(Melinda) ﻿Hello, everyone, and welcome to today's webinar,
Strategies for A Successful Behavioral Health Survey.
Before we get started, I wanted to go over a few items,
so you know how to participate in today's event.
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including a tracer for suicide prevention,
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Thank you for joining us.
I'd now like to introduce Darrell Anderson,
Business Development Manager
with the Behavioral Health and Human Services Accreditation Program
at The Joint Commission.
Darrell.
(Darrell) Melinda, thank you very much for that introduction.
Hello, everybody, and welcome to today's webinar.
We're glad you could make it.
Both Peter Vance and I hope to make this webinar informative for you
as we all pursue our recovery efforts in response to the COVID pandemic.
Joint Commission is now restarted the surveys,
which were suspended on March 16th this year
as the COVID pandemic gripped the world.
Next slide, please.
The material Peter and I are discussing today will be for an audience
with intermediate accreditation experience.
The next slide, please.
In this webinar, I will discuss the accreditation process itself,
and then Peter Vance will present the surveyors, survey process,
and post-survey activities.
I will then conclude
with some strategies for a successful survey
and resources for assistance.
Next slide, please.
Accreditation is a process--
or a journey, as it's sometimes described--
where, over time, certain events occur.
Next slide, please.
The Joint Commission accredits all healthcare services
from customized approaches to ambulatory, behavioral, home care,
staffing, nursing home, and hospital settings,
along with more targeted certifications,
all of which attest to quality and specialty services.
Next slide, please.
As part of the process going through an accreditation,
me and my colleagues in Business Development
issue E-dition access-- that's the online Behavioral Manual.
We can get that to you simply with an e-mail address
we could link access to through your use.
Then my colleagues and I-- also in Business Development--
can provide an orientation of this tool by phone
where you will then end up with a customized online manual to use
to prepare for a survey.
The applicant can then use customized materials
to reconcile your operation manual
against our Joint Commission Manual as a means of preparation.
This really, in my opinion, the heart of the activity you mostly do.
We, in Business Development, can also, at the same time or some similar time,
create an application for accreditation for you
that's also online.
Then as you prepare,
you use the time waiting for The Joint Commission surveyor to come out,
and you would implement the changes in your manual
and your setting and services as you need to do
using the customized manual we help you create.
When you fill out the application, we'll ask you for a ready date,
and we'll schedule the survey as close to the date as we can,
so make sure you're ready by that date, of course.
Next slide, please.
Once the application is submitted,
through The Joint Commission portal,
the Account Executive will review the application with you by phone
to be sure the correct survey is scheduled.
You're aware that there is an incentive in place right now
for the next couple of weeks until the 30th of June,
whereby you can apply
and waive the usual $7,500 deposit,
which accompanies each new application.
If you need further information on that,
contact us here in Business Development, and we can go through that.
Again, keep in mind, it's good until the 30th of June.
That's about two weeks plus-up.
Next slide, please.
At this point, I think I'd like to turn the presentation over to Peter Vance,
the Field Director for the Behavioral Healthcare Program
here at The Joint Commission.
Peter.
(Peter) Thank you so much, Darrell.
As pointed out, we want to give you a little insights today
about what the survey process entails.
Of course, there are many aspects to The Joint Commission.
Your accreditation with The Joint Commission
involves so much more information and resource
and work with people at the central office.
But many people think of the survey, the survey process, and the surveyors
as the key function--and it is-- of that accreditation process.
Because this is our opportunity to work with you face to face
on Performance Improvement at your organization.
All of our surveyors are experienced and licensed clinicians.
They have experience and background
in a variety of different aspects of Behavioral Healthcare,
substance abuse, child welfare, et cetera--
it's just a couple of examples.
We offer training on an ongoing basis here at The Joint Commission
because we have that opportunity.
Each of our surveyors is an employee.
We actually employ all of our surveyors.
That gives us the opportunity to really work with them,
provide ongoing training
to make sure that they're competent at what they're doing,
and that they stay up to speed on what's happening
in the field of Behavioral Healthcare and Human Services.
Each surveyor is either a full-time surveyor
or a part-time surveyor.
They get quite a bit of experience
not only of just having their own clinical background and experience
but that experience of traveling around the country
to see what is going on in the field of Behavioral Healthcare.
Again, we have a variety of surveyors.
We even--as it notes here--
have some Spanish-speaking surveyors as well
because we do have organizations
that do have Spanish as their primary language.
Next slide.
The balancing act here is that...
One of the key pieces we do is evaluate.
It's exactly what you expect us to do.
We come out--
you've been taking a long time to review standards
to put processes in place--
and we're coming to evaluate that based on the standards.
What we also do is educate.
We had that opportunity to come in
and, again, offer you information based on clinical expertise
but offer you information, also knowing what happens around the country
with all of the organizations that we work for.
We're able to kind of point out what's happening in other areas of the country
or what maybe some organizations are doing very successfully,
with a concept that maybe you're challenged with.
We can provide that information as an educator,
while being an evaluator.
We also like to think of ourselves as being inspirational.
Truly, we do want to work with you in a collaborative way
to ensure that you're providing the best, safest quality care
to the people you serve.
We hope to inspire you to do that
with things, like high reliability, that robust Process Improvement,
and leading the way to zero harm.
These are all ways that we really are trying to drive the field,
and we hope to inspire your organization to do, too.
Next slide.
The on-site survey-- just a few nuts and bolts here.
Our shortest survey is one surveyor for two days.
Any survey is at least going to be two days.
Sometimes at a single site--
let's say, a single IOP, for instance--
would still be two days.
We'll get into some reasons why.
But it has to do with all the activity that we put into the survey process.
Again, it's very comprehensive.
Even though it's a snapshot of your organization in that moment,
it is a comprehensive view of what you do,
and, again, a collaborative effort.
Now, some of our surveys, as you might suspect,
based on the size of an organization, volume of clients,
complexity, number of sites-- all of these things.
So a survey can also be with a team of surveyors
and occur over the course of several days.
Next slide.
You do, as an initial, get a notice of 30 days.
Of course, as Darrell mentioned,
you are in connection with your Account Executive,
and you're letting us know through the application process
when you would be ready for survey.
Just as an aside, we take that date very seriously.
If you say you're going to be ready on a certain date,
we may even show up the day after.
I say that with a slight bit of humor
in the sense that we've had some organizations
that say, "Well, wait a minute. We're not quite ready."
We understand that.
We also understand that sometimes that's just anxiety.
It's totally natural to be anxious about somebody coming out
to evaluate what you're doing.
Again, it's our goal to work with you
and be transparent about the entire process.
We do say we have unannounced surveys.
That is true in some cases.
Many of our organizations do, however, also get a seven-day notice
for a re-survey.
What that means is
there are certain situations-- and there are a few examples here--
where we would want to give you a little bit notice.
I'll just use Foster Care as the example.
One of the things we do--
and I'll talk about this a little more in depth in a moment--
one of the things we do is try to see care where occurs.
For Foster Care, we'll actually be out in a home.
But we also want you to be able to give those families a heads-up
and to check in with them.
That's why we're trying to give a seven-day notice
in some of these situations.
Next slide.
The survey process.
You can go to the next slide, too.
The overview of the survey process here is that you will always have an agenda,
and we'll present that to you that will be available.
If you get that seven-day notice, that will be available at that time.
This gives you an opportunity to review the agenda
to see if maybe there's something that can change
because we absolutely want your feedback.
When the surveyors are on-site,
you can give that feedback on the agenda
based on what may happen.
A key piece to this
is that we really want to see what's happening at your organization.
This is not just a tabletop exercise.
This is not just a review of documentation.
It's working with your staff,
working with the people you serve,
and really trying to connect with everyone at your organization.
We know sometimes organizations would like to have the Directors,
the Program Managers, et cetera,
really answering most of the questions.
One of the things we're really trying to do--
and we take this very seriously--
is to work with all of your staff.
We want to ensure that your staff
are fully aware of your policies and procedures
and implementing them correctly.
That, again, is part of the value of the survey.
We're coming in as that extra set of eyes
to really be able to focus on these areas that you may not have seen.
If we can highlight an area that might be an area of risk
and let you know about it,
we feel very successful,
that we've been able to identify that risk area
that you may or may not have known about.
That's our goal on survey.
We do this by really customizing it to who you are,
what your services are, the population you serve, et cetera.
Again, we do this without trying to disrupt the work you're doing
because we know you're at work.
We're trying to come in and evaluate, educate, and inspire
throughout that process,
which is why we also work with you on the agenda
to be more flexible to your needs as an organization.
On the following slide...
Excuse me.
The opening session is really where all of this starts.
That's where we review the agenda.
That's where we learn about your organization.
This really helps set the tone of the survey
so that we can discuss with you
what your needs are, what your expectations are.
We can tell you a little bit more about The Joint Commission,
and we can find out a lot more about you,
about what your mission and vision and values are,
and just what exactly is that you do, and what population you serve.
So there are all of these things.
We try to do this in a relatively brief amount of time.
But we want to make sure
that this is going to be a meaningful survey event for you,
and that starts at this opening session.
Next slide.
The activity that we really focus on the most throughout the survey
is the clinical care and the services that you provide.
Whatever that service maybe or whatever that clinical care may be,
we follow that care through the tracer process.
The Joint Commission created this tracer process
a number of years ago.
It's really become the standard throughout any type of survey
within or without The Joint Commission.
What it does is it really traces the care or the service
across the continuum of that person's experience.
Whenever they come into your organization,
we trace that at the beginning,
throughout, and even through discharge.
Within that, we're touching on all of the aspects:
What type of care do they receive?
How do they interact with people?
Even your staff--
maybe if it's cafeteria staff in a residential setting
or housekeeping-- something like this.
We're really following all of that interaction,
all of the care and service
throughout that episode that the person is there.
This activity is really the bulk of the survey process
and as noted here, involves directly your staff
and, ideally, individuals served and/or the family that's involved.
Of course, it says "as appropriate" on this slide
because we always want to check in with those people
and make sure that they're just fine with talking to us.
There's no need to...
We do want to hear that
because we want to go to the people who are receiving the services.
It's always such valuable feedback for us, and ultimately for you,
for us to have that interaction.
But it's up to them to choose.
That's an important piece for us, too.
Again, as noted here, we try to do all of that
with as little disruption to your day-to-day activity as possible.
Next slide.
I want to point out a couple of examples here
of a couple of special populations.
You'll see also what are the reason why I'm bringing these up.
As you may suspect, and as I noted, in Behavioral Healthcare,
we really have a variety of services, of treatments
that is being provided.
It really crosses the spectrum.
Substance Use Disorder is one of those populations
that we do accredit.
I use this slide to point out some of the specificities that we look for.
Again, when we go out on-site,
we're trying to tailor the survey to your organization.
Whatever it is that you're providing,
we really want to find out how you're doing that.
When you look at substance use disorder,
we have the expectation, based on our standards,
that you are doing a few certain things
to make sure you're meeting the standards for that population.
Are there specific competencies and training that your staff should have?
For substance use disorder specifically,
we're looking at relapse prevention,
any type of detox or withdrawal management protocols--
those types of things.
We're really looking specifically at your organization.
Substance use, of course, also includes Opioid Treatment Programs,
which we are contracted with SAMHSA--
Substance Abuse and Mental Health Services Administration--
to accredit.
If we go into the next slide,
you'll see that what we also do
is, with our standards, we are constantly improving our standards.
As a Performance Improvement organization, we'd like to say that we walk our talk.
We're always trying to improve our standards.
We're always reaching back to the field
to see what is the latest information
and how that should change best practice.
We have recently updated our substance use disorder standards
with 14 new Elements of Performance.
These are just some of the basic areas that we're looking at
as far as transition of care
and the proper use of urine drug testing.
These are mainly focused
on our chapters of Care, Treatment, and Services and Leadership.
Again, our goal is always to make the survey relevant to you,
what you provide.
That's why we enhance our standards from time to time
in order to be able to meet your needs
with a comprehensive survey.
As we go to the next slide, another population
that we focus on are children in families.
Foster care has always been part of our service structure
from a human service perspective.
With Foster Care, specifically about that survey process,
as noted earlier, we do include the homes
in the survey process.
We also try to have direct interaction with the families
and often have at least a single meeting in the evening,
whether by phone or in person,
whichever is most convenient to the folks you're working with.
But we want to get that interaction with the families.
We want to learn how they've been trained
and how interactive you are with your families
and responsive you are with your families.
This is something that we really focus on for Foster Care.
Again, we work with you to help schedule that.
What's going to be the most appropriate time for the families.
As we move into the next slide, too,
we'll see that this is an area
that we've really taken some time to revise and expand.
We have child welfare standards
that we are presenting very soon.
In fact, coming up in September
is when we have our key launch for our new Child Welfare standards.
It's really part of an overall revision
to our Human Services standards that we have.
We wanted to focus on child welfare to make some edits,
really, to just bring it up to best practice,
bring it up to industry standards.
We pulled in a variety of experts from the field
to work on these, looking at various different research articles
and other market research that we completed on our own.
Some of the key themes here, as noted, have to do with the language around it.
We've been really focusing on trauma-informed practices and approaches
throughout all of our standards.
We really felt it was time now to update that for child welfare as well.
Again, that focus on the family,
some of those holistic services,
really touching on making sure that kinship is involved
and protective services,
and other things that we see related to child welfare
that just weren't as adequately annotated in the standards.
We've improved these, enhanced these,
and, again, for our customers to provide a much more specific survey
to your organization.
Next slide.
Another aspect of the survey process has to do with the physical environment.
For some organizations, that'll be a little more complex than others.
Perhaps, obviously, buildings that house people.
If you house people, that creates an element of risk.
And so, we do focus on those,
which is why all 24-hour settings
will be visited.
If your organization has, say, a combination of some outpatients services
and some residential,
rest assured all of your residential will be surveyed.
The outpatient, we tend to sample
because we can usually get a good sense of what your practices are
for those services with the sampling.
But we also realize that the risk is potentially higher for the environment
and, specifically, the Life Safety Code,
which has to do with mostly the Fire Protection Agency Code
and the services that you provide.
This also includes the actual grounds that you have,
the transportation--
all of these elements of the environment,
as noted in our Environment of Care chapter.
Next slide, please.
Data is another area that we focus on.
It's another session that we have.
Throughout the survey process, we do have these different sessions.
They are used to evaluate but, again, also to educate.
I noted robust Process Improvement earlier.
This is a focus that we've really brought to the forefront:
the idea of high reliability in a healthcare organization.
This is something that The Joint Commission,
as a Performance Improvement organization,
has done for a number of years.
This is something that is really a benefit to our customers,
that we can bring this expertise and experience to your organization.
Some organizations follow this process
of data collection and aggregation analysis
and then turning it into Performance Improvement.
Some follow it very well,
some have very little experience with it.
We try to find out exactly where you are
along that journey of Performance Improvement
and help you progress along that journey.
That is our goal during the data session.
The outcomes measures is highlighted here
because as you'll see in the following slides,
that this is something
that we've really tried to drive in the field as well.
Next slide, please.
Outcomes measures has been very important.
We know that everyone has probably done some level of this.
But what we were seeing in the field
is that if there were outcome measures that an organization had,
that maybe they were doing some type of measurements upon admission
and then maybe a measurement upon discharge.
Really, what we found was that that was a bit of a problem
because what if the person's--
their issue, their story, their progress--
changed during that episode of care treatment or services?
If you found that out as the person was being discharged,
then you have no way to actually intervene with that.
We've really focused on leading the field in measurement-based practice.
We've developed our standards around that.
The idea behind measurement-based practice
is that you're getting that feedback
throughout that episode of care, treatment, or service
so that you can then adjust throughout that episode
to make changes to how you're intervening
with that person.
That's really the key component here:
that you're able to do that.
One of the pieces that is important about this
is that we're looking for a standardized tool
to make that assessment
so that you're able to find out how they're doing
throughout the treatment, care, or service episode
and then make those changes
to meet the needs of the individual served.
This is really a key component.
Going to the next slide,
we've added some information to our website
so that this is not just something out of the blue.
We do have a list of instruments
that we've gathered from our customers
as well as outside from various research.
We fully know that this is not a comprehensive list.
But we thought we'd pull together a list
that would, at least, give you a good start
on what some of these tools look like.
Again, this idea of measurement-based care
is so important that you're able to really have effective care
throughout that episode,
that we wanted to be sure to give you some resources,
and this is a great place to start.
But to be clear, it doesn't mean that these are automatically approved
by The Joint Commission
or that this is an end-all, be-all list.
We know that there are other things out there.
When we're on-site, we're going to work with you
on "Hey, do you have something?"
If what you have, does it meet the standards?
If not, then how do we help identify something that will?
Next slide, please.
As noted,
the instrument of care-- or the instruments--
the tool that's measuring the care is going to be important.
These are the key questions and I think I just went over them.
Are you administering it consistently throughout the care process?
Actually, I guess this is most important.
Do you look at that data and do something?
That's the key piece
throughout all of data management.
When you get that information, what do you do with it?
Do you make changes to your programming?
Do you make specific changes for a specific individual?
We want to see that, we want to review that,
we want to see how all of these changes that you do
can affect even policies and procedures based on the population you serve.
Next slide.
The competence session--
I should say "competency"--
has to do with, often, reviewing human-resource type records,
personnel records-- those types of things.
This gives us an opportunity to see
how you have evaluated your staff,
how you train your staff
and orient them to your practices,
and basically making sure that they can do the job.
We also look at their performance evaluation.
There's the difference between can they do the job--your competency--
and then how are they doing the job--the performance.
Those are two separate concepts.
We treat them as such in the standards.
It's a key aspect of what we're looking for is.
That's a distinction to be made, for sure.
If you have any questions about that,
as always, you can contact our Standards Interpretation Group
as a Joint Commission accredited team
and ask questions about those standards
even outside of your survey.
So keep that in mind.
But this is a significant session that we have
usually a little later in the survey process.
So that we've had a chance to interact with some of your staff.
Then we'll choose a certain number of staff
to review their personnel files.
Next slide.
A system tracer may be applicable to your organization.
There are just a couple of examples here.
A system tracer, like the individual tracer,
is really trying to follow that process from start to finish.
It's following that thread or pulling that thread that we think about.
Medication management is a great example of
if you provide medications or administer medications,
we want to see how that happens.
We'll actually observe medication administration.
We'll review your bed cart and your processes
with nurses or staff on hand.
That would be part of what we call a system tracer.
Tracing, say, one individual served,
following their whole process of how they were prescribed medication,
how it's been administered,
how they responded to it, and what you have done with all that.
Similarly with infection control,
which--not to point out the obvious-- has recently, during the COVID-19 crisis,
become a very significant issue.
I know often Behavioral Healthcare organizations have felt like
infection control wasn't necessarily a significant issue.
Certainly, some of the, maybe, inpatient centers and residential
have put more effort into that.
But now, everyone is actually keenly aware
of the concerns, issues, and responsibilities
that infection prevention and control bring.
That's what we do; it's really review what's happening in your processes.
We may follow a process
through its initiation and implementation
to see what you've done for that.
So that's an idea or an example of what the system tracer may look like.
There are many other aspects that could happen.
Could be restraint and seclusion-- something like that-- et cetera,
that we really try to focus on
and, again, follow that process from start to finish.
Next slide.
Throughout the whole survey process,
we try to be as transparent as possible
and as educational as possible.
One of the ways we do that is that every day,
we have a daily briefing.
That's where we review the previous day's discoveries and discussions.
We will talk about in the morning
what happened on the survey, what was reviewed, what was identified,
if things were scored.
We also, during this time, talk about the safer metrics.
This is one of the ways
that we categorize or prioritize information.
And it's based on risk.
We have found over the years
that identifying risk areas for organizations
is a key component.
It's a key thing that organizations would want us to do.
Whether this be clinical risk or physical risk, financial, et cetera,
we try to point this out.
Safer metric is a nice way
of actually showing where that risk lies
based on the standard that may be scored.
So those will be discussed.
You would have that opportunity to have that discussion
and clarification.
If there was a piece that we missed,
this is your opportunity to bring it forward and let us know.
Honestly, you have that opportunity throughout the entire survey process.
But we set aside the daily briefing in the morning
just for that purpose.
So we can start the day knowing exactly what we've looked at
and what we're then going to look for
during that current day's activities.
Next slide.
A session that is also very important is the leadership session.
This tends to be scheduled near the end of the survey,
again, after we've had an opportunity to review your organization,
work with your staff,
then we're able to come back and sit down with your leadership
and have some discussions about what goes on in your organization.
We talk about some Process Improvement Keys.
We talk about safety culture.
How do you know what's going on in your organization?
How do your staff feel about being safe within your organization?
So it's an opportunity for you, as leaders,
to give us some information,
show us where you shine,
and for us to have a discussion
about places that you can have some improvement
and how that might happen, what that might look like.
So it is, really, probably more of an educational process.
But we do look at how the leadership functions,
how are resources available,
what's the budget look like.
Some of these are nuts-and-bolts things.
But a lot of it is more about how do you work with your staff.
We want to inspire you
toward Performance Improvement
in these areas.
Next slide.
You've heard me mentioned education throughout this.
Again, it's a key component to what we do.
Whether it's happening in the moment with your staff,
which is what we try to do.
If we're working through a tracer and maybe discussing a treatment plan,
and we have some opportunities for improvement,
we're going to have that educational opportunity right then.
It may be during that daily briefing.
When we come back and bring some information to you,
we'll have that opportunity then.
Or it may be during leadership or data management-- one of the sessions.
We take every opportunity for educational purposes,
and we hope that you're open to that.
That's what we ask is that you're open to that,
to listen,
to, hopefully, learn
because our goal is to help you, again,
to grow your organization, to improve your organization.
There's a bit of a humorous piece down here at the bottom of this slide.
"How will the organization measure the success of the survey?"
And the big hint is it should not be the number of findings.
We will find things.
We will score things.
We call those requirements for improvement
because these are the areas of higher risk
that need to have the improvement to meet the intent of the standard.
Whatever is scored,
again, if you think of it more as a guide,
a blueprint to Performance Improvement
to help you along your journey to high reliability,
that's our goal.
That's our goal, is to collaborate with you
to create a guide based on the survey process.
When you get the report, and it has a number of findings,
that's a good thing
in the sense that we've identified some areas
that you now have an opportunity to improve
that you may not have even known about before.
It's not a reflection of, "Oh, if you've had too many,
that this is somehow a negative reflection on you.
It's not a list of demerits.
Again, it's a guide.
It's a blueprint for Performance Improvement.
So that's how we'd like you to think about the survey process.
Next slide.
Should we take all of this while on-site?
We'll wrap it up,
and we summarize it.
We then meet with, first, the CEO, maybe the Executive Director,
whoever the leader is, as they want to meet just on their own,
to review the report initially.
Most of the time, we find organizations like to put all their staff together,
or at least their leadership,
to have that review of the report.
You get to choose.
It's totally up to you.
That report that you receive on-site
is everything that you should already know about
because the surveyor will have been talking to you about it
throughout the survey.
We used to call it the "preliminary report"
because that report's then going to go to The Joint Commission
for a final review.
But you'll get that final report within ten days after the survey
just to make sure that everything seems to be correct and on the level.
But one of the things that we offer is that immediate information
not only throughout the survey,
but then you have a report,
and you can start working on any improvement pieces.
That takes me to the next slide.
The post-survey activities.
You can go ahead and advance.
In that 60-day time frame
after the final report has been submitted
or returned back to you,
you have an opportunity to then start working on your Performance Improvement
related to all of these opportunities that we've discovered
throughout the survey process.
This is where, again, you have contact with your Account Executive,
which, hopefully, you will have lots of contact with your Account Executive
because they can really help answer questions
whether during the survey, before the survey, after the survey.
The Account Executive is really your one-stop contact
with The Joint Commission.
If you have any questions about navigating your extranet sites
or anything else,
they're your person to talk to.
I mentioned the Standards Interpretation Group earlier.
You can utilize them at any point in time,
and especially during this time
when you're trying to develop what we call the Evidence of Standards Compliance.
Your way of taking the scored elements
that we've identified throughout the survey,
then actually putting in some Performance Improvement activity toward them.
That's the post-survey-- in a very nutshell way-- process
for you to then utilize still The Joint Commission information
and resources we have as an accrediting organization
to follow up,
and you create these improvements.
Hopefully, these are being now implemented,
and you're seeing some changes, you're seeing some improvements
along the way on your journey to Performance Improvement.
Next slide, please.
With that,
I've given you a general overview of what happens on the survey,
I'll turn it back over to Darrell, so he can finish out this webinar.
(Darrell) Peter, thank you very much.
That was excellent, and I trust very informative for the audience.
So thank you again.
Yes, strategies for a successful survey.
What do you do as you prepare?
These are some ideas we have here for you.
It will help you to have a successful survey
and do well on your survey.
Next slide, please.
As you might think, understanding these standards
is key to this whole process.
Standards Interpretation Group that Peter mentioned before,
these are experts we have internally
but different specialties,
and they can provide answers to your standards questions
through their portal, which you see here on the slide here.
Next slide, please.
Of course, preparing a game plan.
As you prepare, establish your timeline,
and prepare and reconcile your operating manual
against The Joint Commission E-dition online tool.
You can use the Focus Standards Assessment tool
within the manual to set priorities,
and always approach it as a learning experience.
This is progress, not perfection.
Next slide, please.
One thing that helps in terms of preparing,
bringing your anxiety level down, perhaps, is to practice.
There are Mock Tracers available.
Through the publishing company, JCR, Inc. Here, we have the link.
The applicants should investigate these tools, if they wish,
see if there's something useful,
and the practice of surveying, honing survey skills
by conducting even mock surveys within their setting.
This book of Tracer Questions can assist you in doing it as well.
Next slide, please.
We do have a quotation here
of a child care facility.
It attests to this opportunity for improvement
and building on your strengths as an organization.
Next slide, please.
Then we have some resources for further assistance here
I'd like to show you on the next slides.
Next slide, please.
One thing we do, of course, is these webinars.
Here's a listing of them.
We try to do them at least once a month. Here's the topics.
I encourage you to find one that you like
and please register for them, and if possible, attend them.
Here's a link to doing that, and you see different specialties.
We try to make this very timely and topical.
We're always revising and adding topics and so forth,
then trying to set an agenda.
So, by all means, take advantage of this free resource if you can.
Next slide, please.
Even when we complete this, we post them for replay.
Here's a 30-minute video we've posted
on the strategies.
There's also a second registration
for the past webinars there in the second link.
You can pull those up and view them at your leisure.
Next slide, please.
Here's some other sources for preparation.
On your application, when we create one for you on your site,
there's a Survey Activity Guide.
There's some other links to publications we offer
like Perspectives and other things.
The link here also goes back to JCR, the publisher,
which has online plus print materials
for your perusal, should you want them.
Next slide, please.
A new event we've added is the Child Welfare Webinar.
It's a free virtual education event, actually, on August 20th.
There's some information about it.
There'll be an Executive Director
of the Family Focused Treatment Association,
Pat Willcox from the Klingberg Centers.
You'll hear the surveyor talk about conducting pilot studies
in the organization survey.
You'll also hear more in-depth information
about the standards and the survey processes,
including tips for a successful survey.
As Peter mentioned, we have launched
our Enhanced Accreditation Program for child welfare agencies.
So by all means, if you can register
and take in this free educational event on August 20th,
there's the link for it.
I encourage you to do so.
So, please, save the date.
Next slide, please.
Another thing we do annually is in October,
the Behavioral Healthcare Conference.
Normally, it's a two-day event-- it will be this year--
on October 28th and 29th,
but this year, it is now we just changed it to being a virtual event.
Here's the registration link for that.
This is typically attended on-site near O'Hare,
and it could be an excess of 400 people if we build it in last year's event.
Here now we're going to do it online.
I encourage you to register and take a look at that.
It tends to be a very popular and growing event.
This is a new format, but I think it's well worth taking in.
So, please, do so if you can.
Next slide, please.
At this point, I've concluded the summary of that,
and I'd like to open up the webinar to any questions from the audience.
(Melinda) Thank you, Darrell.
As a reminder, you can submit questions to today's presenters
by typing your questions into the Questions pane of the control panel.
Our first question is,
"Does The Joint Commission have any plans to survey virtually?"
(Peter) This is Peter. That's a great question.
In fact, yes, we have, and we are.
For all of our programs, we have started--
I should say most all of our programs-- we've started a virtual survey.
And for Behavioral Healthcare,
we have started this past week
to provide virtual surveys in certain circumstances.
It's an opportunity that we're trying to do.
We've had some interest in virtual for the past few years.
Obviously, the current circumstances with the COVID-19 crisis
have made this something that is very valuable and necessary,
We've had real success.
Really, to comment from both the surveyor as well as the organization,
has been, "This is just like a survey."
We're very excited about it.
We look forward to continuing that, at least during this crisis.
We're exploring the idea of finding out
how we might be able to continue to use virtual survey in the future.
So yes, we have started doing that.
I'll just add one last thing.
We've done this also for organizations
who, perhaps, maybe they're initial,
and they need to have something quickly.
So that's been one of our focus areas.
(Melinda) All right. Thank you very much.
Our second question is,
"If you have an initial audit already scheduled for September,
could this be delayed due to Joint Commission having to suspend audits
between March and early June?"
(Peter) Yes. First, we don't like to use the word "audits"
because, again, it's a collaborative effort.
We're trying to evaluate.
But, yes, for the survey, if you had something scheduled in September,
our goal is to do it as close to September as possible.
But, as you just alluded to,
when we paused or put our survey process on hiatus,
that's given us a bit of a backlog.
We're trying to work through that.
But, honestly, we're trying to meet those needs as quickly as possible,
especially if you are an initial,
and, let's say, you need this survey
for some type of funding or regulatory mandated scenario.
So it's possible.
If you have any question about it, please contact your Account Executive.
(Melinda) Thank you.
Our next question is,
"Will surveyors evaluate what happened during the COVID pandemic?"
(Peter) Another popular and good question.
The short answer is no.
I'll just answer that very specifically that way.
We understand
that many things have happened over the past couple of months.
We understand that some organizations have been very affected by the crisis,
and some not as much.
So what we've decided to do is, basically, from March 1st,
that's going to be at the start of, essentially, what we kind of call
or consider a "blackout period."
Between March 1st
and then the ending of that is a little bit based on you,
the organization.
If you are back up to what we would say normal operating procedures,
and that happened as of, let's just say, June 11th,
then the time frame would be between March 1st and June 11th,
we really wouldn't score those things.
Again, we're going to have some discussion about it.
We'll point out issues.
But even though I've, hopefully, described very well
that what we score and we report
is all about helping your organization,
we understand that that still feels a bit like,
"Wait a minute, we are in the midst of a crisis.
Why are you scoring us during that time?"
There is definitely a blackout period.
It will, in part, however long it is be determined by you
based on is your organization back up to sort of a normal operating procedure?
(Melinda) Thank you, Peter.
The next question is--
probably for Darrell--
"If I would like to practice a mock survey,
how would I go about doing that?"
(Darrell) Well, thank you.
Yes, normally, when people do mock surveys,
you would take maybe your accreditation leader,
if you've identified such a person,
or if you're larger, and you have the luxury of more resources,
you might want to consult one of those books from JCR
I mentioned in the earlier slides back
and get some ideas from that book
about how you would proceed,
find trace-type questions within that manual
that would the fit with what the service and setting that you offer,
pick the ones most appropriate.
Then go through, literally, the process,
follow their direction, do the tracer.
That will illuminate within your manual.
Depending upon what you're taking a look at the question,
the ways that you currently respond to it,
respond to that issue
within your own practice,
that will give you a mock experience
or a trial experience
of exactly what you're doing, where you might be short,
and where you might need to make some improvements,
and where you look good.
As a general answer to your question,
I think you're literally just doing a bit of a training thing there.
That tends to be a very popular way to prepare.
(Peter) I'm just going to add to that really quick.
When I was in the field,
working as both a Clinician and then as a Quality Director,
I found mock surveys to be so useful.
Really, I just even simply based it on
"What did the surveyor do when they were here?"
There are other materials that are very useful.
But just to be able to give your staff
that opportunity to kind of feel what it's like to be asked questions
and to go through these things, the tracers,
it was just super useful.
- (Melinda) Thank you, Peter. - (Darrell) Thank you, Peter.
(Melinda) Our next question is, "When does The Joint Commission plan
to return to surveying on-site?"
(Peter) Another good question.
We've already started some, actually, this week.
We're doing it very slowly
in the sense that what we have done,
we have developed criteria
based on a great deal of information
our Quality and Research Department has been putting together
to make the assessment or determination of what counties are safer to visit
based on, again, a variety of information.
Then when we discover those counties or identify those counties,
then we see if there are organizations who are ready for survey
at that time
or in that vicinity
and for right now
because, again, we want to make sure
that we're conscious of the needs you have.
We're going to contact you first.
At least throughout the month of June,
we will be contacting organizations
if they fit these criteria of a safer county for us to travel to.
That's a long answer.
But we have return to survey.
The volume of surveys that we're completing is lower at this point.
I think of it as sort of dipping the toe back in the water.
But we're hoping if all goes well,
and we continue to see these counties.
Again, we're focused on the counties
because we know some states overall are still having challenges.
That's why we're really looking at specific counties.
We're hoping to be doing more and more-- I guess that's obvious--
and into July
so that we can get back to a schedule that suits your needs.
(Melinda) Thank you very much, Peter.
We've only got time for about one or two more questions.
Actually, we're at time, so I'm going let Darrell finished up now.
If we did not get to your question today,
we will return your answer by e-mail,
so look for an e-mail from us on that.
Darrell, you want to finish us up here?
(Darrell) Sure. The next slide then.
I believe we should have a slide here of the Business Development people.
We're organized by territories.
Basically, west of the Mississippi is Yvonne Rockwood and Tiffany Holloway,
and east of the Mississippi is Colette Bukowski and myself.
Feel free to reach out to any of us.
There's our direct numbers on our e-mails.
Should you need anything at all, we'd be glad to get you going
and give you a hand on proceeding.
The next slide, please.
When you achieve accreditation, you get the Gold Seal.
We give you all the promotion materials,
we post on our website under Quality Check,
and your testimonial that you provide,
patient and client quality and care.
I thank you for attending this webinar today.
I hope you're able to take in some future ones as well.
Thank you.
(Melinda) Thank you, everyone.
Once you exit today, you're going to receive a short survey,
and we'd appreciate it if you provide your feedback on today's presentation.
You'll also receive an e-mail this afternoon, as we mentioned,
with a copy of the slides and a link to view the replay of today's webinar.
On behalf of The Joint Commission, thank you for joining us today
and have a great rest of your day.
This concludes our presentation.