(Robin) This webinar is an introduction to Joint Commission Accreditation
and PCMH Certification for Community Health Centers,
including FQHCs.
My name is Robin Wedell,
I'm an Associate Director for Business Development
in Ambulatory Care Services at The Joint Commission.
My role is to communicate the value of accreditation
to organizations like yours,
walk you through the steps of accreditation,
ensure you're aware of all the complementary resources
available to you for preparing for survey,
and then help guide you in completing and submitting the application
when the time is right.
Today's objectives would be, at the conclusion of this presentation,
you'll be able to know the reasons why healthcare organizations
become accredited by The Joint Commission,
evaluate the benefits of a PCMH Certification,
gain an understanding of TJC Accreditation and PCMH Certification process,
realize the resources available to you
to obtain The Joint Commission Accreditation and PCMH Certification,
including the fact that HRSA does cover fees for 330 funded FQHCs,
and then know where to go when you're ready.
A quick disclaimer
that basically says that them slides are current as of today
and that I am not a surveyor
or a member of the Standards Interpretation Group.
Our agenda today is to introduce you to The Joint Commission,
talk about the value of accreditation,
Primary Care Medical Home Certification Option,
go over the application timeline,
the survey process,
HRSA and BPHC resources,
and tips to getting started.
Please know that the standards for accreditation
can and should be used to provide structure
and standardization of processes across your organization's platform
and supporting the oversight
and direction of your teams and patient care.
We are here to help provide a framework for quality of care.
A little background on The Joint Commission.
We are an independent not-for-profit organization
which accredits and certifies
over 2,200 ambulatory healthcare organizations and programs
in the United States.
Our accreditation and certifications are recognized nationwide
as a symbol of quality
that reflects an organization's commitment
to meeting certain performance standards.
While Joint Commission has been accrediting over 70 years,
we have been serving the ambulatory organizations
for the past 47 years.
So we are not new to the ambulatory space.
If you've been around healthcare for a long time,
you probably know us as JCO,
and we are now called TJC.
We accredit a number of different freestanding ambulatory settings,
as you can see on the slide here, they include Surgery Centers,
Medical Group Practices, Telehealth both Surgical and Non-surgical
Diagnostic Imaging Facilities,
Urgent Care Centers,
Kidney Care Providers, Sleep Centers,
Community Health Centers such as yours
and Health/Work-Site Clinics.
The Joint Commission's mission
is to continuously improve health care for the public,
in collaboration with other stakeholders,
by evaluating health care organizations and inspiring them
to excel in providing safe and effective care
of the highest quality and value.
Why is it important to become Joint Commission accredited?
The Joint Commission and its Gold Seal of Approval
is a widely recognized benchmark
representing the most comprehensive evaluation process
in the healthcare industry.
Going through this process provides a comprehensive framework of care
and reinforces your risk management efforts.
Accreditation enhances staff education,
and puts the focus on patient safety and higher quality of care.
Many regulatory agencies, payers and Managed Care Contractors
actually require Joint Commission Accreditation for reimbursement,
certification or licensure
as a key element of their participation agreements.
Achieving accreditation is a visible demonstration
to patients and the community
that your organization is committed to providing the highest quality services
and it sets you apart from the other healthcare organizations
offering the same types of services.
And finally, TJC offers support, guidance and an abundance of resources
for ambulatory organizations
during and after the entire accreditation process.
We really do want you to succeed.
When you begin the Joint Commission accreditation journey,
you'll be looking to increase standardization
by removing unnecessary variation,
which in turn will lower your risk
and lead to safer quality care for your patients.
Let's talk about PCMH Certification.
PCMH is an optional 3-year certification.
It's based on the Agency for Healthcare Research and Quality's
(AHRQ) definition of Medical Home
which is focused on these five pillars:
care that is patient-centered,
comprehensive, coordinated,
and has a superb access,
and takes a system-based approach to quality and safety.
Let's go through them.
Patient care is the relationship-based care.
It focuses on the whole person and understanding and respecting
each patient's needs, culture, values and preferences.
Second one is comprehensive care.
It has to do with a team of providers which could include physicians,
advanced practice physician assistants,
nurses, pharmacists, nutritionists, mental health workers, social workers,
as well as others that work together
to meet each patient's physical and mental health care needs,
including prevention and wellness, acute care and chronic care.
The third one is coordinated care.
The care that's coordinated across the broader healthcare system,
including specialty care, hospitals, home care,
and community services and support.
This is really critical during transitions between sites of care,
such as when the patients are discharged from the hospital.
Fourth is superb access to care.
Patients have access to services
with shorter waiting times for urgent needs
enhanced person hours
around the clock, telephone, and electronic access
to members of the care team,
and alternative methods of communication, such as email and telephone.
And the last one is systems-based approach to quality and safety.
The PCMH uses evidence-based medicine and clinical decision support tools,
engages in performance measurement improvement,
measures in response to patient experiences and satisfaction,
practices population health management,
and publicly shares robust quality and safety data
and improvement activities.
Studies have actually shown
that medical homes decrease healthcare costs
while improving patient care and access.
Investment in a medical home concept
offers both short-term and long-term savings
for patients, employers and health plans.
Studies also suggest
that this particular model empowers the patient
and actively engaging the patient in their health.
Patients benefit from this model of care because they have increased access
to their primary care clinician and interdisciplinary team.
Their care is tracked and coordinated,
and increased use of health information technology
supports their care.
PCMH Certification through TJC
requires your organization be accredited with Joint Commission.
You can do both the accreditation and certification surveys
at the same time
or, if you'd like, you can be accredited and then do the certification later.
Most FQHCs and Community Health Centers,
do the initial survey and PCMH Certification at the same time.
Please note that the outcome of the PCMH Certification
does not impact your accreditation.
So for PCMH, there's no separate application.
When you apply for accreditation, you're simply going to check a box
that you are also applying for PCMH.
You're not required to submit or upload any documents
before the survey,
the Accreditation and Certification surveys are combined
and done at the same time.
Both the accreditation and PCMH certification are for 3 years.
And once you're accredited and certified,
your organization will be listed in our QualityCheck.org website
where we show all
of The Joint Commission accredited organizations
and include their certifications.
To be an eligible PCMH site, you must follow this definition.
You're a location where on-going established relationships exist
between a primary care clinician and a panel of patients.
The site needs to provide an on-going and continuous primary care
to a majority of its patients,
irrespective of the location of the site
or the population of patients being served.
So on this slide, you can see some of the sites
which are not PCMH elegible.
Things such as an administrative office or dental-only, lab-only,
PT-only or mental health services-only,
these are sites that are not PCMH eligible.
Let's talk about your accreditation timeline.
The first step is to reach out
to your Joint Commission Business Development contact.
They will guide you through the process,
provide helpful resources, and work with you every step of the way.
They'll help you to determine your timeline,
which is understanding when you'll be ready for your survey
and when you'll want to complete your application.
They'll go over the cost of accreditation.
And please note that if you are a 330 funded FQHC,
HRSA will cover the costs of your accreditation.
A general timeline for application submission
is four to six months prior to your survey ready date.
So this allows you time to prepare for the survey
and gives us time for scheduling.
We have organizations that are prepared more quickly
and others take a longer time.
That's why it's really important to first reach out
to your Business Development person,
so that they can help you understand the timeline
and work with you to come up with your survey ready date.
This is your survey activity guide, it's a blueprint for your survey,
and your Joint Commission contact
can provide this prior to submitting your application.
You'll also find it on the Connect Joint Commission portal,
which you'll have access once you submit your application.
A quick look at our standards.
The Joint Commission Standards are comprehensive.
They're not prescriptive,
we're not going to tell you how to do something,
we're going to provide a standard and ask you to meet that standard.
They're going to be applied to settings and services.
So the standards that you are following are based on your specific setting
and the specific services that you offer,
they're tailored to your setting and services.
They help providers achieve, maintain, and demonstrate consistent excellence
in the services they provide,
and they can help develop strategies to address most complex issues,
and identify key vulnerabilities in the patient care experience.
This is a picture of our E-dition which is our online standards,
and your Business Development person
will provide a complimentary 90-day subscription to the standards
and we'll show you how to navigate through E-dition.
Just some things to note here, and again, your Business Development person
will walk you through it...
The big red circle on top,
is actually the name of the standard and the ID of the standard.
The purple arrow, is the Elements of Performance.
And then over to the right,
the blue oval, which says FSA, which means Focus Standard Assessment,
if it has an R underneath it,
it's a heads up that this is one of them that is cited more often,
it's a more challenging standard or element of performance.
And then when you see DOC and you see a D with a circle around it,
that means that it requires written documentation
and that your surveyor will ask you to see written documentation.
Our survey process is patient and customer focused.
So they'll be direct observation of patient care processes
with minimal disruptions to patient flow.
The surveyor will have discussions with patients and staff
and for the PCMH eligible sites, they'll go visit them
as well as they'll spend time reviewing the medical records and HR files.
This process is really meant to be educational and informative for you
and your staff.
Our surveyors are clinical and administrative professionals
experienced in ambulatory and outpatient settings.
They are your peers.
They have extensive ongoing training in standards and the survey process
and they will be collaborative
and share observations, best practices, tips, and strategies.
The survey complement is based on number of your sites,
volume and distance between the sites.
So as you work with your Business Development person,
they'll be able to tell you how many days that is.
Patient tracers include examining the files,
interviewing the staff and patients.
And we will also be looking at the whole organization
and tracing systems when we start to look at Infection Prevention and HR practices.
For the PCMH on-site initial review,
we ask that you implement the PCMH in at least one of your eligible locations
for at least one population.
You'll need the supporting written policies and procedures in place.
Then we will ask that you have a plan in place
so that you can implement the rest of your eligible PCMH sites
by your next triennial survey.
For the PCMH Onsite Review Process,
surveyors will be doing the same.
They'll be interviewing the patient, the staff
and be doing some direct observation.
So one example of direct observation for the PCMH
would be observing to see
if the self management goals were addressed.
And those would include educating your patients
and encouraging them to self manage their condition or disease
and allowing your patients
to take an active decision-making role in their care.
So what happens on the last day of the survey?
There's a leadership briefing
and the opportunity for you to ask questions
and provide additional information regarding the survey findings.
There'll be no surprises
since you will have discovered many of these RFI's,
which are called Request For Improvements,
together with the surveyor,
and you will have discussed each one of those findings
as you find them.
So, the briefing is really a summary.
If you feel a standard was met,
you have 10 days to provide the supporting information.
The final report will be in your Joint commission Connect Portal
within 10 days.
At the briefing, your surveyor will use the SAFER Matrix,
which stands for Survey Analysis for Evaluating Risk.
It's really a transformative approach
for identifying and communicating risk levels
associated with deficiencies cited during the surveys.
It helps organizations
prioritize and focus corrective actions,
and it provides one comprehensive visual of survey findings.
So if you look at the Matrix, there's nine squares.
From left to right has to do
with the frequency that they may cite deficiency.
And then from bottom to top has to do with how much risk they see.
So, you know, the lower left yellow box
is low risk and very limited sightings.
And then if you're at the very top,
you would have high risk which means harm could happen at any time
and they've seen it very widespread.
This is an excellent bird's eye view
of being able to understand where you need to put your priority
in addressing each of the sightings that are found during the survey.
So once the survey is complete,
you will have 60 days to turn in your Evidence of Standard Compliance,
we also call those ESCs.
You don't have to take up to the full 60 days,
you can submit your ESCs as soon as you're able.
Once they are reviewed and approved by The Joint Commission,
you'll be awarded the Joint Commission Accreditation Gold Seal.
if you're an FQHC,
your survey report will be sent to BPHC central office
and available to the Health Centers Project Officer.
Just another reminder,
if for some reason you fail to comply with all the PCMH requirements,
it will not jeopardize your accreditation status.
The Joint Commission has a long relationship
with the Health Resources & Services Administration,
also known as HRSA.
The Joint Commission has had a contract with HRSA since 1996.
Our common goal is to improve the quality of health care
and outcomes for health center populations.
So, becoming Joint Commission accredited,
you're really indicating
that you're providing high-quality health care services,
you're improving patient experiences
and you're improving health outcomes and safety.
The accreditation process provides structure and resources
to support your health center's quality improvement and risk management.
The accreditation initiative encourages and supports health centers
in undergoing systematic and comprehensive survey processes.
Your participation is voluntary and it provides an excellent opportunity
for your health center to achieve
the Joint Commission Gold Seal of Accreditation.
If you're a 330 funded FQHC,
HRSA does cover the cost of accreditation.
When I attended an ACHC conference last summer.
I was surprised to find out how many of the FQHCs
were unaware that HRSA did cover their accreditation costs.
This is actually a copy of HERSA's Program Assistance Letter,
which outlines the process and requirements
for applying for accreditation
and PCMH Certification,
and it can be obtained from HRSA.
For 330 funded FQHCs,
they will cover the cost for certain service types.
And those are:
Ambulatory care, Behavioral health,
Opioid treatment program, lab services
and certain extension survey fees.
However, the special funding does not include:
Home care, long-term care and critical access hospital surveys.
For FQHCs,
you're probably going to be told to submit your "Notice of Intent" first.
And I would say that really your first step should be
to contact Joint Commission
and begin working with your Business Development person.
And the reason that I say that
is they can help you determine your timeline.
Many times,
the community health center needs a little bit more time
than a year to prepare for survey.
And that Notice of Intent is really only good for a year.
So it's best to work with your Business Development contact,
understand your timeline,
get a good understanding of your survey ready day,
and then you'll know when to put in your NOI.
So, for instance,
once you figure out your survey ready date,
you'll know your application should be filled out
four to six months prior to that.
So probably seven months prior to your survey ready date,
we'll ask you to submit your Notice of Intent with HRSA.
When you do submit your Notice of Intent,
you'll need to tell them about your timeline,
identify the lead person,
complete a self-assessment and provide your survey ready date.
You'll also want to let them know
that you're going to be doing PCMH Certification.
Also, you can request technical assistance.
This is a very valuable resource that HRSA offers.
It covers two days of on-site consultation
from a Joint Commission Resource consultant.
We usually refer to this as the mock survey.
HRSA will review and approve your Notice of Intent,
and they'll send a notice to Joint Commission,
and then we'll send you a welcome packet.
But remember, you're already working
with your Joint Commission Business Development person,
you're going to continue to have regular meetings
so that they can help you every step of the way.
They will guide you through the process
of understanding your timeline working with you throughout the timeline
and then completing and submitting the application at the right time.
There are many resources that are provided by both Joint Commission and HRSA.
The portion of our Joint Commission website
that's dedicated to the Bureau of Primary Health Care,
also called BPHC,
is one of our top visited pages.
You will find a whole list of resources available to you,
including such things as a recorded webinar on demand,
a podcast that's highlighting how Joint Commission Accreditation
has made a positive impact on a community health clinic
in East Harlem.
There's information on our annual Ambulatory Care conference,
which is held in November.
You can also explore resources for PCMH,
including a self-assessment tool,
Q&A guide, lists of PCMH most challenging standards
and the Gap Analysis tool.
So there are great resources that are readily available to you.
We also provide a comparison grid
between HRSA standards and Joint Commission standards.
A couple of tips for getting started.
So how do you gauge your readiness?
Again, I'm going to tell you the first step
is to contact Joint Commission
and work with your Business Development person.
They're going to provide E-dition, which is our online standards.
Then, you're going to conduct a self-assessment
where you're basically physically walking through your facility
and seeing how well you are meeting the requirements.
Again, you're reviewing E-dition or online standards
and you're comparing them
against the policies and procedures that you have in place.
Where do you have gaps?
And that's the next step, it's identifying those gaps
where you do not have a policy or procedure in place
for our standards.
Once you identify those gaps,
then you can start developing a timeline
of how long it will take you to close those gaps.
Then you'll come up with your survey ready date.
And again, your Business Development person
will work through this timeline with you, step by step.
Three things successful surveys have in common.
One, engaged leaders, they're fostering teamwork
and the value of the opportunity to learn and improve.
Two, staff.
Involves staff that is taking ownership for patient safety and quality
and they feel empowered to make changes.
And three, an organization that owns its processes
whether they're good or whether you need some improvement.
Suggestions for success.
Establish an effective governance structure
to provide oversight and support.
You need leadership to be making sure
that they're providing that oversight.
And then identify "Chapter Champions."
Those are team members who are experts in specific chapters.
Maybe you have someone
who's an expert in Medication Management
or Infection Prevention,
you'll probably have a different team member
who is a specialist in Environment of Care.
Start assigning chapters to each of these specialists,
then meet on a regular basis
and track your progress in the gap analysis.
Suggestions for continued success.
Make everyone feel involved.
We're going to want everyone involved in the survey process
because, again, it's staff education and it helps them
with meeting all of the requirements.
Two, ensure that any new employees that you have
are educated on patient safety issues
and related Joint Commission standards within 60 days of hire.
As we talked earlier,
there are a lot of PCMH Resources and you'll find those on the website.
You go to jointcommission.org,
I would suggest you type in PCMH or even BPHC.
It'll take you to the website where you'll find these tools.
Next step, as I keep saying,
is to really connect with your Business Development person
at Joint Commission.
The phone number here, 630-792-5286
will connect you with our Ambulatory Team Coordinator,
who can then let you know
who your dedicated Business Development contact will be.
You can also use the email address
and your Business Development person will respond to you as soon as possible.
Also, listed on here is our Joint Commission website.
So as you see,
this is how you contact us.
Please reach out.
We very much appreciate your time today
and look forward to guiding you through the process of accreditation.