joint Commission for our accreditation."
So we stuck with it.
But I didn't really noticed that much of a difference in cost
when you really looked at what you're getting
and what's included in the accreditation fee
because with other organizations, the add-ons is where it built up,
is where the increasing price came from.
That's what I discovered.
(Kathryn) Yes, I would agree with you and I think...
All organizations, regardless of size, regardless of how many years
they've been in business,
cost is always a factor.
Cost is always a priority, especially in healthcare today.
So...
we are continuously looking at costs
and looking at where we can improve
and where is the best value.
So cost is always a consideration.
But it's balanced with value
and the hours that you would spend if you didn't perhaps have
all the resources that The Joint Commission provides.
So we are continuously-- and I would even say
we continuously challenge The Joint Commission
to try to provide the best value for our dollar,
regardless, again, of the size of the organization.
We need a lot of value for our dollar
and we do feel like we've been getting that.
(Rommie) Thank you, thank you for that feedback.
I don't see any other questions come up
so I think we'll probably wrap up or wait maybe a couple of seconds.
But again, it's been a pleasure.
The next slide has some information around how to contact us.
So if you're already accredited, you know that you can definitely reach out
to your contact executive.
For those that are not accredited and you have questions
maybe about the standards, the E-dition, if you have questions around
maybe our standards interpretation group,
if you have questions about getting started,
what you see here is our direct general line,
and email address.
Feel free to reach out to us.
One of our representatives will definitely be in touch with you
to get you started based on your timeline.
We also are in LinkedIn
where we share various resources
with the upcoming change to our standards,
whether it's a tool
or whether it's just showcasing organizations that are accredited.
We do have an active LinkedIn base so feel free to stop by there.
You might make connections that are helpful
for your organization moving forward.
I still don't see any other questions, so with that being said,
I do want to thank you on behalf of The Joint Commission,
our panelists today.
I want to thank everyone for your time today.
And again, this is just an opportunity for us to showcase
what folks see as valuable
and we hope this was helpful.
As my colleague, Gina, mentioned, this recording will be made available.
But again, if you have any questions, please feel free to reach out
to our entire team.
Thank you and stay safe.