(Gina) Hello, everyone. Good afternoon.
Welcome to our webinar
to learn about the Joint Commission's newest accreditation program, Telehealth.
I'm Gina Doruff, the Associate Director of Marketing,
and I'll be the moderator for today's event.
Before we get started, I just wanted to go over,
a few items so you know how to participate in today's event.
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We are recording today's call and all of the attendees
will receive a follow-up email
within 24 to 48 hours with a link to the recording.
And I'd like to introduce you today to our speakers.
First we have Zach George.
Zach is the Executive Director of Ambulatory Healthcare Accreditation
at the Joint Commission
where he leads strategic planning, business development,
and external relations with industry and state associations.
Christina Cordero is the Senior Project Director
of Healthcare Standards Development.
Christina was the lead on development of the telehealth standards
for this new program
and then we have Sheila Chapman.
Sheila is the Field Director of Survey Management
and Support Accreditation and Certification Operations.
In this role, Sheila is responsible
for the management support and oversight of the surveyors
in the home care and telehealth accreditation programs.
And now I'd like to turn the call over to Zach George.
Zach?
Well, thank you, Gina.
And thank you everyone that is joining us today.
We are excited to announce that the Joint Commission is launching
a new Telehealth accreditation program.
And I wanna thank you all for joining the celebration today.
I'll just share a little bit about our background with Telehealth
at Joint Commission,
the benefits of accreditation for a telehealth organization,
as well as an overview of the program.
Then I'll hand it off to our experts that created the program
in our standards and in our surveyor cadre.
Alright. Next slide. There we go.
So, as you're all very familiar on this call,
during the beginning years
of the COVID-19 pandemic in the United States,
the use of telehealth has increased 154% as a whole,
and then stabilized, and it remains at levels 38 times higher
than in previous years.
With continued support by CMS waivers, states, and payers,
we expect telehealth
to continue moving into additional settings and evolve.
And this successful growth is a top priority for the Joint Commission.
As you know, we are involved in the accreditation
and in the survey of organizations
in all domains of health care,
all domains of health care,
including telehealth,
which I'll share with you in a moment.
The point is reaching patients,
improving access,
improving utilization,
improving equity,
improving the care that is provided
to all people within the country is a top priority.
And for that reason,
so is telehealth.
This successful growth in telehealth
is affording access to more and more people,
improving consistency of health care,
as well as access and utilization.
So in keeping pace with the continuing growth of virtual care
the Joint Commission is providing a new Telehealth accreditation program
for hospitals, ambulatories,
and behavioral health care organizations
effective July 1st, 2024.
The new program provides updated,
relevant,
streamlined standards
that support a very successful
and a very tailored survey process
reflective of contemporary telehealth modalities.
Next slide.
In this dynamic and increasingly significant telehealth channel,
you might ask, "What role does accreditation play?"
When you decide to become accredited,
you're going through a formal process
that is widely recognized in the domains of health care
as well as with regulators as well as with payers.
And it represents that you are showing your patients and your population
that you serve as well as other providers, as well as employees,
that you put top value on the quality of care and patient safety.
And you're willing to go above and beyond with an accreditation process.
Accreditation is an easy to identify confirmation of quality.
Being accredited with an organization supports your organization's identity
and has set you apart from other organizations.
Payers recognize and often,
put value in being accredited in conversations that you have
and building the relationships with the payers.
So there are many reasons to pursue accreditation,
and we really wan to present this to you all because as you know,
in the telehealth field, it is largely unaccredited.
This is something that we definitely look forward to helping to remedy.
Next slide.
Now now the Joint Commission offers,
a very comprehensive framework
to help you establish consistent approach to virtual care,
reducing variation
and unnecessary risk or harm to patients.
It's all about reducing variation,
and that's something that the Joint Commission has established
a very successful structure for accomplishing.
So the Joint Commission Telehealth accreditation is a standalone
three year accreditation program called Telehealth Accreditation.
It's no longer incorporated
within another accreditation program,
like ambulatory or behavioral.
It now is its own accreditation program.
It creates, once again, a framework that helps reduce unnecessary variation,
and it is a set of standards
that have been built by advisory panels and experts
and existing customers over the years.
You'll learn more about those standards in a moment.
Our surveyors in this virtual survey structure
are also experts in the field of telehealth.
They are also employees of the Joint Commission,
meaning that they are performing a good volume of surveys.
They have history in surveying this field
and they understand the details and challenges
really associated with the day-to-day activities
of a telehealth practice.
So the Joint Commission, unbeknownst to many,
currently accredits over 120 telehealth organizations.
Now over the years, we have been surveying these organizations.
We've been updating our standards.
They've been involved in multiple advisory panels
and are constantly engaged in creating what we believe is now,
a highly effective
and very Telehealth-specific accreditation program.
Now one of the biggest benefits of accreditation
with the Joint Commission, in general, is that gold seal.
First of all, that gold seal hangs on the wall
of more health care organizations
around the country than most symbols.
And at the same time, it's something that our telehealth organizations
are hanging on the wall of their web page or on their business cards
or in any electronic communication they may use.
And that's very recognizable.
It is an easy to identify confirmation of quality
from the leading performance improvement organization, the Joint Commission.
Being accredited by the Joint Commission supports validity multiple ways.
It strengthens confidence with patients.
When a telehealth organization is accredited by an accredited body
that is well known for accrediting other in-person settings,
they can have the confidence
that the patients are receiving the same quality as in-person encounter.
It also facilitates payer contracting and reimbursement discussions.
Payers are very familiar with the Joint Commission
as the gold standard,
and we have a dedicated payer department who collaborates with payers
to support the inclusion of accreditation and certification requirements
for network providers or in value based performance initiatives
or centers of excellence designations.
Another thing that the Joint Commission accreditation enables is
it promotes alignment with other provider organizations.
These standards are in have many common qualities,
and they do align with one another throughout the continuum of care.
And these are the organizations that you're going to be partnering with
to serve your communities
or perhaps to provide telehealth services with.
That alignment causes tremendous efficiencies
and also grows confidence in the relationships.
Finally, the accreditation with the Joint Commission
helps facilitate credentialing.
Joint Commission accredited Telehealth organizations meet regulatory requirements
for telemedicine credentialing
and are qualified to conduct credentialing by proxy.
Next slide.
Now this program was developed for health care organizations
that provide telehealth care treatment services.
Obviously, the first checkbox,
any organization that is 100% telehealth is eligible.
If you are exclusively or only providing care treatment services by telehealth,
then this accreditation is for you.
This includes all modalities as well, real time interactive, asynchronous,
remote monitoring, and behavioral health and human services.
Now the important thing is that it's just telehealth exclusive.
Those organizations that are offering telehealth in addition
to in-person care for their own patients,
that telehealth is not separate.
That's part of an integrated omnichannel approach
to serving their patients.
Those folks are still able to be accredited
under their traditional hospital or ambulatory manuals.
Those manuals will cover that because there is a physical location.
There is on-site care.
This is specifically for those organizations
that are 100% telehealth
and do not have any physical interaction with patients.
So the consensus based requirements
that we have developed were input from a technical advisory panel
of telehealth experts, current customers, as well as industry experts,
as well as feedback from internal and external stakeholders.
So many of our Telehealth standards will look familiar
to any of you who have been accredited elsewhere.
That's because they align with the current requirements
in other Joint Commission accredited programs.
However, they are some of the top topics relevant to Telehealth
on the minds of CMS, states, payers.
And that is credentialing and privileging,
the information management structures and processes you have in place,
leadership,
structure and governance,
medication management by a telehealth organization,
patient identification and documentation in the record of care.
Now at the same time,
during our time over the years
in this field and with feedback
again from external advisory panels,
we've curated a specific set of standards
that target the most current and pressing quality and safety concerns
specific to telehealth:
equipment devices and connectivity,
streamlined emergency management requirements,
expanded requirements regarding the written agreements
and policies you have with any organizations
to whom you provide telehealth
and also some new standards relevant to provider and patient education.
It has to do with receiving and delivering care by way of telehealth.
So I'm not going to belabor those because my partner, Tina Cordero,
is gonna go through the details for you.
But if we go to the next slide,
I just want to point out the Joint Commission is
a terrifically resourced organization,
and we understand you have many questions throughout an accreditation journey.
So while we provide a wealth of convenient online resources and tools,
there simply is no substitute for one-on-one support when you need it.
So count on our Business Development team
to help you through the application process
and provide exclusive access to the informative preparation resources.
After you apply, you're going to meet your Account Executive
who becomes your long-term point of contact
with the Joint Commission.
They are there to support you during your initial application
and your ongoing accreditation over the years.
And finally, you're obviously going to interact
with Standards Interpretation Group.
They are internal.
They are here to help you interpret any standards that might be relevant
to growth initiatives or improvement opportunities at your organization.
And then the pinnacle is the Surveyor.
The magic of accreditation is
that time in-person, virtually, but in-person
with a surveyor who's able to find
any areas for improvement with you together.
They're able to share best practises they've seen elsewhere
and then point you in the direction of improvement.
That time together is one of the most exciting parts of accreditation
and luckily, we have our Field Director, Sheila Chapman,
on the line to share more about that with you in just a moment.
And I will just point out once again, we have,
one of the largest libraries of electronic tools and resources
that are there for you as accredited organizations.
I'll tell you, these often are the most helpful
when you do have a new member of the team.
A new member of your team joins
and you want to onboard them about accreditation,
about Telehealth, that's when you use these resources.
So before I pass it off to Sheila,
I just wanted to thank everyone that has shared their voice over the years
and really helped us develop this new Telehealth accreditation.
And they also have shared a lot of positive feedback about the accreditation
that we have been offering already,
again, to over 120 organizations at this point.
I'm just going to share a few of those.
First of all, Bright Heart Health
was one of the first to point out that when they first got started in telehealth,
"I knew that there would be some suspicion around providing treatment online
and people would question the quality of care that we are providing."
Does that sound familiar to anyone?
"I knew I needed the top of accreditation I could get,
so I reached out to the Joint Commission.'"
And next,
Avel eCare is another fantastic organization
that we work with, and they have said, "Our surveyor was a tele-radiologist.
They understood the industry and it was really valuable survey.
There wasn't a whole lot of introduction to what the industry of telehealth is,
but more of how the standards apply to telehealth
and how he could help them improve their processes."
This is just a small sampling of the feedback we received,
but I thought I would share those with you today
just to show that we look forward to talking with you
about building a similar relationship in the long-term
and really helping you take full advantage of the accreditation
with the Joint Commission.
So with that being said, I'm going to hand it off to Tina Cordero.
She is our standards expert here who developed this program.
I give her a lot of credit for that.
So thank you very much. Take it away, Tina.
Alright. Thanks, Zach.
On the next slide,
I just wanted to take a few minutes here while we're all on the call today
to give a brief overview of the standards
and highlight some of the key components of what we have in this new program.
I will say for those of you
who are looking for a deeper dive into the standards,
we'll have a second webinar, probably sometime early to mid June.
So we'll make sure that we get information about that
but there'll be a kind of a longer walk through the standards in a separate event.
So this is just to give you
a bit of a highlight of what's in these manuals
and then again, we'll have some additional education
as we move forward.
So as Zach mentioned the standards
provide this framework to address the structures and processes
that organizations need to provide
safe high-quality care using a telehealth platform.
So the chapter structure within this manual is very familiar
to those of you who are familiar
with our other Joint Commission accredited programs
or for those of you who are partnering or contracting your services
to a Joint Commission accredited organization.
So the structure of these standards, a lot of the standards are very similar.
So the requirements that you as a Telehealth accredited organization
would be following the same requirements that we have
for many of our other accredited programs.
There are streamlined standards within this program.
I'll highlight a couple of those.
Shared expectations, as I mentioned, that are across programs,
very similar expectations across programs.
And then we also did incorporate a few new standards
and add a little more specificity around telehealth
because we felt there were there were opportunities to improve our requirements
and add some more quality and safety issues
that are specific to the telehealth encounter.
We know that not all telehealth organizations are the same
this isn't sort of a one size fits all program.
There's a lot of variation in the applicability based on the modality
that you're using or the service that you're providing.
So we have a standards applicability grid that was able to
filter the standards that make the most sense for your organization.
And then compliance with these standards will be evaluated
during an off-site survey process
that Sheila will talk to you in a few minutes.
On the next slide, just a brief overview of the standards development process
because people always wonder, how do we develop these standards?
So the first thing that we did is we looked at the existing requirements,
the legacy requirements that we had across programs
to identify opportunities to streamline those requirements
and adapt them to the telehealth organizations.
We also did a literature review
to identify any emerging quality and safety issues
that were specific to the telehealth environment.
We did three different technical advisory panels
with experts in telehealth
as well as current customers to get feedback on the existing products
that we had in telehealth and to start to build consensus
for the new requirements that we were drafting.
We also had customer feedback on the proposed standards
and an opportunity, as Zach mentioned,
to get some input from the field.
And then we've continued to refine that virtual survey process
in order to evaluate compliance with these requirements.
So just to talk a little bit about, on the next slide,
the streamline opportunities
because we know that, again, your telehealth organizations
that are either exclusively telehealth
or organizations that are providing services via telehealth
to another organization's patients.
So you see them in a virtual setting
and you're never seeing them in-person encounter.
So we didn't need any of the standards
that we would typically have in our accreditation manuals
around Environment of Care, physical environment,
fire safety utilities,
because again, there's no patients or individuals served in--
you don't have brick-and-mortar facilities.
We also didn't need infection prevention and control standards
although we did maintain some components of those chapters
in other requirements within this program.
We didn't use our traditional standards in these areas.
Emergency management, we can just skip to the next slide,
is a great example of how we tried to take an existing standard that we have.
We wanted to preserve
the key components of emergency management
but tailor that standard to a telehealth organization.
So this is the content of the exact standard
that we're talking about in an emergency management chapter.
We still want organizations to perform
a hazard vulnerability analysis to identify potential emergencies
just like we would expect for any of our accredited organizations.
But we know that telehealth organizations are structured in a different way.
So we wanted to be able to accommodate
the fact that organizations may want to include
their business occupancy location, if you have one,
or remote provider sites,
if that's how your organization is structured
and be able to incorporate
those two different types of areas
into that hazard vulnerability analysis for emergency management.
Communication plans during an emergency,
again, we expect all organizations to be able to do that,
but we're specific here in the Telehealth program
that we wanna make sure that your process includes notifying your office staff.
If you have a business occupancy location,
making sure clinical staff are aware,
any external entities that might be receiving services
from your organization under a contractual agreement.
So just trying to make sure that these requirements were flexible
and that they could meet the needs
of the various telehealth models that we're seeing.
Plan for providing care and clinical support.
Again really focusing on how organizations can transfer the care of patients
from their organization to another,
if you're experiencing an emergency event or a disaster incident,
and how are you sharing information and medical documentation
with different organizations
or with providers depending again, on what the emergency is
and how your organization is structured.
On the next slide,
just talking a little bit about some of the shared expectations.
I won't read through all of these,
but just to point out that there is a lot of familiar work--
there are a lot of familiar requirements in this program
that are familiar to you if you have experience
with Joint Commission accreditation products
or if you're working directly with an organization that is accredited.
So as I mentioned, the standards that other organizations have to comply with
you also as a telehealth organization in this program
will also be complying with many of the same requirements
around staff qualifications,
credentialing and privileging, information management,
structure and governance in leadership, performance improvement.
There's a lot of foundational requirements
that are very similar and consistent across our different programs.
On the next slide, I think the first question we would get
when we first started talking about this program is,
"Did we change anything around credentialing and privileging?"
Because a lot of our organizations want to maintain that consistency
with what our expectations are across programs
because you're want to maintain
the same compliance with credential privileging
as perhaps the hospitals
that you might be working with and partnering with.
And so this is just a snapshot, again, of the standards
and some of the highlights within the requirement.
What we have in the Telehealth program
for credentialing and privileging
is identical to what is in our current accreditation program
for ambulatory care.
So if you're an organization that was in ambulatory
or sort of familiar with those requirements,
nothing has changed there.
As far as the requirements we have for behavioral healthcare and human services,
the standard is listed here.
Those components are equally reflected
in the new Telehealth program.
Some of them are at different locations
but all of the original requirements that we had in behavioral have been preserved.
On the next slide,
just to talk a little bit about clinical practice guidelines.
This is a legacy standard we've had for years
but we just adapted it to the telehealth environment.
We know that for some settings and specialties that you're providing,
there aren't clinical practice guidelines
or there may not be industry recommendations available.
So we know that that may be the case,
but when they are available
we want to make sure that our accredited organizations
are incorporating into the different processes that they have in place.
And so here we just provided some examples
and we just acknowledge that
there may not always be clinical practice guidelines
and industry recommendations that you can use,
but if they are available, we do encourage organizations to do so.
So on the next slide, this is just again,
an existing standard on accepting patients
and we added a little bit more specificity here
for telehealth organizations.
"The organization accepts a patient or an individual served
for care, treatment, and services delivered via telehealth
based on whether the scope of services
can meet the patient or individual's needs."
So this is really about your organization creating criteria, developing criteria
for which patients you can treat via telehealth
and which may be outside of the scope of your service.
We're not prescriptive on what is or is not appropriate.
This really depends on the type of organization that you have,
the type of services you're providing via telehealth.
Our surveyors will just want to know and really want to hear more
about what that criteria you have are
about accepting patients and then what's your process
if they don't meet the criteria that you have--
you're not able to provide services at the time.
So new requirements, again
I'll just talk through a couple of the highlights.
There's a lot of different standards
that we incorporated into this program.
We have a new chapter on Equipment, Devices, and Connectivity,
which kind of replaces our old chapter on Environment of Care.
This is really focused in on what's important to telehealth organizations
in terms of the equipment and devices
that you provide to your staff or to patients
as well as how you manage and respond to disruptions and connectivity.
I'll go to the next slide just to show you the content of that standard itself.
As I mentioned, it's really focused on procedures
for responding to disruptions in connectivity.
What is your process for rescheduling
or transferring patients to another provider
if you have a disruption or if there's a possibility that
that telehealth encounter can be converted to audio only.
Again, that sort of depends on
what types of services you would provide,
but we just want to create that flexibility for organizations
to make these types of requirements fit with what they're doing.
On the next slide, Information Management.
This is really about making sure that organizations have
the technical infrastructure in place
and that capability to transfer information from one location to another
to meet the needs of your organization.
And so we don't have very specific technical specifications
about what that needs to be
because we know your organizations are probably all doing different things
and you may have different modalities in place
that require a bit more on the infrastructure side than others.
So again, we left flexibility for organizations
to identify what technical capabilities they need
and then our surveyors would be interested in hearing about what those are
and then how you make sure that you can maintain that infrastructure
so you can provide care treatment and services via telehealth.
Staff Education and Training.
We've always had requirements around what staff needs to be educated on,
what topics need to be included.
So we added here
that the organization needs to provide training
on the use of the telehealth platform and software applications,
trying to make sure that you can optimize
the telehealth encounter,
understand how to provide care in the virtual environment.
We're not overly specific
about what the education topics need to be
because, again, it sort of varies
depending on what care treatment and services you provide,
but your organization can identify what the educational topics need to be
and then we'll want to hear more about
how your staff receive education in those areas.
Written Agreements for Telehealth Providers.
This is particularly for the organizations on the call
that are providing telehealth care via telehealth
to another organization's patients.
And so this is about what you include in those contracts.
So what are your scope of services that you will provide
to another organization's patients?
What are the expectations and the metrics
that you're going to use to measure your own performance?
So that can be, again, just a couple of examples.
It can be provider availability,
timeliness of care, adherence to those clinical guidelines.
So it really just depends on what service you're providing
but we want to make sure that it's outlined,
how are you going to measure data?
What data you're going to collect
and how are you going to measure your own performance
and look for opportunities to improve your services?
What competencies are required for providers
that you have in your organization?
What is the communication process for any unexpected incidents,
adverse events, those types of things.
What is the communication process with the organization
where the patient is located?
And what is the involvement of your organization,
your Telehealth organization in the analysis of those events.
What's included in the contract and how is that relationship established.
And then, again, looking for your organization to evaluate
and take steps to improve the care that you're providing.
Changes in condition of the patient or the individual.
This, again, is a standard in our Provision of Care chapter
that we've always had about assessing and reassessing patients.
But for the telehealth encounter,
again, depending on what types of services you're providing,
we wanted to add a little bit more specificity about
how is your telehealth organization communicating with providers
at that other facility where the patient or the individual served is located.
How are you communicating changes in their condition?
Particularly for tele-ICU organizations, for example,
how are you escalating the care of deteriorating patients
so that the organization where the patient is located
can provide immediate care?
Again, just what's that process to alert the patient site
of any changes in the patient care
or any decision that need to be made
or any additional care that needs to be provided.
This last bullet here is how does your organization notify
the emergency contact or local emergency services
to respond with immediate care
if the patient or the individual served is not in a healthcare facility?
So maybe for some of the telebehavioral healthcare organizations on the call
maybe you have a patient
at a residential facility or another remote site,
what's that process for you to notify someone
that's closer to the patient location
of any major changes in their condition?
On the next slide, I just want to end here.
We mentioned these standards
some of you on the call may be thinking that last standard didn't apply to me.
So we really did try to group these standards by modality
and then telebehavioral health care has their own group of standards
just because there are some very specific requirements
for BHC organizations that didn't apply to everyone else.
And so we tried to group these standards and make them applicable
based on the modality that you're providing
or the modality that you're using.
And so when you go into,
for those of you who have access or when you gain access to the standards,
when you go into our E-dition
and you see see the electronic copy of the standards,
you can actually filter the standards based on the modality
or based on BHC, if that's your type of organization,
and see the standards that make the most sense for you
without seeing all of these other requirements that may not apply.
On the next slide, just a quick example of that.
This is that standard we were just talking about
about assessing and reassessing
and notifying patient location of changes.
You'll see for those of you that are asynchronous organizations,
you don't have any of those standards applicable to you
because you're not really in that same type of environment
where you're notifying someone of changes in someone's condition
that they need to provide immediate care.
But behavioral health care will have that standard towards the bottom here
about having a process to notify the patient
or individual's emergency contact person
or local emergency services if there is a change in their condition
and a need for additional assistance at the patient location.
So with that I will turn it over to Sheila
to talk a little bit more about the survey process.
Great, thank you so much, Tina.
So as we move to the survey process,
we'll go ahead and I'll start talking about our surveyors.
As it was previously discussed and identified,
we do directly employ experienced and knowledgeable surveyors
that have telehealth practice services and platform,
background and experience.
All of our surveyors are master's prepared
or higher in that respective educational background.
And with all our telehealth surveyors,
they participate in ongoing and continuous training and education
so they can stay contemporary
and relevant with the specialty knowledge of telehealth services and awareness
of regulations that impact these services and platforms.
We have changing times
and they keep up to date as much as possible.
Next slide.
So let's talk about the survey process itself.
With the Telehealth program,
we utilize an off-site or virtual survey process.
This will provide a real-time review and analysis
of your organization's compliance
with the Joint Commission standards and regulations.
The surveyors will collaborate with your team
in identifying any known and unknown risks
while highlighting strengths and challenges
within your organization
and providing a thorough written evaluation
at the conclusion of the survey process.
The surveyors will also provide better or leading practices
gleaned from extensive survey experience
and practical evidence based strategies
throughout that survey process with your organization.
The surveyors do pledge to be collaborative
and transparent and open in dialogue
to create an inspiring and meaningful survey
for your organization.
Next slide.
So how does the virtual survey work?
Well, a secure and unique survey SharePoint site
is set up between the Account Executive and your organization.
Your organization will be required to upload any requested
or required documents that's applicable to your teleservice for surveyor review.
Surveyors will review the uploaded documents prior to survey.
This allows a more focused review
of the processes during the real-time event
and offer a true one-on-one engagement with the surveyor.
The surveyor will arrange the off-site platform call through Teams,
which is the Joint Commission preferred platform,
and provides access to your organization for conducting the off-site survey event.
Next slide.
So let's talk about the component
or components with the survey process.
Tracer methodology.
The Joint Commission utilizes
a tracer methodology during survey process.
This tracer methodology utilizes information
from your organization to follow the experience
of care, treatment, or service
for patients throughout your health care delivery process.
These tracers allow the identification
of any performance issues in one or more steps of the process
or interfaces between those processes.
We indicate there's two types of tracers here.
We have individual and system.
Individual tracers follows an individual patient's interaction
with your organization.
This allows actual patients being utilized as the framework
for assessing standards compliance
through the real-time observation during the survey process.
With system tracers,
they evaluate how your organization integrates your related processes
and coordinates that communication across your organization
and outside of your organization.
Next slide.
So three topics that are evaluated by the system tracers
are going to be the equipment,
devices and connectivity, and emergency management,
the competence and credentialing of your staff,
and then also with your leadership and data use involvement in the process.
The goal of these tracers are really
to identify risk points and safety concerns
within the type of care, treatment, or services
that are being provided by your organization.
And it is a thorough review of each of these topics
in discussions with the surveyors.
Next slide.
So let's talk about the SAFER dashboard.
The Joint Commission developed the SAFER dashboard
to provide your organization with a visual approach
of identifying communicating risk levels
associated with deficiencies cited during the survey process
through scope of impact
and the likeliness to harm patients or individuals.
The SAFER dashboard allows your organization
to see one comprehensive visual representation
of the areas that are non-compliant at an aggregated level.
This helps to prioritize your resources and focus corrective action plans
in those areas of most needed compliance activities and intervention.
It also breaks it down to that visual
to prioritize so you know where to start first
and then move further down
things that necessarily don't take as many resources
or won't need to take as much opportunity and time for corrective action.
Next slide.
Let's talk a bit about how to prepare for your survey
and here's some tips for success.
So first of all, take a look at your standards.
You should get the ability to review those standards prior to.
Utilize the self assessment prompts and any of the checklists that are included
to identify any gaps in compliance.
This is really a self-assessment to start the process.
Gear yourself and your team up. Have that right mindset.
Rather than ramping up just before the survey,
make this part of your quality and safety routine
as you move through the process of everyday activities.
Ensure that you involve your team.
Involve the direct team that will participate in the survey process,
but also any ancillary teammates that could be actually supportive.
Discuss this accreditation process with everyone.
Get very creative if you'd like,
create multiple champions to participate
and write it on the wall.
Share it across your Continuity of Care
with the team members and ancillary team members.
Right before, as you get started with accreditation process,
your Account Executive starts a road map
for just accreditation in general, how it starts,
but develop your own road map with your organization
so that everyone knows what's going to happen, how does it go,
where are you at in the process?
Make it transferable.
This will serve as a storage point
for your tools and documents that are important to the survey process
that makes it easier to access and to share across your organization
and also with the surveyors.
Also, make the most of the experience in your one-on-one time with the surveyor.
Ask questions.
As I identified, surveyors are going to pledge to you to be collaborative.
They'll be transparent and open to all dialogue.
They will work with you
in identifying any known and unknown risks within your organization
and actually discuss those with you.
We are here to help you, your staff, and your organizations
to improve and to succeed.
But make sure that you understand the requirements for improvement
and this is helpful by talking with the surveyor.
Again, they can suggest and share with you better and leading practices
from their experiences and successes
that they've participated in and have seen with themselves
in their experiences and with other organizations.
And then also, as follow-up to the survey,
share all your findings with your team and the ancillary teammates.
Get them to understand the known and any unknown risks that were identified,
and any underlying reasons for that non-compliance,
because sometimes you don't know what you don't know.
And then develop a plan to eliminate these issues
and utilize that information shared by surveyors
and any evidence-based resources provided and shared by surveyors
to help develop that plan for compliance.
Next slide.
And Joint Commission,
they also utilize a continuous process improvement platform
for improving our survey process,
survey experience,
and also with our surveyors
that provide the meaningful
and hopefully inspiring survey to your organization.
And some of the activities and strategies
for that compliance improvement is utilizing feedback
from our organizations based on their post-survey evaluations.
Also during feedback,
during discussions real-time with the organizations during the survey,
and also with any calls with our staff members.
That could be with Account Executives
or the Standards and Interpretation group
or also with the Field Director in regards to that survey process.
So please utilize your voice and share your feedback with us.
We cannot improve if we don't hear from you, our customer.
And with that,
what we'll do now is we'll go into our next steps
of how to obtain that accreditation
and I'll send this back over to my colleague, Zach.
Well, thank you, Sheila.
Thank you very much for sharing that about the collaborative survey experience.
Again, that is really one of the most outstanding elements
of a Joint Commission accreditation,
and that is largely thanks to Sheila and her team.
So I just wanted to cover the steps to becoming accredited.
This is something that we've fine tuned over time
as well to become a very efficient process.
The first thing is,
we actually have you connect with one of our Business Development representatives.
We do have a general email address you could use,
which is ahcquality@jointcommission.org
If you wish, you can email that email address.
If you're visiting our website as well on our Telehealth pages,
there are a variety of places where you can request the standards
or request for us to contact you.
You can also go that route.
But that's the first step
because we actually want to walk you through the process,
hold your hand throughout that process.
Before you apply,
the Business Developer representative will provide a standard and, I'm sorry--
they will provide you acces
to the standards in E-dition,
that's our online standards manual.
You want to review those.
You want to make sure you get your questions answered
with that BD representative,
and then you'll want to identify a ready date
for your initial virtual survey.
So just think about how long until we think
we'd be ready for that first virtual survey.
At that time, you will also, with your Business Development representative,
will take you into the Connect portal.
We'll walk you through the e-application,
and we'll help you to submit that.
Now that application is available on July 1st.
Your Business Development representative and you have plenty of time
to walk through the standards and walk through the process before then.
Now I will let you know, as an aside,
that we are offering a pre-application prior to July 1st.
So, for those of you that
were already considering Telehealth accreditation
with Joint Commission
that are excited about perhaps being one of the first to be surveyed.
We do have one page pre-application form that is available
on the jointcommission.org website
that you can fill out
that will put you in touch with the Business Development representative
and it also allows you to identify
a ready date for your initial virtual survey.
In that way, prior to July 1st,
you can communicate your intention to apply,
and you can also communicate when you would like to be surveyed.
Now you'll still have to go back on July 1st with your BD representative
to actually submit the application.
But what the pre-application does is it informs us,
and we're able to share that with the survey and the scheduling teams
so they can be aware that you are going to apply on July 1st
and you're hoping to be surveyed shortly thereafter.
That is the application process.
On July 1st it becomes available.
But if you want to pre-apply, you're also able to do that.
And then the final step is that initial virtual survey
that is scheduled according to your identified ready date,
but not before.
We provide a survey activity guide that will give you
all the steps you need to know to prepare for the virtual survey.
And, again, in most cases, this indeed will be one surveyor for one day.
One thing I also wanted to point out that I realized we left off of this flowchart.
In between the time you submit your application
and the time your survey takes place,
that is where you meet your Account Executive.
Your Account Executive becomes your primary point of contact
for this initial survey, this initial accreditation experience,
but also over the years as you maintain accreditation.
One of the most important parts of this flow is that you will meet
that Account Executive shortly after you apply.
I can't believe it's not on this flowchart
because that's probably the most important person you will meet,
over the years,
because they are there to continuously support you.
Regardless, the process is something that could take a short period of time.
It's something that you could-- some organizations take six months,
other organizations are ready in a week or two.
So it really is something that is up to you, but...
we're here to work with you and make sure that you feel comfortable
with your own timelines for being surveyed.
So with that being said,
I'd say we have a good amount of time, 11 minutes.
So we're going to go ahead and open it up for any questions that may have come in.
Again, type those in the chat.
We have a few already
but if anyone can think of anything in the meantime,
go ahead and enter those into the chat.
(Gina) Alright. Thank you, Zach and Christina and Sheila.
As Zach mentioned, we are going to address our questions now.
First question that came in is,
"So this is not for an integrated health care system.
What if we are providing services
that are telehealth in nature outside of our system?"
Okay. I'll clarify that one.
So the question here is,
what if we are providing services that are telehealth in nature
to somebody outside of our system?
So if that is contracted services
that you're provided externally
to an external organization that's not part of your system,
then that is something that may be eligible to be accredited.
And the reason why is because that is separate
from your treatment of your own patients through an integrated healthcare system.
In other words, you might have on-site and telehealth
that you're using to serve your own patients
in this integrated healthcare system.
If at the same time,
you're offering telehealth services to an external organization,
you're assisting them.
So for example,
you're a hospital and you're contracting
with a small critical access hospital that's not part of your system,
but you're contracting with them to provide that telestroke consult
to their emergency room doctors.
That's an example where that is something we could accredit
because it is separate and it is exclusively telehealth.
That's on a case-by-case basis, for sure.
So we would want to connect with you,
and we can definitely talk through your scenario
and what you have structured, and we can determine
But I think there's a good chance
that'll be eligible for the Telehealth accreditation.
(Gina) Thanks, Zach.
Next question.
"Is a standard applicability grid available yet?"
I can answer that one.
You'll still have to get access to the standards first.
So if you contact, as Zach mentioned,
you can contact the email address here
and someone from our team will reach out to you
to provide some information on how to receive access
to the electronic standards, which we call our E-dition.
And in there you should be able to see
a standards applicability grid,
which looks very similar, if you're familiar with our previous products.
There's a PDF document where you see just a chart
that has check boxes for the standards that apply to different modalities.
So you can do it sort of the old school way,
or you can filter the E-dition, the electronic standards,
and based on the service profile and click in which modalities you're using
or what services you're providing
and then it will electronically filter the standards
so you can see which standards apply to your organization.
So the first step is just to make sure that you can get access to those standards
but then that applicability will be accessible through that system.
Brilliant.
One other thing I'll point out, we are going to email everybody
that's on the call today with some instructions.
It will have the contact information for your BD representatives
as well as instructions for us to obtain those standards for you.
We will send you an email with further guidance on that.
Okay.
(Gina) Next question.
"On one of the survey slides,
it indicated competence and credentialing will be surveyed.
Can you speak more to this?
Are you referring to the competencies credentialing for that of the provider?"
I can answer that one.
With the competence and the credentialing, it is for your staff individuals
that are providing the service
or the teleservice dependent,
and it will be relevant to their educational background,
and the applicability if there is credentialing associated with it.
So it is a review of all the HR information.
And again, when you get that listing of required documents
to upload to that secure SharePoint site,
it will also indicate certain aspects within the HR file
that they will need to review
and also with the credentialing side as well.
Any indicative and applicable information will be identified at that time for you.
(Gina) Thanks, Sheila.
Another question that came in.
"What is the pricing structure cost for this accreditation?"
Oh, thank you very much.
So the pricing structure is the same that we use for all our accreditation programs.
We prefer to break the fees down into an annual basis.
We have an annual fee
that is invoiced January of each year.
And then at the same time after the virtual survey,
you will receive an invoice for the virtual survey.
So that takes place only after the survey.
So in the event that we do have a delay, such as we did with the pandemic,
there are no costs incurred until the survey takes place.
So again, it's a combination of annual fee
and then every three years you'll be invoiced for the survey fee.
The amounts actually are gonna be based on the size
and the complexity of your telehealth organization.
So it is really hard to say, here's what the price is for that.
But it's very comparable to the prices
we currently have with our ambulatory and behavioral programs
as well as our other accreditation programs.
(Gina) Thanks, Zach. I think we have time for one more question.
This person asks, "I manage a large telestroke grad program.
We are an academic hospital, partnered with 34 rural hospitals.
It's a very well-established program.
Not sure how this will be applicable for us."
First of all, thank you for partnering with those 34 hospitals.
Telestroke is so essential.
That system of care needs you to be assisting those emergency rooms.
So thank you.
So because those are external to you, those hospitals,
as long as they are not your hospitals, they are external,
which I imagine they are in this scenario,
then because that is a separate operation
outside of your own comprehensive stroke center, let's say,
because that is separate,
that is something that you that might be eligible
to receive a Telehealth accreditation.
Right now that's not necessarily included under your hospital accreditation
because it is this external service
that you're providing someone else's patients.
It is a a stroke center, though. It is a telestroke.
Those patients might end up coming to you.
So in the end, it is something let's just jump on the phone to discuss that.
That is exactly the type of organization we're hoping this will be applicable for.
(Gina) Thank you, Zach.
Well, I want to thank everyone
who took the time to join us today
to learn about our new accreditation program.
As I mentioned in the beginning of the call,
you will receive an email within 24 to 48 hours
with a link to view this recording as well as some additional information.
So on behalf of the Joint Commission and all of our presenters,
thank you for joining us today and I hope you enjoy the rest of your day.
Thanks again!