(Moderator) Thank you for joining us for our webinar:
First Timer’s Roadmap to Behavioral Health Care
and Human Services Accreditation.
(Darrell) Hello, everybody. Thank you for attending our webinar today.
I'm Darrell Anderson.
I work in the Business Development Group here at The Joint Commission,
and we help you with everything from the application, the eligibility,
your timeline and resources.
So what we have is the E-dition,
that is the electronic version of our standards manual,
which is what the surveyor looks at on the survey
as they conduct their survey.
Now, we're also available in The Joint Commission
on the Business Development side to get you a fee,
give you a quote for the type of thing you have to offer.
One is the subscription fee.
That is an annual January billing
each of the three years of the accreditation life.
And then, when we do the survey itself,
we conduct the survey,
typically that's a two-day survey with one surveyor,
and we bill you after we do the job.
So those are the two components of the fees,
and again we can provide you with a customized quote
based upon what you offer.
So what are the steps in the accreditation process itself?
Well, we tried to provide a timeline here for you.
So you do a self-assessment to identify gaps.
That's when that E-dition comes into play,
where you look at that manual
and compare it to your policy manual for your agency,
and you see where you might have any gaps,
and you rectify them in preparation for that survey.
Take the action plans you need to meet those requirements,
whatever they are.
You actually have your on-site survey
that might be two to three months after you apply.
And then after the survey itself, if you have requirements for improvement,
and most people do,
you know, nobody gets perfect surveys, or not very often,
then we accept those changes, you report them online,
and you're considered to be accredited when we accept those changes.
So here are some resources that you can use.
We have an electronic preparation tool;
a written documentation checklist;
we have a survey activity guide;
we also provide free publications;
and then, as you prepare your standards and your manual,
the Standards Interpretation Group is a group of experts internally here.
Now, here's an excerpt
from the required written documentation checklist I just mentioned.
This is for a chapter called: Care, Treatment, and Services,
CTS for short.
So if you look at it, you'll see that the chapter itself is abbreviated.
We number the standards with a six-number, three-dot numbering shorthand system,
and something called an EP.
EPs are Elements of Performance.
So you see listed there EP1, EP5,
depends on which one you're looking at there,
but there's always at least one EP.
The survey activity guide I mentioned before
is a go-to resource for help you prepare for a survey.
It shows you what to expect during each survey activity,
other sample agendas,
suggested participants are listed,
and a document list displaying all the document-based standards
in one place.
There's some publications I mentioned before.
The first three there on the left are free publications,
which you can take in.
You can also get other things, get some policy source,
and also documentation you see on the right there.
Those are two examples of things you can purchase should you need to.
One resource I mentioned before is Standards Interpretation Group.
These are specialists who are internal people,
employees of ours.
They have engineering, social work, other behavioral backgrounds,
which allow them and give them the ability
to answer all of our standards questions for you,
and they help you in general to prepare and pass surveys.
And so that's available to everybody as a free service.
Applying for accreditation.
You can go online here through this link and request an application,
or I can create one for you.
So you complete it, submit the application.
One of the things we're going to put on there is the ready date
within the next year, 12 months out,
where you'll be ready for survey.
There's also a $1,700 deposit, non-refundable $1,700,
which is credited toward the accreditation fees themselves.
This is your portal for your account.
So it's a dedicated secure site.
And your Account Executive,
once I hand you over on an application to the Account Executive,
and segueing over to that,
I'd like to bring Mary Armstrong into the conversation.
She would be your Account Executive
in most parts of the country
to work with you as a Behaviorally Accredited organization.
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(Mary) This is Mary Armstrong.
I am one of the Account Executives here at The Joint Commission.
So the first thing that's going to happen
is your organization is going to get a primary contact person,
the Account Executive.
This person is going to help you coordinate the survey planning,
the policies.
We also provide ongoing education and resources to the organization.
The portal that you have
will house the organization's specific information.
We call this the Joint Commission Connect.
In the upper right hand corner,
this is where the organization's name, address,
the HCO ID number.
The Continuous Compliance tab,
that's where the application and some other things are included.
The Communication tab.
This is where you will find official emails
sent to the listed primary contact person
or any correspondence that was previously posted.
Resources and tools.
This is where E-dition, which is our standards, will appear.
Also in there is the Perspectives publication.
Also which will be there our current and archived copies of the publication
and the award certificates.
Additional tools can be found in that area as well.
Where it says Security Administration tab,
this is where the organization can create and assign people to the portal
from their organization.
The next thing I want to point out is called What's Due.
This is going to tell you what's due.
Below that, has to do with your Official Report.
That's where it's going to be posted.
Important updates.
If we have updates that we want the field to know about,
we're going to put it here first.
Notification of scheduled events.
When your organization is scheduled for survey,
it's going to appear in this area.
So you see, it says Survey Process.
Off on the left-hand side, it says Pre-Survey,
and you see the Survey Planning Tool.
And below that is the Survey Activity Guide.
So that's what's in the Pre-Survey.
I'm going to move on over to the Post-Survey.
And this is where the evidence standards compliance
is going to reside after 30 days.
It comes off and this is where it gets to live.
The same thing with your report and your accreditation letter.
The general application also resides a little bit below that under Application.
The other area below that that I want to talk about
is Resources and Tools.
This is, again, another area where you'll see E-dition.
And below there is Perspectives.
Another important area is under Tools.
It's the second one that says Standards Interpretation.
If you click on that,
the top part, you will see all the questions somebody has asked
about the Standards Interpretation, about standards.
And you might want to check that if you have a question,
because you might find, lo and behold,
somebody asked the question beforehand.
All right, let's talk about that E-application.
This is what it looks like.
And we use this to schedule, as I said, all events.
That includes your initial survey.
That includes if you're going to have to have an extension survey.
Maybe you added a program or a service.
All of it is going to start with this.
I can't stress enough
how important it is
to maintain complete and accurate information in this.
When you have your initial survey,
a behavioral health organization will receive 30 days notice.
This will enable you to notify staff and begin preparing for the survey.
After you've had your initial, and now we're doing your triennial,
your resurvey is called,
you will receive a seven-day notice.
This will let you know, it's all OK,
you know, in seven days The Joint Commission is coming.
The scheduling of it,
we're going to take a look at things like what the program is,
what your products are, what the volume is,
how many sites do you have, how far are those sites,
what type of survey is going to be needed,
what's the length of survey.
All of these are things
that are going to be going into when we create this
and determine the survey length.
First thing on day one, at 8 o'clock we have the survey team arriving
and then from 8 to 9, they will have a Planning Session.
Then there's an Opening Conference.
This is where we talk to the CEO, top management at the organization.
Actually, it's anybody the organization wishes to participate in this.
Then the surveyors will have a little bit more time
to plan what's going out.
And then they start with Individual Tracers.
The other area I want to point out on this,
and you're going to see it on day one and day two,
is the Special Issue Resolution.
And then before the surveyors are going to leave,
they have a Planning Session to prepare for the next day.
All right, again, we start with a Daily Briefing,
and you see there's a System Tracer in here
and we have Environment of Care,
and then you're also going to see the Individual Tracers
and also, there again, is the Special Issue Resolution.
And then there's a Planning session at the end for the surveyors again.
All right, now we're at day three, last day of the survey.
So again, Daily Briefing.
And when I say Daily Briefing, it's not only just for the surveyors,
but representatives from the organization can be there
so they can kind of hear a little bit of what happened the day before
and what they look to be doing today.
You'll see we have a Leadership Section in here.
We also have a Competency Section.
Again, another Individual Tracer Activity.
And then the surveyors will do the Survey Report Preparation.
The first person that's going to get to see it is the CEO.
So there's a private meeting with the CEO called the Exit Briefing
that we talk about and we say, "Okay, here are our findings,
here's where things are,
this is what you're going to have to correct."
Then if the organization wishes, there's an Organization Exit Conference.
Again, talk a little bit about, at a higher level though,
of some of the things that have been found,
but they'll also talk to you about all the wonderful things
that are going on at your organization.
And then after that, the surveyor will depart.
What happens after the survey?
After the survey,
the surveyor is going to prepare the report
and submit a preliminary report to the central office.
This will also be available on your organization's Extranet site
for 24 hours,
and then it disappears from your Extranet after that.
If everything has been looked at and everything's fine,
the organization is going to get a final report.
And it's going to list what the findings were,
exactly where it was located,
and then it will also talk about the Evidence of Standards Compliance.
You're also going to get information about Award Letter and Certificate.
Now, the clarification.
Clarification's going to come in-house
and it will be reviewed by a member of the Standards Interpretation Group.
And then the official report is posted to the Extranet site.
And then the organization has 60 days
in which to do the Evidence of Standards Compliance.
The Final Report gets posted, as I said,
then the Evidence of Standards Compliance.
A decision date.
An initial survey with requirements for improvement
will have an effective date for their accreditation,
which is based on the date the ESC was accepted.
If there are no RFIs,
the effective date then would be the last day of the survey.
The ESC is accepted
when the organization has demonstrated resolution of all RFIs.
We do have two areas for support.
First off, you can send information,
as I said earlier, to the Standards Interpretation Group.
You fill out that form and they will give you a written response.
The other one, the monthly Perspectives publication,
because that's the first place we put everything in
when things are coming out.
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