(Donna) Hello, and thank you for listening to check in with The Joint Commission
for Ambulatory Care Services.
My name is Donna Rutkowski,
and we're delighted to be able to spend some time with you.
Today, we're going to let you know what's new and what you need to know,
regarding standards updates,
and permission regarding actual survey process,
current RFI and frequently asked question information.
And then, we'll talk about AMP for ambulatory healthcare,
which could be helpful with compliance.
And I'll also tell you about some upcoming educational conferences
you may be interested in for your team.
So, we'll send you both these slides and a recording to you via email
a few days after the recording comes in,
so most likely, either tomorrow morning or Monday.
Who you'll hear from today is Joyce Webb
from our Department of Standards and Survey Process.
Dana Dunn, Field Director for the Ambulatory Program,
Liz Even from Standards Interpretation Group,
and Bhavna Mishra from Joint Commission Resources
to tell you about AMP.
With that, I'm going to turn it over to Joyce,
who will help you learn what to expect regarding standards updates.
(Joyce) Thank you, Donna.
So I'm going to cover our standards that have gone into effect,
earlier this year, specifically starting this month, July 2022.
And then, standards that will be going into effect
as of January 2023.
So let's begin.
There are new COVID vaccination standards and elements of performance
for deemed ambulatory surgical centers.
There's a new standard in the Infection Control chapter
at IC.02.04.02
and several new elements of performance.
Those went into effect as of January of this year.
And they address the fact that all staff who provide care treatment and services
must be vaccinated,
regardless of their level of political responsibility
or patient contact,
and that includes your contracted staff.
We do have provisions for exceptions, and I'll cover that as we move forward.
We require also that you have policies and procedures in place
that ensure that all staff received COVID-19 vaccination
before they began providing care treatment or other services,
that you have policies and procedures in place
that track and document staff vaccination boosters, and any exemptions.
And also, policies that address what precautions are you putting in place
that would help mitigate transmission and spread of COVID-19
for any staff who have not been vaccinated or not been fully vaccinated,
as well as some contingency plans.
Policies and procedures need to address
those contingency plans that you have in place
for staff who are not fully vaccinated.
These requirements, the detailed language,
I encourage you to go to
The Joint Commissions' Prepublication Standards page
on The Joint Commission website
and download the exact language of these requirements
so you're familiar with them, share them with your team,
and you want to ensure you're compliant with them.
And for more details, background on these requirements,
you can refer to your May 22 issue
of The Joint Commissions' newsletter, Perspectives.
Next slide.
Now we also have new requirements that will be going into effect
beginning of next year.
And they address healthcare equity.
There's a new standard in the Leadership chapter.
You'll see here LD.04.03.08,
and there's six new elements of performance
that will be going into effect.
They really address-- they require that you address healthcare disparities
as a quality and safety priority.
These requirements apply to those settings of care
that provide primary care.
They're not applicable to settings that provide only episodic care,
only dental care,
and they do not apply to ambulatory surgical centers.
These new requirements
specifically require you to designate
an individual or individuals, with an s,
to lead activities to reduce healthcare disparities.
These elements of performance require you to assess
your patient population,
to assess patient's health-related social needs,
and then provide information
about what resources might be available,
if support services are available
to assist them with their health-related social needs.
There's a requirement that requires you to identify healthcare disparities
within your patient population and development action plan
to address at least one identified healthcare disparity,
put [circles] to address that identified healthcare disparity,
and then act when the goal that you have set,
or goals that you have established are not achieved or sustained.
And then at least once a year inform leadership,
inform your licensed practitioners, your staff, all of those key stakeholders
about how you're progressing towards your goals
to really reduce healthcare disparities.
Next slide.
More requirements that relate to healthcare disparities.
We have a new requirement in our Patient Rights chapter
at RI.01.01.01, element of performance 29.
This requirement may seem a little bit familiar
because this has been in place, some of this collection of information
has been in place in some of our programs already.
But there's a new location for this EP
and there's more detail added to the element of performance.
We require that you prohibit discrimination based on age, race,
ethnicity, religion, culture, language,
disabilities, socioeconomic status,
sex, sexual orientation, gender identity or expression.
And there's a requirement at the Record of Care chapter,
RC.02.01.01, element of performance 25,
that was revised.
And the collection of patient race and ethnicity information--
that was moved to a new EP where we felt that it better fit,
and that is located now at RC.02.01.01
at element of performance 31.
These changes go into effect January 1, 2023.
The language for these requirements,
these new healthcare disparity requirements,
are currently posted on the Prepublication Standards page,
so I encourage you to go there and get that language
and share with your team so you're familiar with it.
And for more detail, see the January 2022 Perspectives.
Next slide.
We also have some new and revised Environment of Care requirements
that apply to ambulatory healthcare organizations
and OBS practices.
These changes really seek to clarify expectations
and align with NFPA codes,
National Fire Protection Association codes,
and there were a couple of deletions at EC.02.03.05,
the two elements of performance that were removed
because our engineers determined that most organizations
no longer have water storage tanks so that was no longer needed.
These requirements went into effect in January-- July, I'm sorry.
Went into effect July 1, 2022, so they're already in effect.
And for more detail, see the January 2022 Perspectives.
Next slide.
We have some revised requirements in our Patient Rights chapter.
Specifically, RI.01.03.01, EP 1 was revised
and a new bullet was added
that requires that organizations have a policy
that addresses who can conduct that informed consent discussion
with patients.
The bullet that addressed circumstances that would allow for exceptions
to obtaining informed consent was deleted
because that is already addressed in your informed consent policies.
So that bullet was no longer needed.
Also, there was a deletion of an element of performance
in the Patient Rights chapter.
RI.01.03.01, EP 3 was deleted.
And that particular element of performance required orgs to obtain
patient's informed consent
before making and using recordings, films, or other images of patients.
It was replaced with a new element of performance
at Standard RI.01.01.01.
This change really was made
because the concept of informed consent
is understood
as a type of consent where you're ensuring the patient is informed
of any potential untoward effects
of the procedure or the imaging that's going to be occurring.
It was determined that was somewhat confusing and unclear,
and this new standard really speaks to protecting patients' privacy
and respecting that
when making or using recordings or other images of a patient.
So it's a more appropriate location for that.
These requirements apply to all ambulatory healthcare organizations.
They went into effect in July 1 of this year.
And for more detail, I will direct you to the January 2022 Perspectives
to get the background.
Next slide.
I've mentioned the Prepublication Standards.
They are a tremendous resource for you
along with the Perspectives newsletter.
The Perspectives newsletter is the official way
that we communicate standards or revision standards, changes.
So be sure you're checking those Perspectives monthly,
Perspectives newsletters.
And this resource here, here's the link to the Pre-publication Standards.
We do post our standards changes six months in advance
so that any requirements that are going into effect in January,
January 1, 2023,
will be posted on the Prepublication Standards,
with the exception of any
where they're having some minor editorial changes.
But any with substantive changes
are posted on the Prepublication page,
so make sure you go there and download the exact language
of any new and revised standards.
It's a tremendous resource for you.
With that, I will hand it over to my colleague Dana Dunn.
(Dana) Well, thank you, Joyce.
I'm going to talk a little bit about survey process,
considering some of the nuances around on-site safety,
questions that surveyors keep getting asked,
and also some common problems seen on surveys.
Next slide.
We've received several questions
regarding what has changed about the survey process.
I want to highlight that if you are currently a survey,
prepare as you normally would any other survey prior to the pandemic.
The survey itself is going to be very similar.
It is highly recommended that while preparing for the survey
to utilize the survey activity guide that is available to organizations
on the secure Connect site.
The guide breaks down the different survey activities
that require documents and policies expected to be in place.
What may look a little different are some of the logistics of a survey.
This may include limiting the number of individuals
participating in group sessions.
It's recommended to use audio and video conferencing
to expand the number of attendees in a session
in order to continue being safe.
The surveyors are encouraged to utilize technology
as much as possible,
and to maintain physical distancing
to avoid prolonged sitting next to each other
while conducting survey activities.
Examples may include screen-sharing
or utilizing the video or audio conferencing tools.
The use of masks, eye protection, and distancing will be a routine practice
until further notice.
We've also asked that organizations please comply with masking and distancing
when the surveyors are on site.
Also, we ask that surveyors to drive in separate cars
to any offsite or satellite locations.
Next slide.
What will the focus of the survey be?
We know every organization has had a unique experience
during the pandemic.
The surveyor or survey team will want to discuss
the impact to your organization soon after arrival.
They'll want to discuss both infection control
and emergency management challenges your organization has experienced.
The survey process will be focused on the current situation
of the organization
and not so much on the timeframe during the public health emergency,
particularly back in 2020.
They want to understand how you were impacted
and how your organization has adapted.
Were there lessons learned?
What changes to policies and procedures were needed?
However, in general, it is expected that ambulatory organizations
are up to date on inspection, testing, and maintenance
of equipment, utilities,
and environmental safety features at this time.
Next slide.
Some of the most common risk areas or requirements for improvement
continue to include infection control practices,
particularly in sterile reprocessing and high-level disinfection
of instruments and equipment.
Other most common cited areas include environment of care
and human resources standards.
The pandemic has had a tremendous impact in all areas of healthcare
and ambulatory organizations are no exception.
The scheduling logistics have been very challenging
for both The Joint Commission and for ambulatory organizations.
In addition, the number of past due surveys
have added to the demand on surveyors,
as we've been working hard to get caught up.
Some major impacts have been due to the changes
in hours of operation, days of surgery,
and also fluctuations of patient volume and staffing.
We've experienced a number of surveys being postponed
after the surveyors arrive,
due to changes in hours of operation
and days when performing surgery have not been updated
in the electronic application.
Also, ambulatory surgery centers, there were surveys
with fluctuating patient volumes have also been impacted.
So when a survey is scheduled and there's not an active patient,
it becomes a problem,
as the survey process requires observation at the care provided
to validate standards compliance regarding patient and staff safety.
The account executives have been working very hard to increase outreach efforts
to ensure we have a successful survey.
Another concern that is more difficult to control has been around staffing.
The latest variants of COVID have been spreading aggressively,
and smaller organizations have experienced unexpected needs to cancel procedures
when staff call out with short notice.
We also appreciate that because staffing has also been impacted
with our surveyors.
And the surveyors have been instructed to not travel if they're not feeling well,
particularly if they are experiencing any COVID-like symptoms.
Sometimes they may also need to be removed at the last minute.
And when this occurs, it's rare to find a short notice replacement,
causing additional delays in scheduling.
In addition to continuing safe practices to limit exposures,
I encourage organizations to make sure they've updated
their electronic application
and quickly notify their account executive when there is an unexpected closure.
Now I'd like to hand off to my colleague, Liz Even.
(Liz) Thank you, Dana.
Hello, everyone. My name, again, is Liz Even,
and I'm one of the clinicians in our Standards and Interpretation group.
I very well may be one of the folks you interact with
if you submit a question online.
So let's go everyone's favorite topic of the Top 10 most scored standards here.
What we have here may look familiar to many of you.
I pulled this data from June of last year until June of this year
for all of those surveyed under the AHC Manual.
A few things that I want to point out.
The data that we had can be sliced in a million different ways.
Some charts may show only deemed ambulatory surgical centers.
Here you can see that I've added just those
that are in the Medium to High risk
because those are the ones that we want to focus on primarily.
So just keep in mind when you look at some of these
and read the table of what the list is representing,
to ensure this is the data that you want.
As you can see by that top red square,
we're going to be looking at IC.02.01.01, EP 2
and IC.02.02.01, EP 2.
Next slide.
First up, the most scored standard is IC.02.02.01, EP 2,
and this has to do with personal protective equipment.
You can see that from June to June, it was scored 225 times.
It was in those top red boxes, which is the high risk boxes,
about 20% of the time.
When you go ahead and click forward here in this slide,
we'll see some actual observations
that were scored at the standard and the EP.
So lancet devices or protective equipment not used appropriately,
not adhering to CDC guidelines from multi-dose files,
just to name a few.
So move on to the next slide.
We're going to move on to IC.02.02.01, EP 2,
and this was pretty close to the one we just went over,
and that was scored 223 times for that same timeframe.
Well, you could see the red part is much larger,
so the high risk category.
You can also see up there, the standard and EP
are for the most immediate threats to health and safety.
So again, let's move forward here and see some of the observations
that were from reports that were scored to the standard and EP.
Now you can probably see why this is a higher risk to patients
as many times this has to do with sterile instrument reprocessing
or high-level disinfection of intracavity probes.
Obviously, a much higher risk to patients
and one of the things that we always do a deep dive
while out on survey.
Next slide.
So why does this happen?
Well, it's very similar for both the standards that we just covered,
and many times, it comes down to leadership.
Either leadership is unfamiliar with the sterilization process
and fails to bring in the right folks that are familiar with it
to run the program,
or they do that, but just not enough of them.
We see this a lot with organizations that may have multiple sites.
The main site is great,
but there's little to no oversight at the other locations,
and that's typically where we run into issues
while on survey.
Another issue that we see is that organizations
have been running on this set-it-and-forget-it mode,
and that just cannot happen
with something as complex and dynamic as infection prevention and control.
Things change.
COVID hits, products are in backorder,
your sterilizer breaks and you need to get a new one,
a surgeon comes in with new instrumentation--
the list could go on for days.
Leaders need to ensure that they're reviewing their program,
all of it, in all areas, including dental,
and ensuring that the resources and tools are given where needed.
This includes staff, equipment, education, training,
and the leaders themselves.
Self-audits is one way to ensure
that you're touching on your process often,
and we'll talk about those in the next few slides.
Next.
Remember what I said about a complex and dynamic process?
This is a life cycle of an instrument. Isn't that amazing?
This is why you need to ensure you have the right folks
leading your sterile processing or infection control program.
Next slide.
And what if you don't do sterile processing?
Do you not have risks?
Well, we all know that's not true, this is healthcare.
You've probably heard the term "risk assessment" many times,
and maybe you've done a few or many in your career.
But for those of you that are less than clear
on exactly what that means,
a risk assessment is simply gathering information on your organization.
And how do you do this?
Well, there is no substitute.
Now you can't see that I typed that in capital letters, but I did.
So I'll say it again:
there is no substitute
for walking through your organization and looking at it with your own eyes.
You identify risks,
you evaluate them and the potential harm to your patients and staff,
and then prioritize how you mitigate those risks.
Let's look at some examples on the next slide.
I'm not going to spend a lot of time on this slide,
but I wanted to include it
as I know you all have access to these slides after the webinar.
This slide breaks down some basic risks
that can be both internal as well as external.
We here in Chicago, for example, are a travel hotspot.
So we need to be mindful of that
when thinking about our infection control risks.
COVID definitely taught us that lesson in a big way.
Maybe you have a risk and that your community
has a large prison that it serves
and you may see more cases of infections in other areas
that may not.
So why do we do this?
Well, in short, to be prepared
with a plan, with the right people, and with the resources.
Okay, moving on.
We touched on these self-audits,
and there are so many that you can choose from.
But basically, it's looking at your process and all of the steps,
ensuring that you're getting it right each and every time.
The more organizations self-audit,
the less staff feel like this is punitive.
In fact, some of the great organizations we have talked to
said they're on this for the patient
and they owe it to their patients to keep them safe.
They know that these instruments
go through many hands and many, many steps
before they get back to the patient.
And there are many opportunities for something to get missed
or not done correctly.
Self-audits are one way to keep your finger on the pulse
of how you're doing.
Okay, enough infection control for now, let's move on to a different topic.
Moving out of the clinical world into the physical environment,
we have our top-scored standard in the Environment of Care chapter,
which is EC.02.05.01, EP 7,
and this one has to do with pressure relationships.
As you can see, we have a lot right over there
associated with this one,
and pressure relationship deficiencies in critical care areas,
such as the operating rooms,
are typically scored as condition-level deficiencies
for our deemed organizations on this webinar.
Surveyors will come in and ensure that the OR is positive,
and they'll also look at the pressure relationships
of other areas,
such as the sterile processing department,
as well as the temperature and humidity
for designated central sterile storage areas
to ensure they're within the required range.
Temperature and humidity issues are definitely challenges
for some of our southern customers.
And this type of weather may be identified
on their physical environment risk assessment.
Next slide.
Of course, we get asked questions about everything under the sun,
but what we'll talk about in the next few slides
are the things we get asked about more frequently than others.
Next.
Hands down, credentialing and privileging
takes the award for the most asked-about topic.
As straightforward as credentialing and privileging can be,
there are seemingly infinite numbers of ways to get it accomplished.
For example, if we move forward here on this slide,
one of the questions that we get
is about providers coming from the local hospital and organizations
want to know if they need to credential and privilege them as well.
The short answer is yes, you do.
There are several reasons and four of which we'll get into.
If we move forward again a bit here on this slide,
you will see an excerpt from the August 2019 Perspectives article
that talks about sharing data between CMS certified
or Joint Commission accredited organizations.
The article starts talking about OPPE and FPPE,
which is for our hospital programs.
But further down in the article,
it outlines what can be shared for credentialing and privileging.
The list contains items such as training verification,
physical abilities to perform the privileges requested,
and peer and/or faculty recommendations.
There are some items that organizations must do on their own,
which includes license verification,
and querying the National Practitioner Data Bank.
Privileging is a completely different topic,
and I remind folks all the time that the only people
that can grant privileges to take care of your patients
is your organization,
by way of whatever process that has been approved by leadership.
This is especially true when you have providers
who come over from the local hospital,
as they may be performing many services
that you do not offer at your facility.
And you are granting them privileges
to do only what you offer to your patients.
When we move forward to the next slide,
we're going to talk about credentialing once again.
Okay.
Here we have telehealth.
Although telehealth was around before COVID,
we really saw it explode during the last few years
and for good reason.
Telehealth allows many more patients the opportunity to speak to their doctor
than would be allowed via a traditional route
for the appropriate cases.
But what about privileging them?
One group we get asked about a lot is our remote radiologist.
Next.
I often remind customers that reading a film or a scan
is providing care treatment and services,
and yes, they need to be credentialed and privileged to do so.
Next.
Following the same concept as before,
information may be shared between organizations,
but they must be privileged by your organization
to do whatever it is
you all have determined they are qualified to do.
Next.
Here's a way I like to explain it as I know it can be confusing.
You contract with someone to come out and test
all of your physical environment areas,
your smoke detectors, your generators, et cetera.
Because we're clinicians,
and we're not really familiar with some of that kind of stuff.
When the employee leaves every month,
he gives you a report that says, "All passed."
Joint Commission surveyors come in and ask,
"Er... were all 43 of your smoke detectors checked?"
And you realize you assume yes,
but you're really not sure
as you never gave them the specific requirements
that you would be held to as part of a contract.
When an organization says
they have credentialed and privileged someone,
unless they're CMS certified or Joint Commission accredited,
you may be playing from two very different rule books.
And your organization has the ultimate responsibility
to ensure that the folks you hired to treat your patients,
whether in person, through a contract, via telemedicine,
or a combination of those,
are qualified to be granted the privileges requested.
The other standard that comes into play here
is LD.04.03.09 in the Leadership chapter,
which talks about care treatment and services
that are provided via a contract.
The contracts will also be evaluated by the survey team
to ensure that the proper expectations are established in writing
and that steps are taken if these expectations are not met.
Okay, time to move on to another topic.
As I mentioned in the beginning of this section,
we get asked seemingly every question under the sun,
and if we move along here on this slide,
these are a few that have come in to us,
and the last one is definitely my favorite.
When it comes to infection control in a healthcare setting,
there are virtually an unlimited number of questions that can come up
and do come up.
And many organizations turn to us
as someone they can trust for information and resources.
On the next slide...
is the hierarchy of decision-making for really any decision
you're trying to answer in infection control.
In other words, this is your roadmap to hopefully finding an answer.
This was originally published in our Perspectives article
on April of 2019.
So I encourage you all to go into your Tools and Resources tab
on the extranet site
and check this out if you haven't seen it
as it goes into more detail and give some examples.
But let's take the multi-person drops from the last slide
to walk through this.
Are there state laws or local regulations regarding multi-person drops?
You can actually do a quick internet search,
and I think we all know what the answer to that question is:
No.
Then looking at conditions for coverage.
You won't find anything that specific in CMS guidance,
but this is a public document so you can type in
"CMS State Operations Manual Appendix L"
and this is also a surgical document, which is great.
So maybe you took a look at the medication management section there.
Well, let's say we find nothing there,
so we move forward
to the manufacturer's instructions for use.
It tells you how to use the drops but nothing about multiple patients.
A quick email to the manufacturer via our suggested step
as they are the makers of this product and the source of truth
for how to use it safely.
Ask them to send you their response in writing.
But for the sake of argument,
let's say they won't do that for some reason
or you can't get hold of anyone.
Maybe there's some medication management guidelines
that are nationally recognized and evidence-based
that discuss the proper steps to ensure this is done correctly.
That may be your answer and so forth.
Again, going on a [ladder] to find what you need
as the customer put it on this previous slide,
"to stop the madness."
Next slide.
It's hopefully, all of you are aware, we get asked so many questions so often
that we have a very robust list on our public page
that is now even easier.
Once you click on your homepage, if we move forward on this slide,
you will see our little Chat button function here
that you can type more of a regular question
instead of having to know the keywords in the title of the FAQ.
And using artificial intelligence, the Chat bot finds you, hopefully,
what you were looking for.
In the event that it does not, do not despair,
as we're just an email away
and are always happy to lend some clarity when we can.
As someone who continues to practice bedside nursing,
I want to thank all of you for everything that you do for your patients and staff
during this particularly challenging time.
And know that we're happy to help out in any way we can.
With that, I'm going to turn this over to my colleague Bhavna.
(Bhavna) Thank you, Liz.
Hello, everyone, I am Bhavna Mishra,
and I will be presenting today about our software platform
that many healthcare organizations are using to automate
their risk assessment journey.
Next slide, please.
So this is the platform that organizations are using,
not only for their current accreditation readiness
but also for digital tracing and grounding,
and I will show you some examples of that.
Next slide, please.
So as you're working with the leading healthcare organizations
across the country and beyond,
what we have learned from our user base
is that they are seeking innovative ways of solving their challenges
regarding improving their automation journey
towards the compliance readiness and the accreditation readiness;
reducing the risks
with data-driven solutions or decisions;
operation excellence by doing more with less;
and then, of course,
having that business intelligence information available
for the leadership to be able to prioritize their decision-making.
We support all of the healthcare settings
that are available by Joint Commission.
And of course, today I will be focusing on ambulatory healthcare.
Next slide, please.
So how do we help our organizations?
We have developed this innovative solution that is web-based.
So all of your users,
once they have access to the platform,
can access without much dependency
on the IT.
The standards are always available, up to date.
We work closely with The Joint Commission on monitoring of the upcoming standards,
and we make them available to our customers
before they are effective.
And the organizations really enjoy that feature of the product.
In addition to that, the license for an organization
has unlimited user-based access.
And the idea behind that
is we really want to partner with our users
unlike any software--
the traditional way of doing in software license is user-based.
But we have intentionally provided an unlimited access to staff
within an organization.
The idea is until and unless
everybody and as many people,
the leaders want to be involved in one central location,
it is very difficult to spread that information and education.
Because the information is stored in one place,
the risk assessment information,
it becomes an education tool for staff members
of why we need to do what we need to do
and why it is a high priority.
And this helps them identify the trends across the healthcare system,
achieve their obligatory compliance,
and on top of that, bridge the silos with this central location
of all the information.
Next slide, please.
So how do we automate to your workflow?
There are different steps that are built within the platform
that organizations can use
to have that close loop compliance readiness,
as you must follow right, not either using another tool
or paper or spreadsheets.
We have tools in the application available
that are helpful to create your customized tracers.
There are many tools that are already pre-built
and can be easily disseminated from a healthcare system
to different sites, different locations,
different departments, or individuals.
These staff members, as they get assigned the tracers,
they can download an app, a mobile app,
or just collect data on paper,
and they can identify all of the risks through that,
responding those tracers into the application.
The analytics and business intelligence, also known as Illuminate Analytics
is available in the platform, it is already included.
Again, you want to see the full value of one place to go
for all your risk assessment activity.
So this business intelligence tool helps identify the trends
and the risks across the system.
At that point, organizations may choose any advisory services if needed.
That's not part of the automatic platform,
or you may have your internal action planning team.
The action plans are implemented, they are monitored,
and then organizations go back to schedule additional tracers
to monitor if the improvement plan that was created is working.
Next slide, please.
So I want to show you some of the examples
of the tracers that I was talking about, the tools that are already available here,
some screenshots I took from the application.
You can see the various topics that are already available.
Now, the value of having these available on the platform
is not only that you have the questions that are ready,
but they're automatically linked to the EPs, the applicable EPs.
We have a very strong team of clinical advisors on our team.
They have been, in their past life, before they joined our team,
either they worked as consultants for JC
or even some of them had worked as a surveyor
for The Joint Commission in their past life.
So they bring their expertise and knowledge to our team,
and they utilize that to build all of this content for our users.
You can see on the right-hand side here,
I've listed some examples of COVID-19 topics.
So just to show you an example
that our team always keeps up to date
but not only the changes in the regulations
and how to manage that and update this content,
but also the changing environment,
what are the requirements that you may be looking for
that you may want to assess against.
On top of that, we also added-- we call our tracers "flexible tracers."
The idea is that, initially, about 10 years ago
when we released the platform,
it was supposed to just do a compliance and non-compliance assessment,
but we have gone beyond that,
learning from our users, listening to them.
We have almost 2,000 organizations across the country
using the platform right now.
And what we have learned from them is everybody wants to have
that central location of their risk assessment,
so why keep it limited to just compliance/non-compliance?
So other types of audit tools or checklist with a Yes/No question,
multiple choice--
all those can be very easily built into the product.
The users have the flexibility to develop that
and disseminate that to their staff members.
Next slide, please.
Here's a sample of what...
building of a tracer tool looks like.
You can see on the left-hand side, there are various topics available
that the staff members can-- or your administrators, leaders can pick.
Can you please click one more time?
Thank you.
And then you can see here that
the questions can be selected from the topics.
Of course, the questions can be mixed and matched
from different topics to build the customized...
tracer that the organization may be looking to build,
based on your own policy and procedures or the process you wanted to follow.
The questions can be edited.
If the intent is changed, they can be re-linked to another EP.
And of course, other questions based on your own policies can be added.
Next slide, please.
Now, the fun part begins when the data collection happens
from these tools.
As I said earlier,
that once this is disseminated to different locations,
the staff members within these areas have access to a mobile app
that they can download through the stores on their app,
and they can easily get to the topic that they need to respond to.
It becomes very easy on what they have been assigned.
And not only they can respond to these questions
while they're mobile on the floor,
they can use the mobile feature
of enabling the voice
because you can just record,
so it makes it easier to collect data.
And on top of that, they can also take any pictures and upload
during this observation,
as our users have said, and a picture speaks a thousand words.
And I do want to clarify here that the data that is being collected,
all of this data in the application, it is completely independent.
It's your data, only accessible to you,
and it's only for your internal mock data collection
and survey preparation.
Next slide, please.
Once the tracers are being collected,
you can see that there is a lot of data analysis available
to identify the risks.
But on top of this,
for those who are looking into the compliance for the EPs,
all of this data,
especially the questions that were linked to an EP,
feeds into the information for that EP.
So the decision-making for the compliance
of an EP
really becomes simpler
because now the observation data
is helping you objectively determine that EP compliance.
And they, of course, are available just with a click.
For example, here, if I was looking at Emergency Management,
Standard EP,
any tracer observation that came out of your team's work
would show up right there with a click,
what findings were made during tracing
that impacts that specific EP.
Next slide, please.
As the team is recording their compliance activity,
regarding an EP,
what this is also helping you see
is that it's not only your self-assessment here.
Our platform also allows you to download your RFIs
from your past surveys.
It also allows you to upload your FSA if you're preparing to upload one
to The Joint Commission.
But it is all in the control of the user.
None of this information can be downloaded or uploaded without your consent.
In the application, everything is recorded.
Every activity is recorded, who is doing what, when.
So if you needed a historical information of when an FSA was uploaded, by whom,
you will be able to pull reports on that as well.
It really helps organizations to see that--
as I was talking about-- the centralized location,
one-stop-shop to see all of the risk assessment data
in one place.
On top of that, if you have any contracts
with the JCR mock survey consultant team,
and if they are performing any consulting for you,
and they have done a mock survey,
all of that data can also be pulled in here
to integrate all the information in one place.
Next slide, please.
And here's a sample of our dashboard that I was talking about
that is also known as Illuminate Analytics.
It is automatically included.
After all, it is a world of data-driven decisions,
and data is the key
for any information system
to help move forward your decision-making.
So the decisions can be not only made
for the safer matrix, what your risks are,
the high-risk areas are,
but on top of that, you can also look at standard by standard,
location by location,
based on the previous findings, the trend if the risk is going up or down.
There are various views of data that can be seen or developed,
even customized, if needed, based on what you are looking for
to present to your leadership.
Next slide, please.
Here's a sample of an example of one of our customers
on how they view the outcome of using the tracer tool.
And of course, we have many other customers
and their references available and how they are using the product.
If you were to--
We host every year a user group meeting for all our current users.
It's a very popular annual forum where everybody comes together
and shares how they're using technology to really transform their business.
And it is a great platform to hear from your colleagues
across the country
how they are automating their journey to their goals,
to meet their goals.
Next slide, please.
So at the end of the day,
technology is the way to really reduce these system risks
by creating and gaining greater visibility and dissipate and reduce risks
and report those risks to the top leadership.
And this is what we have observed and learned and proven with our system
for many healthcare organizations.
Next slide, please.
If you want to learn more, to see the product,
please register here to see a light demo.
We host them every month
for healthcare organizations across the world.
On top of that, if you needed to speak with somebody
for your organization, to have a customized demo,
you can always email us at the email address below.
You can just let us know with the Subject
that you're looking for a tracers demo
for your AHC Standards,
and we'll focus on your program to provide you that presentation.
And I've provided you more information, if you go to our website.
There's a lot of great information already available there
to learn more on how we are helping healthcare organizations.
Next slide, please. I think this is my last slide.
And with that, I'm handing it over to our moderator, Donna.
(Donna) Thank you, Bhavna, Joyce, Dana, and Liz.
And we'll just take a few minutes here, a real quick minute to tell you,
there are a couple of educational events coming up for ambulatory.
Both of the events actually are in November,
one for Primary Care Medical Home
and then another for the Ambulatory Care Conference,
which is very popular.
So we put the links in there if you're interested.
It's sometimes easier to get the links than to go look for them on the website.
And there's also the Ambulatory Care Breakfast Briefing webinar series
that you can tune into if you need to.
You saw a link that Bhavna provided regarding a demo, if you're interested,
and AMP, if that works for your organization.
And then Joyce also provided a link about how to get more information
to check in with standards.
So with that, we'll sign off for the day.
Thanks for checking in with us.
Thank you for all you do, and have a great rest of the day.