(Andrea) And thank you so much for joining us for today's Webinar,
How Joint Commission Accreditation Helps Address the Unique Quality needs
of Multi-Site Skilled Nursing Facilities.
We are thrilled that you are here to join us today, along with my colleague,
Sapna Patel, and our special guest, Jamie Dlatt,
who's the Chief Operating Officer
of the Illinois Division of Legacy Health Care.
What I'd like to do is introduce you to our initial speaker today, Sapna Patel,
She is the Associate Director
of the Nursing Care Center Accreditation Program here at the Joint Commission.
And Sapna's role is to shepherd all of our organizations,
especially the large, multi-site nursing care center organizations,
through the initial stages of the accreditation process,
and Sapna is the one who's going to provide you those needed resources
to begin your journey to accreditation.
So, Sapna, I'm going to hand it over to you to begin.
(Sapna) Thank you, Andrea, and good afternoon, everyone.
And thank you for taking your valuable time and joining us
for this webinar.
In today's presentation, we will go over some of the key ways
how Joint Commission Nursing Care Center Accreditation
can help create a standardization
of processes and policies across multiple sites of an organization.
And then later, as Andrea had mentioned, we will also get a chance to hear
about the value and experience of the accreditation
from one of our existing Joint Commission accredited nursing home customers.
Over the years, we have engaged large organizations in defining
how accreditation can best serve their needs.
And we have identified that these organizations are looking
for an expert's opinion to provide them with the framework and best practices.
They're also looking for efficient, streamline processes,
and they want results.
They want recognition from payers.
They want recognition from the hospitals, from patients.
And in order to achieve such outcomes, organizations are also looking
for a guided journey through this process.
So, over the course of this presentation, we will explain you how accreditation
can deliver these key characteristics that customers are looking for.
Next slide.
We feel that The Joint Commission possesses the expertise
of providing your industry with practical solutions
by making sure that the services are current and are relevant
to ensure critical patient needs.
Next slide.
Going back to the roots of The Joint Commission.
The company was founded in 1951,
and today, we accredit more than 22,000 healthcare organizations in the nation.
We have a full continuum of care services,
and our Gold Seal Award really shows the commitment
to meet the highest national standards for safety by providing excellent care
and safer environment for patients and residents.
Joint Commission has also been a market leader in accreditation
for over 60 years,
and we have been serving the nursing home industry
for over 50 years now.
So the goal is to improve health care delivered to patients
by really collaborating with healthcare organization, such as yours,
in creating a safer environment for the healthcare community.
Next please.
We believe in offering the industry's most comprehensive foundation
for providing safe and effective care of the highest quality and value.
Our standards can be the roadmap to quality,
and they are prepared by seasoned professionals in the industry.
These evidence-based standards go through a rigorous development process.
So before incorporating these standards into an accreditation program,
new standards are tested in the field to ensure that they directly relate
to patient safety, quality of care.
They have positive impact on health outcomes.
They just not only meet, but surpass some of the laws and regulations,
and also can be accurately and readily measured.
And when you ever take an opportunity to review these standards,
we suggest that these standards
should not be viewed as rules to be followed for survey purposes,
but as ideals that can be incorporated or translated into tasks and processes
in order to integrate these into your daily operations.
They are designed to act as a guidepost
for self-assessment of your facility's performance.
Next slide.
Being a leader in patient safety and quality improvement,
The Joint Commission accreditation raises the bar for nursing home settings.
We evaluate the care you provide to your patients.
We want to see how you implement your processes,
and the best way to do that is to observe the care you provide.
Our nationally recognized standards undergo robust performance measures,
and, hence, it includes not only looking
at the provision of care, treatments, and services,
but also incorporates national patient safety goals.
Next, please.
The foundation of accreditation for the Nursing Home Program
is our patient-focused comprehensive standards.
Accreditation is a way you can establish a solid foundation
for a high quality of care and safety for your organization.
By learning about The Joint Commission Standards
and incorporating these into your policies and procedures,
you can implement quality systematically within all the sites of your organization,
and these standards are by no way
just limited to clinical aspects of operations,
but it includes all aspects of your day-to-day operations,
from management operations to staff competencies,
and staff knowledge, all the way to environment of care and life safety.
Next.
Here's a snapshot
of what Joint Commission Nursing Care Center Accreditation Standards include.
As you can see, the Standards are not just limited to the provision of care
around clinical operations,
but goes beyond, including leadership, environment of care,
information management, human resources, rights of individual,
and pretty much your overall operation as a skilled nursing facility.
Again, these serve
as a foundational platform for an organization.
Next.
This innovative delivery of quality of care is obtained through our experts,
who have an extensive background in the nursing care industry,
and they really understand the day-to-day challenges.
All of our clinicians are masters prepared,
and have experience in the nursing home industry
with clinical operations, quality improvement, or education.
The new surveyors receive extensive training
of Joint Commission Policy Survey Processes and Standards
during their orientation, before going out in the field.
We also have educational conferences that highlight new processes,
CMS requirements, new standards, and new industry trends
to really ensure that the surveyors are up to date with all the requirements.
All of our surveyors are employed by The Joint Commission.
We do not use any consultants or other type of non-employed individuals,
because, again, we believe that this practice really allows
for a more consistent and committed surveyor workforce.
Next.
After investing their valuable time and energy
into the accreditation process,
it is valid for organizations to look for results.
And we'll look into how Joint Commission can help you deliver for the results
that you're looking for.
Next.
Accreditation can be a deciding factor
when a family or referral sources are choosing the right fit
for their loved one or patient.
Accreditation in itself is a method for ensuring a strong foundation,
which can be also served as a risk-mitigation tool.
And, at the same time, accreditation acts as a differentiator
in a highly competitive market.
So achieving The Joint Commission's well recognized Gold Seal Award
definitely distinguishes your organization from other nursing homes,
offering the same type of care, and treatment, and services.
And the collective achievement of accreditation by the organizations
also strengthens the morale,
and it includes a sense of accomplishment and distinction
that attracts high-level candidates.
Accreditation is also a process to recognize an entity's status
or qualifications to perform certain activities,
typically also recognized by third-party validations
for its operations.
Finally, voluntary accreditation strengthens the community confidence
in your facility's ability to provide that high-quality and safe care.
It communicates and demonstrates to your community that you are willing
to meet the higher standards of care and safety
that is required in the accreditation.
Next.
This value of partnering with The Joint Commission
was also illustrated in a study that was published in JAMDA,
which measured long-stay and short-stay measures
where The Joint Commission accredited organizations
scored statistically higher compared to their non-accredited counterparts.
We saw that long-stay residents
in The Joint Commission accredited organizations
were performing better with ADL, had less likely to experience falls,
and were resulting in... were less likely resulting in major injuries.
Also less likely to experience moderate to severe pain.
There was minimal use of prescribed anti-psychotic medications.
So, the Joint Commission accredited orgs,
scored higher on all five short-stay measures
when they were compared with the non-accredited organizations.
Next.
More Stars, Better Outcome.
We are aware of how heavily the outcomes impact the overall star ratings.
The study also concluded
that The Joint Commission accredited organizations perform better
than the non-Joint Commission accredited nursing homes
across a broad range of measures,
and scoring statistically higher ratings on overall five-star ratings,
as well as the each of the subcomponents: Health Inspections, Quality Rating,
Staff Rating, and also RN Staff Rating.
Next.
And the study also showed how Joint Commission accredited orgs
perform better on the quality measures, the scope and severity ratings,
financial impacts, compared to the non-accredited orgs.
Next.
Here is the graph of what the study showed.
Here, we can see the blue bar is showing the accredited organizations
along with the add-on post-acute certification.
The yellow bar is indicating the accredited orgs,
and the red bar depicts the non-accredited organizations.
And, as you can see, that the accredited organizations,
including the post-acute certification and just accredited by itself,
performed better in health inspection, quality rating, and staff rating,
and RN staff rating.
Next.
We do realize that we have seen over the years,
that Joint Commission accreditations,
in fact, do increase or enhance patient volumes and referrals.
We get calls from families and even insurance providers
to just check
if a particular facility is accredited with the Joint Commission or not.
And so, our name is trusted by your health care partners and patients,
which have shown an increase in access to referrals
and also contractual relationships.
Next.
These results and outcomes
of the Joint Commission accredited organizations
that are outperforming, compared to the non-accredited orgs,
play a very important role in many value-based models
that are introduced by both public and private payers,
may look at this as a demonstration or an indicator of quality
to really qualify how providers are paying for additional incentives
or even include in the contract participation.
There are state and payers that are widely recognizing
the Joint Commission accreditation.
And we'll look at some of the examples here in a minute.
Next slide.
There are several states in the nation,
such as these 14 states shown in this slide,
where the Joint Commission accreditation can effectively boost the reimbursement
for plan participation and meeting various quality metrics.
Next.
There is a Joint Commission Nursing Care Center,
which is recognized under the Quality Credential in the State of Florida
under the Florida Medicaid Prospective Payment System.
Next.
And also, in the State of Illinois, certain payers
require accreditation for nursing home as a network participation requirement.
Next.
Same goes with the State of Massachusetts,
where certain payers require accreditation as a participation in their network.
Next.
The Ohio Department of Aging
recognizes Joint Commission Nursing Care Center Аccreditation
for its quality initiative that requires licensed nursing homes to participate
in a quality improvement project for every three years.
And as you're aware, Joint Commission accreditation is good for two years.
So, this qualifies the Ohio nursing care centers
for this particular quality program.
Next.
In the State of Tennessee, nursing homes can earn
up to 10 bonus points by achieving The Joint Commission accreditation,
which places the facility into one of the three quality tiers,
along with enhancing the reimbursement.
Next.
Now, I would like to invite Jamie Dlatt, the Chief Operating Officer
of the Illinois Division for Legacy Healthcare.
Legacy Healthcare and The Joint Commission have been able to establish
a long-term collaborative relationship,
and we're very happy to have Jamie here to share the experience and the value
of accreditation for her organization.
Jamie?
Next slide.
(Jamie) Thank you, Sapna.
Good afternoon.
I'm Jamie Dlatt, Chief Operating Officer at Legacy Healthcare.
In 1998, I began my healthcare career in Social Services,
after completing my degree in gerontology and sociology.
A few years later, I was given an incredible opportunity
to become an administrator.
Since joining Legacy, I've had the opportunity to serve
in various leadership roles, including Regional Director of Operations,
Chief Compliance Officer, and Vice President of Operations.
Next slide, please.
Legacy was founded in 2008 with just two facilities.
Today, we have over 52 facilities
across three states, and are still growing.
We are an organization, extremely proud of our accolades and achievements.
In addition to all of our Joint Commission certifications,
we have achieved
Individual Team Member recognition and Facility Specific Quality Awards.
We're proud to recognize that we have 21 AHCA Bronze Awards,
seven AHCA Silver Awards,
three McKnight's Women of Distinction Award winners,
Crain's Notable Women in Health Care,
Newsweek and U.S. News Best Nursing Home Award winners,
and an Administrator Director of Nursing and Environmental Director of the Year
from IHCA.
We were also just recognized for Best Places to Work.
Next slide, please.
In 1998, while working as a social worker for a 300-bed long-term care facility,
I was told by the administrator that we were going to obtain accreditation
from the Joint Commission.
I really had no idea what that meant for the facility, or for me, personally.
I understood there was a lot of work that was needed to prepare for it.
And as I worked on Joint Commission preparations,
it became clear to me how effective The Joint Commission survey's process was.
My first Joint Commission survey was very powerful,
and one I remember vividly to this day.
Joint Commission surveyors are among the most experienced in the business
and come from a variety of healthcare industries.
My surveyor was extremely knowledgeable,
and the lessons she taught me are still of value to me today.
Fast forward to 2008, when I joined Legacy Healthcare,
I had discussed the benefits of Joint Commission with my owners
from the beginning.
And we knew it was something we wanted to be a part of.
Going through the Joint Commission survey process and accreditation,
help shaped our best practices and established
the most rigorous standards to raise the bar in our performance.
We believed that once you hit your bar, keep raising it and continue to do so.
And in 2013, we applied for over a dozen facilities
to become Joint Commission accredited.
The tools and resources that Joint Commission provided
were practical for everyday standards of practice,
and quality improvement, and performance excellence.
I believe going through the Joint Commission survey process
and adopting their tools and protocols,
helped our organization
with the rapid growth we had
and continue to have.
Many people often ask why Joint Commission?
My response is usually the same in return: Why not Joint Commission?
It is an opportunity to align your organization
with one of the most respected names in healthcare.
In addition to the external gains,
with Joint Commission comes many internal rewards.
The survey process brings staff together as a team.
Every staff member is an enormous asset to the survey process,
and Joint Commission recognizes that.
The team members are equally interviewed, and each area is equally important,
whereas in many other types of survey processes,
the focus is often on administration and nurse management.
The feel of importance that is given to all staff empowers every position,
and it should, as without each and every team member's part,
the facilities would never reach the levels of excellence
and achieve their goals.
Next slide, please.
To achieve our accreditation, we decided on a plan and a timeline
between the preparation and the actual survey process,
and then communicated the process to our staff and residents.
We discussed what The Joint Commission survey process and accreditation
meant to our organization.
We reviewed standards,
and made sure we all understood exactly what those standards were.
We then assigned responsibilities for each category,
and conducted an internal assessment
to understand where our current benchmark was,
versus where we needed to be for the actual survey
and for outcomes we were proud of.
As we began to prepare, the tools and resources we used
became very much integrated into our daily routine,
and simply became our best standards of practice, and continue to be so today.
Residents were notified about the survey prior to its starting,
so they felt just as comfortable, as the staff did,
and I recommend that being communicated to residents.
Anything you can communicate to residents
should always be communicated to staff and vice versa.
They should be part of the process and the achievement.
Once we earned our accreditation, everyone celebrated,
especially our residents, and we made sure to celebrate them.
Next slide, please.
The impact enabled us to provide exceptional care and clinical excellence,
and to ensure we have met performance, quality, and safety standards.
The process taught us how adaptable people can be
when you work hard to develop and execute a plan.
People appreciate accountability and are motivated by quality.
They want to be part of something amazing.
I'm extremely employee-driven.
I have always recognized the value of employees and their hard work.
This process reinforced that our employees are the key to our success.
The process energized our staff by allowing them to be challenged
and feel empowered by being able
to measure themselves against higher standards.
Next slide, please.
My advice: plan and prepare.
There is never enough planning
that can go into achieving quality and sound outcomes.
The more you feel prepared, go back and plan again
and prepare, and prepare again.
Engage with your staff.
Staff should be part of the vision
of why an organization wants to achieve accreditation.
Communication is essential, whether the communication lines are top to bottom,
bottom to top, or side-by-side.
Clinical proficiency is necessary.
There's never enough education and training that you can provide to staff
or obtain for yourself while in a leadership position.
Look at what your overall organization means to its community, the residents,
their families, your physicians, and staff.
The quality and dedication of those mentioned are what drives your success
and makes your goals attainable with Joint Commission accreditation
or with any other certifications you're going after.
(Andrea) Thank you so much, Jamie.
And we wanted to make sure to post up some contact information in case
you all do have questions after this webinar.
Here's Jamie's contact information that she was so gracious to provide to us.
Okay, Sapna, back to you.
(Sapna) Sure.
So, thank you, Jamie, for for believing in The Joint Commission
and for such a wonderful, collaborative,
long-term relationship with The Joint Commission.
And, as Andrea mentioned, now we will continue our presentation
by moving on to another characteristic
that was of interest for the organization,
and that is that they are looking for efficiency, efficiency in the process,
and efficiency across the organization.
Next.
But, as we know, efficiency is linked to operational challenges.
Research has shown that as much as 40% of healthcare dollars goes to waste.
And the three main forms of waste are processing inefficiency,
overuse of tests and procedures, and preventable harm or errors.
But, what if there were a single point of framework
for both the leadership and staff to reference
when designing enhancing care and operational processes?
Imagine how that can impact
the communication and efficiencies in your operations.
This is where Joint Commission Standards can help an organization
overcome those operational challenges, help them eliminate the waste,
reduce variation, reduce risk, and, of course, improve quality,
and ultimately, create an operationally efficient process
by fostering a safety culture.
Next.
Here is a complete portfolio of the comprehensive accreditation program
that The Joint Commission provides,
which enhances the efficiency that the organizations are looking for.
Among each of these programs, we also have different certification programs,
which provide an optional add-on to the accreditation.
For nursing care centers, we have
the Post Acute Care and Memory Care Certifications as an option.
And as you can see, if your organization is obviously providing services
to the multiple programs' service lines, then it might be worthwhile
to look into The Joint Commission accreditation
across all of the programs and service lines.
Next slide.
Why our standards help your organization create efficiency?
We start the efficiency right when you decide to apply for the accreditation.
With the Joint Commission accreditation, it's on your terms, you can decide
when you want to apply.
You pick your survey-ready date, along with your own avoid dates,
to help you schedule for your first announced, on-site survey.
Our standards are non-prescriptive,
and hence, we tell you the "what," you tell us the "how."
You have your Joint Commission-connect extranet site,
along with your dedicated account executive,
to guide you through the survey process.
The Gold Seal of Approval can also be earned right after the completion
of the first successful survey.
So, there are no progressive levels
to achieve the accreditation of The Joint Commission.
Next slide.
Along with the dedicated resources,
we have the Business Development staff,
the Account Executive.
There's also Survey Activity Guide and E-dition
to help you prepare for the survey.
And there is a lot of other publications, webinars,
that we conduct to provide an ongoing education
and help you prepare to succeed the path of accreditation.
Next slide.
At the end of each survey, each site receives their survey analysis
for evaluating risk matrix.
The Joint Commission has developed the SAFER Matrix
to provide healthcare organizations
with the information they need to prioritize their resources
and focus on corrective action plans in areas
that are most in need of compliance for activities and interventions.
Each requirement for improvement,
if there was anything noted at the time of the survey,
is noted on this SAFER Matrix, along with your final report.
And the RFIs are plotted on this SAFER Matrix,
according to the likelihood of the RFI,
which could cause harm to patients, staff, or visitors,
and the scope at which it was observed.
Safer Matrix will be included in all the survey's reports,
and the goal is really to drive the level of post survey follow-up that is required.
Next slide.
The SAFER Matrix is provided to each center,
but the C- suite of an organization
has an automatic access to the SAFER Dashboard,
which is a very powerful business analytic tool.
The purpose of SAFER Dashboard
is really to make the survey data available on demand
to our healthcare organizations.
The analysis of the survey finding data
will assist your organization to improve efficiency, bring insights
to aid in identifying potential risk areas,
resulting in better outcomes and higher reliability.
There is an executive summary,
also, that is designed to initially give you a high-level of overview
of your organization,
and there is an organization Survey Detail,
which is intended to give you a deeper dive
in the findings within your organization.
Next slide.
SAFER provides your organization
with an aggregated view of survey findings at the corporate, multi-organization,
and at program level.
It is a self-served centralized data analytic tool to help your organization
compare current and historic performance metrics.
This visual representation of this Dashboard makes it really easy
for you to share the data with other stakeholders,
to draw conclusions, and, obviously, to make timely decisions.
SAFER includes on-demand
Joint Commission National Accreditation Comparison Data,
so you can easily identify your strengths and weaknesses,
compared to your peers,
to help you make critical business decisions.
Next.
And, if you're interested in learning the specifics
of the Nursing Care Center Accreditation Program,
feel free to reach out to us directly,
or you can also click on the links on this slide
to review some of the materials on the programs and the process.
Next.
(Andrea) Okay, well, thank you both Sapna and Jamie for your presentation.
At this time, I'd like to invite our attendees
to submit any questions that they have.
Please use the Question section on your Control Panel.
Just send those on through and do know that no one can see your questions.
So you do have that anonymity.
And I do have some questions for both panelists.
The first one that I have, we had talked about the recognitions,
and we had talked briefly about referral sources.
The question asks: "Jamie, can you talk a little bit more from your experience
about the impact of accreditation on referral resources?"
(Jamie) Sure.
It's a huge part. I mean, we're all familiar with the requirements
from any insurance companies, obviously, to have Joint Commission accreditation.
But it's just so attractive, regardless of the insurance companies,
just looking at your overall referral sources
with hospital-based, community-based and what the consumer looks up.
It's a widely recognized organization
and pairs you with a name, with quality, and that to me
is most important for, I think, any of our referral sources.
(Andrea) Excellent.
And Jamie, if you don't mind, another question that came in,
it talks about... can you talk about the difference
between going through Joint Commission survey versus other experiences
that you've had when it comes to meeting regulatory requirements?
(Jamie) It's a partnership.
I think that's the biggest thing that anyone who has never gone
through Joint Commission accreditation should keep in mind.
The other agencies, shall we say,
that regulate us, are very punitive,
whereas the survey approach for Joint Commission is collaborative.
It's a learning lesson.
It's educational.
Again, it's that effort on both parties to achieve the same goal,
and that doesn't always happen with other regulatory surveys.
And being our same goal is quality, safety, and good care for our residents.
(Andrea) Thank you very much.
Sapna, can you answer this question for us,
and it asks to give a rough timeframe
about how long it takes for preparing for accreditation,
to when you would expect to have your first survey.
(Sapna) Sure.
First of all, when you do start to go forward,
move forward to the accreditation path,
we ask that you sign up for an electronic application.
And that application is good for the whole year.
So, that might answer this question
that it could be as soon as 3 to 6 months, up to a whole year.
But the good thing about this process is as soon as you do apply,
you have a whole one year of timeframe to really prepare for the survey,
using the tools and resources that the Joint Commission has available.
But I have also seen organizations
achieve the accreditation within less than a 3 to 6 month timeframe.
(Andrea) Excellent.
Thank you. I did get a question about the presentation slides,
and they are in the Control Panel.
That's here where you can download the presentation,
and we will be sending a follow-up copy of those along with the recording.
Probably within 2 to 3 business days.
Another question does ask about the requirements.
So, I'm actually going to go back a slide here
just to show this resource
that has hyperlinks here.
Under the link that does refer to request standards access.
If you were to click on that, that will take you to a form
where you can go ahead, fill that out, and it will submit a request for us
to send you access to our Electronic Standards Manual,
which is E-dition, and that will be good for 90 days.
So, that is where you can go ahead and access the Standards
so that you could see what we would look for when we come on site.
Jamie, I do have one more question here for you.
Can you talk about the engagement during the survey with the residents,
when the surveyors are on site and how they interact with your residents?
(Jamie) Sure. I think it's important
when you're doing your initial tour with the surveyor
that you're also introducing the surveyor to a lot of the residents
that are either out and about, or in the hallways,
or would like to meet the surveyor.
Keep in mind, the residents through the communication
are already preparing for the survey as well.
So, they're expecting the surveyor.
So, I think that's important.
No different than the surveyor meets and interviews the staff members day one,
doing the same for the residents.
Or asking the surveyor, and I've done this before,
if they are open to some sort of time limited meet and greet
with the residents prior to the survey beginning.
(Andrea) Great. Thank you so much.
Okay, well, at this time, I do not see any additional questions.
So what I'm going to do is just make sure that we've already presented
Jamie's contact information.
So I wanted to make sure that you had a way to contact us
here at the Joint Commission.
You'll see Sapna's name, and email, and phone number,
along with our other members of our Nursing Care Center Program.
I also wanted to point out,
if you would, please, at the conclusion of today's webinar,
we will post a four question survey.
If you'd please take a few minutes just to fill that out,
that helps us planning content going forward.
And, again, we will be providing a copy of the slides from today,
as well as a recording.
And if you'd like to see some of our previous webinars
that we've recorded, there's a link to our Resource page,
along with our phone, email, and web address.
And please, don't hesitate to follow us on any of the social media buttons
that you see below.
And with that, I'd like to thank you all
for taking time out of your extremely busy day.
Also, of course, to both you, Sapna and Jamie,
for joining me today and presenting today's content.
With that, I'd like to wish you all a wonderful rest of the day,
and we look forward to speaking with you soon.
Take care, everyone.
Bye-bye.