(Moderator) Hello, everyone, and welcome to today's webinar
on Advanced Certification in Spine Surgery:
The Backbone of a Quality-Driven Spine Program.
Before we get started, I'd like to go over a few items
so you know how to participate in today's event.
You will see the webinar control panel on your computer desktop.
When you joined today's webinar,
you selected to either join by phone call or computer audio.
If, for any reason, you would like to change your selection,
you can do so by accessing the Audio pane in the control panel.
You will have the opportunity to submit questions to today's presenters
by typing your questions into the Questions pane
of the control panel.
You may send your questions in at any time and we will collect these
and address them during the Q&A session at the end of today's presentation.
The handouts are available
in the Handout section of the control panel.
And tomorrow, you will be getting an email with the recording,
a link to the recording, and a copy of the slides
so that you will have access to that content
or share it with your colleagues.
I will now turn it over to Loren Salter,
Associate Director, Hospital Business Development for The Joint Commission.
(Loren) Thank you so much and welcome, everyone.
Thank you for taking some time out of your day to join us.
My name is Loren Salter,
and I am one of the Associate Directors
of Hospital Certification here at The Joint Commission.
And today, we're going to be discussing
the new Advanced Certification for Spine Surgery
that launched July 1st of 2021.
By the end of the webinar,
you'll have an understanding of the components
for Advanced Certification for Spine Surgery;
you'll learn the differences between the Core and Advanced Certifications;
you'll learn about the American Spine Registry;
and we'll discuss the steps to become certified.
There will be a Q&A session at the end of the webinar
so you have the opportunity to ask questions about the above topics
or any other questions related
to the Advanced Certification for Spine Surgery.
As you know, the number of spine surgeries in the US is increasing
and it's probable that your competition is increasing as well.
The Joint Commission Advanced Certification in Spine Surgery
helps elevate your program
with the evidence-based proof of clinical quality and safety
sought by both patients and payers, giving you a leg up on the competition.
Certification is your organization's commitment
to continuous performance improvement,
providing high quality patient care and reducing risks.
Our Advanced Certification for Spine Surgery
is evaluated under the Disease-Specific Care Certification Manual
and it has three main components.
The first component is our standards
and these are something that The Joint Commission publishes,
and it lays the framework for how your program will be structured.
The Advanced Certification has its own set of standards
with verbage specific to requirements,
for Advanced Certification for Spine Surgery.
The next component is Clinical Practice Guidelines.
And providing clinical care consistent with evidence-based medicine
is at the heart of Joint Commission Certifications.
A reviewer will be looking to see
that your chosen clinical practice guidelines
are integrated into your program
and are consistently being utilized.
And the last component to certification is Performance Measurement.
The performance measures
for the Advanced Certification for Spine Surgery
are standardized.
And there are four standardized measures that you're going to collect data on.
And the structure of utilizing these three components
provides a framework for consistency of care
to improve patient outcomes.
By upholding to the highest standards and performance measures,
you gain verified proof of the quality you deliver across the continuum of care.
And when it comes to accreditation,
The Joint Commission is at the center of exceptional patient care.
And these same standards of care
are applied to our Advanced Certification for Spine Surgery.
The certification is more than a badge of honor
and it symbolizes the quality of care
that you can provide to your community
and the passion your program has for its patients.
Evidence-based practices along with our certification standards,
help your organization improve its spine surgery services.
For more than 60 years,
The Joint Commission has been the leader in helping organizations
with quality, safety, and performance improvement.
Our surveyors and reviewers are among the most knowledgeable in their fields
and our accredited and certified organizations
are among the top in the marketplace.
Our experienced supportive advisors help you get started
building upon your existing program to involve the entire continuum of care.
So, we have a team of individuals, our Associate Directors,
that will help you throughout the certification journey.
You'll also have resources from AAOS to help you throughout the process.
So I always like to point out that you have resources available to you
throughout the entire certification journey.
Our viewers will want to observe the handoffs
that occur within each of the phases of care
and really look at that communication that's taking place.
So as part of the two-day review,
the reviewer will observe a spine surgery procedure.
The reviewer wants to get an idea of how your program runs
and how everyone is working together to deliver the best patient care.
If you're interested in learning a little bit more
about what that two-day review entails,
we have a resource known as our Review Process Guide.
And you'll be able to reach out to your Business Development staff
to get that Review Process Guide
to learn about the agenda and materials you should have prepared.
This new Advanced Certification Program helps healthcare organizations
develop consistent communication and collaboration
among all healthcare providers involved in the care of the patient.
Everything from the presurgical consultation
with their spine surgeon,
to the intraoperative, hospitalization or ASC admission,
rehab activities,
and then the follow-up visit with the surgeon.
This premiere certification for Advanced Spine Surgery
elevates your organization for improved patient care.
The Joint Commission offers this certification
in collaboration with the AAOS and the American Spine registry.
The Advanced Certification in Spine Surgery
is available to Hospital and Ambulatory Care Settings.
And it is required that you're participating
in the American Spine Registry,
which is a collaborative effort
of the American Association of Neurological Surgeons
and the American Academy of Orthopaedic Surgeons.
For now, I want to run through a list of the eligibility criteria
for the Advanced Certification for Spine Surgery.
The Advanced Certification is awarded at a site level.
Multiple sites under the same health care
or HCO ID number,
may choose to apply for the DSC certification
for each individual site or only selected sites.
For an individual site to be certified,
that site must be able to independently meet all standards
and requirements for the desired DSC certification program.
The program is in the US,
operated by the US government,
or operated under a charter of the US Congress.
And the program is provided within an organization
that is Joint Commission-accredited,
accredited by another accrediting organization,
or non-accredited.
The program uses a standardized method of delivering clinical care
based on clinical practice guidelines
and/or evidence-based practice.
The program uses performance measurement
to improve its performance over time.
The data collection for these measures must commence four months
prior to the initial certification review visit
for organizations seeking certification.
Data collection is then ongoing after
for all of the ACSS-certified organizations.
The program must have provided spine surgery procedures
to a minimum of 200 patients.
Like I mentioned earlier,
the program must be an active participant
of the American Spine Registry,
and use the data collected from the registry
to analyze and improve processes.
An on-site intraoperative observation
must be conducted by a Joint Commission Reviewer.
So now I'm going to go through the steps that you'll take
if you'd like to pursue certification.
So if you are sitting there
thinking that you want to start this certification journey
but you're just not sure where to begin,
that's where I come in.
And we have a team of individuals like myself
who are there to help you through the certification process.
It's our job to provide you with the necessary resources
that you need during the certification process
and serve as a point of contact if you have questions along the way.
So you can reach out to that email address
that's provided on the screen, which is:
certification@jointcommission.org
to be connected with your local Associate Director.
You'll then want to get a copy of the standards,
and our Business Development Team can set you up with a free 90-day trial
to the online standards known as E-dition.
You can then perform a gap analysis
to see how your program currently compares to the standards.
If you need any assistance walking through the standards,
you can ask your Associate Director for help.
If you need help interpreting a standard,
you can also reach out to our Standards Interpretation Group.
They'll provide you with a written response
on your compliance with the standard
or offer concrete clarification on the standard in question.
And this resource can be found on the Standards tab of our website.
In order to prepare for your application process,
you'll want to identify your clinical practice guidelines.
And like I mentioned in my earlier slide,
providing clinical care consistent with evidence-based medicine
is at the heart of Joint Commission Certifications.
And a reviewer will be looking to see
that your chosen clinical practice guidelines
are integrated into your program and consistently being utilized.
The performance measures
for the Advanced Certification for Spine Surgery are standardized.
Or you may notice that they're referred to as Stage II measures in the manual.
Our guest speakers from AAOS will discuss these in more detail
later on in our webinar.
You're going to share four months worth of data
from those defined measures
when the reviewers are on site for the initial review.
After becoming certified,
you will monitor this data on a monthly basis
and then report it
through the Joint Commission Connect portal on a quarterly basis.
The final step to preparing for the application
is to complete the Performance Improvement Plan.
And this is a series of five questions
that are related to your performance improvement initiatives in your program.
Our Business Development staff can provide you with a template
for these questions
so that you can complete this before even getting into the application.
The application will be done all online
through that Joint Commission Connect Portal,
and your Business Development staff can assist you through this process.
We do ask that your organization submit your online application
about four to six months before you want that onsite review to occur.
And since this would be an initial review,
you will get a 30-day notification of when the onsite review will occur
and this will be a two-day review with one reviewer.
So if you're interested in learning more
about the Advanced Certification for Spine Surgery
or looking to connect with your Associate Director,
you can reach out to this email address on the screen which is
certification@jointcommission.org
And with that, now I'd like to hand it over
to my colleague, Helen Larios, the Project Director
in the Clinical Department of Standards and Survey methods
here at The Joint Commission.
Helen, I'll hand it over to you.
(Helen) Thank you, Loren, and welcome, everyone.
The Advanced Certification for Spine Surgery Program,
as Loren mentioned, is a collaboration
with the American Academy of Orthopaedic Surgeons, known as AAOS,
the American Association of Neurological Surgeons, AANS
and the Americans Spine Registry, ASR.
The ASR is a collaborative effort of the AANS and the AAOS.
The ACSS program is now available
to hospitals; critical access hospitals;
ambulatory surgery centers with Spine Surgery programs
that are accredited, non-accredited, or accredited by other organizations.
Next slide, please.
As Loren mentioned, the ACSS helps healthcare organizations
provide consistent communication and collaboration
of all healthcare providers involved in the care of the patient
from the initial spine surgery consultation
through the follow-up visit with the spine surgeon after discharge
and will assess the level of comprehensive education
in shared decision-making of the spine surgery patient
throughout the entire continuum of care.
Next slide, please.
The ACSS is evaluated
under the Disease-Specific Care certification manual
and has three main components:
the Standards;
the Clinical Practice Guidelines, also known as CPGs;
and the Performance Measures.
The standards incorporate the latest research, literature,
and evidence-based practices,
and were designed to encourage collaboration with the clinical team
and focus on key structural components necessary for safety and quality.
The Clinical Practice Guidelines,
follow the entire scope of the program
and are based on current evidence in the field of spine surgery.
A set of four performance measures from the American Spine Registry
are used to evaluate processes and outcomes of care for the ACSS.
Next slide, please.
The ACSS goes beyond the Core Spine Certification
in that it provides an on-site intraoperative observation,
consistent communication and effective collaboration,
demonstrated application of and compliance with the clinical practice guidelines,
and data collection for clinical performance measures
through the ASR.
Next slide, please.
The principal concepts of the ACSS requirements are as follows:
program composition,
collaboration among all providers,
interdisciplinarity specialized care team,
standardization of care,
preoperative optimization,
education,
performance measures,
and reporting of data through the ASR.
Next slide, please.
The Program Composition includes:
all phases of care in the scope,
standard of care is consistent 24/7,
there's ongoing initiative,
evaluation,
and performance improvement.
Next slide, please.
Collaboration among providers
is the first topic which we will talk about.
Here, we include written transfer protocols,
standardized handoffs and order sets,
transitions of care,
which are consistent communication
--methods and timelines, information exchange,
program's expectations, medical record--
and interdisciplinary pathways.
Next slide, please.
The Interdisciplinary Specialized Care Team.
There are two positions identified for the ACSS
under the leadership roles.
One is the Medical Director and the other is the Spine Coordinator.
A Dedicated Care Team includes:
specialty trained surgeons, nurses, physical therapists.
It also includes: a dedicated spine unit
and an OR Team.
Next slide, please.
Here, we'll be talking about the standardization of care.
The clinical practice guidelines
should be specific to spine surgery patients;
Evidence-based protocols and interventions
will include wrong-level and wrong-site surgery protocols;
perioperative peripheral neuropathies, and visual loss, prevention strategies,
postoperative OT and PT protocols.
The interdisciplinary care pathways are to address and include:
the preop phase, the intra-op phase and the postoperative phase.
Next slide, please.
Preoperative Optimization includes:
patients confirmation and understanding of the procedure,
indications for surgery,
patient assessments and reassessments
that include one general tool and one functional tool.
Next slide, please.
Education can be broken down
into patient education and staff education.
For patient education,
continuum of care education should include:
coverage of medications and incision care,
infection prevention and the follow-up appointment.
A back or spine class should also be included in the program.
For staff education,
program-specific orientation/competencies,
include medical equipment training,
best practice information should also be provided to all staff
and continuing education
and certification will be provided to staff.
Next slide, please.
As Loren mentioned,
a set of four performance measures were adopted from the ASR
and those are: Surgical Site Infection Rates,
New Neurological Deficit,
Unplanned Return Visit to the OR
and PROs, Patient Reported Outcomes.
Next slide.
A little bit more about Reporting of Data to the ASR.
For data collection,
this includes complications related to the procedures.
For the American Spine Registry,
we need to make sure the organizations are using that information
to monitor data and to measure outcomes.
Review measurement results is also included.
And prioritizing identified opportunities
is all part of the reporting structure for the ASR.
Next slide, please.
And now we're going to jump into the differences
between the Core Spine Program and the Advanced Program
Next slide.
So for the scope of the program,
for the Core Program, we currently are looking at hospital or ASC only.
For the ACSS,
this is a more comprehensive look which starts at the physician's office,
and includes the inpatient/hospital-based and outpatient/ambulatory surgery settings
and follows through to the post-op follow-up care organizations.
Next slide,
Under surgical procedures performed,
currently our Core Spine Program
has a Core Spine Certification,
Microdiscectomy, Discectomy, Laminectomy, Spine Fusion
where the requirements are 10 per each Core Program are offered.
The ACSS has a minimum of 200 patients served annually requirement.
Next slide.
Visit and Tracer Sites.
Our current Core Program addresses Hospital and ASCs.
Whereas the ACSS offers
visits and transfer sites that include Physician Office visit
and direct communication with the office staff.
Hospital and ASCs are included.
Next slide.
As Loren mentioned, the reviewer days are different.
For the Core Spine Program it's just one reviewer day
with a Core Spine Certification.
And for the new program, the new ACSS,
there's a two-day intense review of the entire spine surgery program,
which includes an intraoperative observation
on day one or day two of the review,
depending on the schedule for surgery.
Next slide.
Under standards, our Core Spine Certification--
Here, organizations are required to meet the Core standards
under disease-specific care manual.
For the ACSS program, they start off
with the base Core standards in the DSC manual,
and they also need to meet the requirements of the Advanced standards
for the Advanced Certification in Spine Surgery.
For those non-accredited hospitals and non-accredited ASCs,
they will also need to meet additional requirements
found in the AXA appendix and the AXB appendix in our manuals.
Next slide, please.
When we talk about surgical tracers,
the Core Spine Surgery Certification,
we're looking at visit and communications with just the perioperative team.
We expand that for the ACSS to look at surgical observation
and conversations are completed with the entire perioperative team,
meaning that we'll have conversations with the preoperative team,
with the intraoperative team and with the postoperative team.
We look at observations of the hand-offs between each of these care areas.
And we arrange for a reviewer to observe a spine surgery procedure
either on day one or day two.
Next slide.
Hand-offs are an essential component
of the ACSS.
For our current Core Spine Certification,
there are discussions with the staff regarding hand-offs.
But for the ACSS, we look at direct observation
of these hand-off communications
throughout the entire care continuum.
Next slide, please.
As mentioned, communication and collaboration are essential.
For the Core Program, we look at the team within the hospital or ASC.
And we want to see evidence
of organizations working toward High Reliability.
Whereas in the ACSS,
we look at several other components
including shared decision-making,
physician's office visit to post-op discharge care,
we look at hand-offs and transitions within all care areas.
We're looking for evidence
and consensus among practitioners to limit variation
using concepts of High Reliability.
Next slide.
Uniformity or standardization they go hand-in-hand.
The Core Program currently requires programs
in the Hospital or Ambulatory Surgery Center.
And then, the ACSS
looks across the entire continuum of care
starting at the physician's office,
moving through all phases of care and ending in the post-discharge phase.
We're looking at consistency of all physicians in the program.
There should be no significant outliers in the physician practice.
Next slide.
Order Sets are just one way to meet compliance of the standards.
For the Core Program,
we're looking for movement toward standardization of order sets
for all physicians.
For the ACSS,
we're looking for evidence that shows consistency in the use of
standardized pre- and post-op order sets
for all physicians.
Next slide.
Preoperative Optimization.
For the Core Program,
we're looking at notes regarding this being completed.
But for the ACSS, all notes need to be available from providers
as part of the medical record.
Next slide.
As mentioned, standardization is a hallmark of the ACSS program.
Currently, our Core Program has clinical practice guidelines
and order sets available.
The ACSS takes a deeper dive at the clinical practice guidelines
and we want to ensure that they're following
the entire scope of the program.
Order sets should be standardized,
and standardization should occur among physicians, both inpatient and outpatient.
And these clinical practice guidelines should be specific to spine surgery.
Next slide, please.
Physician engagement is a critical factor in the ACSS.
Currently, our Core Program
looks to see if there is a physician champion
and a medical director,
and that they are involved in program initiatives.
Specifically for the ACSS,
a medical director as well as a spine coordinator identified.
The surgeon must have involvement in key performance issues
and program initiatives,
team meetings, data analysis, and performance improvement,
as well as staff in-service and education.
Next slide.
For patient education,
our Core Program looks to see that there is content review
of the preoperative education, such as a back class.
For the ACSS, there's content review of the preoperative education,
but also direct observation of a part of that class.
Just as a side note, there is no minimum class number required.
We just want to observe and make sure that one is being offered.
Preoperative patient interviews, therapy sessions,
patient discharge teaching, and other patient education,
is all a component of patient education for the ACSS.
Next slide.
And then for post discharge,
our Core Program currently reviews hospital and ambulatory surgery settings
discharging processes.
For the ACSS, we're also looking at review discharge processes
but we're taking a deeper dive into reviewing the data communication
from post-discharge entities
to see engaged tracking through patient follow-up visit.
Next slide, please.
And then, functional outcomes.
Our Core Program, at this point, should be considering,
if not implementing, some of the functional outcome measures.
For the ACSS, at this point,
organizations should have strong functional outcome data.
Next slide, please.
Performance Measures.
For the Core Program,
four performance improvement measures of your choice
are included in the program.
Two of these four must be clinical.
But for the ACSS,
four standardized performance improvement measures are required
and, as Loren mentioned, you must be an active participant
in the American Spine Registry
and use the data collected from the registry
to analyze and improve these processes.
Next slide.
And that concludes my presentation on the standards
and the differences between our current Core Spine Program
and the Advanced Certification for Spine Surgery.
I will now turn over the presentation to our colleagues at the AAOS,
Diane and Mariah,
to speak to you about the American Spine Registry.
Thank you.
(Mariah) Great. Thank you, Helen.
As mentioned, today we'll be giving an introduction
to the American Spine Registry.
We will be reviewing the data elements and measures
that sites will need to collect
in order to help meet the Advanced Certification in Spine Surgery,
Next slide, please.
So really,
the purpose for this partnership
between the American Spine Registry and The Joint Commission
is based off of the need for spine data.
As I'm sure many of you are aware,
degenerative spine disease is one of the most prevalent
and costly diseases state and worldwide.
In addition, many different spine cases are a common cause
of work-related disability in the US.
And also, the direct costs from spine care
also exceed over a hundred billion dollars annually in the US.
In addition, utilization of common spine procedures
has increased up to 600% over the last decade.
So there's really been a high increase in the number of procedures being done
as well as the spending on these types of procedures.
In addition to that, about 10 to 25% of spine care,
whether it's diagnostic or therapeutic, is unnecessary or ineffective.
Next slide, please.
So as for the American Spine Registry, we will be asking sites--
hospitals, ASCs-- to collect data and then submit it to the Registry.
When submitting data to us in the American Spine Registry,
these will be for Cervical and Lumbar Degenerative Cases.
We separate the data that we have hospitals collect and submit to us
into three different segments.
The first segment is our procedural-level data.
Within that information, we collect patient demographics,
as well as information about your hospital or site,
and your surgeons who are completing those procedures.
And in addition to that information,
we collect ICD-10 codes for the procedure and the diagnosis of the patient,
as well as other information related to the procedure itself,
including any implementation or instrumentation devices
and graphs that are used during the patient's procedure.
The second segment of data that we collect is any postoperative complications
or any readmissions that a patient may have
after their initial index procedure.
We will collect any of that data.
If a patient comes back in within 90 days of that index procedure,
we'll be collecting that data
as well as any secondary surgical procedures.
If a patient has a stage procedure,
we'll also be collecting that data for the patients.
Next slide, please.
The last segment of data that we will be collecting
is our patient-reported outcomes.
So if your site's currently collecting patient-reported outcomes,
or if you're looking to start collecting those for your patients,
we do have ones that we recommend.
So these are those surveys that patients will take
about their pain and daily functions.
The first two that we collect are either-or.
So there's a PROMIS-10 Global or the VR-12.
Both of those instruments are questions that ask the patient
about their daily quality of life and function.
And then we also collect anatomically specific surveys for the patients,
specifically related to their spine procedure.
For those, we collect either the PROMIS Physical Function survey,
or the Oswestry Disability Index,
or the Neck Disability Index,
depending on if it's a lumbar or cervical case.
In addition to those,
we're also collecting the numeric rating scale for pain.
So, just on the number scale of how the patient is feeling.
Those are the ones that we recommend
because those are the patient-reported outcome surveys
where we will benchmark how your patient scores
versus what we see happen nationally,
if you're collecting additional patient-reported outcomes
or different PROs from what we have listed here,
we do accept additional options, which you'll see a listed at the bottom,
which are just many different versions of the PROMIS survey
as well as the EQ-5D.
Sites can utilize any type of PROM collection method
they're currently using,
or there's also a tool built into the Spine Registry
to help you distribute and collect those surveys
from your patients as well.
Now, I will pass this over to Diane
to go more into the specific measures for the ACSS.
(Diane) Thank you, Mariah. Hello everyone.
So now we'll take a closer look at the performance measures
for the Advanced Certification in Spine Surgery
that are supported by the American Spine Registry.
Next slide, please.
There are four performance measures.
So we'll walk through the numerator, denominator, and description of each
as well as how sites will collect and submit the data to ASR.
The first measure that you see here is Surgical Site Infection Rates.
So this is specific to patients
with a postoperative, surgical-site infection
within 90 days of the primary spine procedure.
The denominator refers
to all primary cervical and lumbar degenerative spine cases
that are submitted to ASR.
And the numerator includes spine cases with documented surgical site infection
within 90 days of the primary procedure.
You'll find for all of these, we're looking at that 90-day interval.
On the next slide we'll review the next measure,
which is New Neurological Deficits.
This is specific to patients with new neurological deficits
that present within 90 days of the primary procedure.
You'll notice we have the same denominator here.
It's inclusive of all primary cervical and lumbar degenerative spine cases
that are submitted to ASR.
And the numerator for this measure includes spine cases
with new and unexpected neurological deficits.
It's defined as having focus motor strength
that's 3 out of 5 or worse.
The next slide covers the third measure, Unplanned Return Visits to the OR.
This measure's specific to patients
who had an unplanned return visit to the operating room
within 90 days of the primary procedure.
The denominator here is the same as the previous measures,
so all primary cervical and lumbar degenerative spine cases
that are submitted to the registry.
The numerator includes all spine cases
that are not part of multi-stage procedures--
and that's an important note for this measure--
with an unplanned return visit to the operating room.
Next slide, please.
The fourth measure pertains to patient-reported outcomes
and collection at pre- and postoperative intervals.
This is defined as the proportion of patients
that are submitted to the registry
who've completed both general health
and spine-specific functional status assessments preoperative,
so 90 days prior to surgery within that 90 to 0 window,
and then 90 days postoperatively,
ASR has recommended PROMs measures that Mariah just shared with you,
as well as those that are also accepted.
The measures are listed here, again, for your reference,
and any of these measures fulfill the requirements
for the fourth ACSS performance measure.
Happy to answer any questions about these.
As Mariah said, if you're already collecting these,
that's great.
If you're not, our team can certainly work with you
to implement this at your facility.
Next slide, please.
This slide provides a nice comparative table
​of the four measures
along with the description, denominator, and numerator for each,
here for your reference.
And then on the next slide,
this is a high-level overview of the data collection
for each of these measures.
The measures are captured via ICD-10 coding
and these lists will be provided for sites by ASR.
Again, this is a high-level overview
you're welcome to share with your team for reference,
but additional details will be available in the data specifications.
Next slide, please.
That example is available here.
The table that was just shared appears here,
it's embedded within the data specifications files.
We have a snapshot for reference.
The tabs are color coded for ACSS content within the 2021 data specifications.
So they're both coded purple for ease of reference.
Again, this will be available within the ASR 2021 data specifications
which should be released to sites shortly.
Next slide, please.
And these specs also include a list of the ACSS coding,
which you see here.
Each measure and corresponding coding
appears in this tab for your team's reference.
And our team's happy to answer any questions you may have
as you begin your participation in the registry.
Next slide, please.
Thank you for your attention during this overview of ASR
and the ACSS performance measures that are captured within ASR.
I'll now pass this back to Loren to continue the webinar.
(Loren) Thank you so much, Mariah and Diane.
So now, we are going to go into the Q&A session.
Just as a quick reminder to folks,
you have the ability to type in questions into the Questions pane
of the webinar panel there.
So go ahead and you can type those in.
Looks like we have a couple of them here,
so I will go ahead and start asking these questions.
Alright, this first question is going to go to Helen.
"The minimum of 200 surgeries, what period of time is this over?
Is it annual or monthly, etc.?"
(Helen) Hi Loren, thank you for that question.
It is annual.
200 patients served annually, thank you.
(Loren) Thank you.
Alright, so this one is going to be for either Diana or Mariah.
It says, "Can the data for ASR be automated
or does it need an abstractor for practice at the hospital?"
(Diane) So I can take that, this is Diane.
It can be automated.
Typically, sites will participate in collaboration with their IT team.
The IT team would typically write queries to pull data from the EMR.
Again, the way sites will submit for the performance measures
is via ICD-10 coding,
which would be associated with the patient's case.
So there is a way to do that electronically,
which obviously makes that easier for sites.
(Loren) Perfect. Thank you.
And then this one is also going to be for you, Diane.
It says, "Do you have specific ICD-10 and CPT codes?"
So there are specific codes.
The coding lists are available within the 2021 ASR data specifications,
which should be released shortly.
For any site that's already
submitted an application for the program
or is considering doing so,
feel free to reach out to our team.
Once those specs are available, we'll be sharing those with sites
so that they have them for reference.
(Loren) OK. Thank you.
This one is going to be for Helen.
It says, "Can you clarify if thoracic spine cases
are included in the certification
and just not in the registry?"
So I guess, what type of spine cases are included in the certification?
(Helen) Thank you for the question.
So, the ACSS includes adult patients
that are undergoing elective cervical, thoracic, and lumbar
spine surgery procedures, including revisions.
- (Loren) Thanks, Helen. - (Helen) Thank you.
(Loren) And then this question is going to be actually for me.
So it says, "Will the slides be available after the presentation?"
And the answer is yes, the slides will be available to you.
Right now, they're actually available in the Handout section
of your webinar panel.
Then you will be getting a link with the recording of this webinar,
along with the slides,
I believe either tomorrow or within the coming days.
Then we just got another question in. And this one is for Helen.
It says, "Can you speak about the designated spine unit?
Is it required for both the Core and the Advanced Certification,
or just the Advanced?"
(Helen) Thank you for the question.
It is just a requirement for the ACSS
and it does not need to be a dedicated spine unit.
What the intent of the standard was that we have qualified individuals--
meaning nurses, practitioners-- on a unit
that would be considered a designated spine surgery unit.
We want our spine surgery patients to be cared for in an environment
where there are qualified practitioners.
(Loren) Great. Thank you.
And then one more for you, Helen.
This one says, "Just to clarify, so this is for elective cases only."
(Helen) Correct. At this point, this program, the ACSS,
includes all adult patients undergoing elective cervical,
thoracic, and lumbar surgery procedures, including revisions.
Pediatric and Trauma cases are excluded from the ACSS at this time.
(Loren) Okay. Thank you.
And then this question is for me.
Actually, I have a couple of questions that I'll answer here.
So the first question is about pricing for the certification.
What I recommend is that,
if you're interested in learning about the pricing for the certification,
you can reach out to the certification team
which was that email address certification@jointcommission.org
to be connected with your local Associate Director,
and they'll be able to provide you with the pricing
and the pricing structure for the certification.
And then another question for me, it says,
"The length of the certification review as well as the certification cycle."
So the certification review will be a two-day review
with one reviewer,
and all of our certification cycles are two years.
So that means every two years you would go for recertification.
So every two years you would have an onsite review.
And again, it's a two-day review with one reviewer.
And then another question that just popped in here.
When do you expect onsite reviews to begin?
So, for this certification,
the Advanced Certification for Spine Surgery,
officially launched as of July 1st,
and all of our initial certifications are now going to be onsite reviews,
so we will be able to have onsite reviews.
I guess that's starting July 1st for this certification.
And then this is another question for myself here.
It says, "Do you recommend a facility obtain Core
prior to applying for the Advanced Certification?
And how long do you need to be a part of the Registry
prior to application?"
I'm going to go ahead and answer that first part here.
You do not need to be Core certified prior to being Advanced certified.
Really it depends on the organization.
Some organizations like to pursue the Core Certification first,
to kind of get their feet wet within the certification process
and go through a two-year certification cycle.
Some organizations like to jump right into the Advanced Certification.
It's really up to the organization and their readiness.
That's when I recommend that you reach out
to your associate director for guidance.
We'll be able to provide you with some resources,
help you throughout that process so that you're able to evaluate
which certification is a best fit for you at this time.
So you do not need to be Core certified
prior to applying for the Advanced Certification.
As far as how long do you need to be a part of the Registry
prior to application,
in the application for certification
you will attest that you are currently participating
in the American Spine Registry.
We want to make sure that you guys are already signed up
and participating in that Registry at the time of your application.
Great questions. And then this one is for Diane or Mariah.
It says, "For the ICD-10 data that's submitted,
is the logic with coding completed on the Registry end
or on the end of the submitter?
(Diane) I can take that.
Sites will submit all eligible cases to the Registry.
And as I mentioned before, that's done so electronically.
So those queries are written at the site level to pull eligible cases.
So any coding associated with those cases
that's specific to the four measures that we discussed today
would be included with the case as it's submitted to the Registry.
So that happens at the site level, the flow of data is really a push
from this site to the Registry.
(Loren) Great. Thank you.
It looks like that is all of our questions, actually,
for right now.
Let me just give it another minute to see if anything else rolls in.
Alright.
Oh actually, here we go. We just got one more.
And maybe, Diane, you can answer this one.
It says, "Does ASR submit data to The Joint Commission?"
(Diane) Thanks Lauren.
So I'm actually going to pull Mariah in for this one.
Mariah, can you speak to the process for ACSS?
(Mariah) Yeah, no problem.
We don't directly submit any information to The Joint Commission.
There will be a report within your dashboard
and within your login to the Registry itself
that you'll be able to pull.
There'll also be a letter they're able to generate
as a self-service option.
And when The Joint Commission comes for their visit,
you're able to pull that information out of the Registry
and then present them with what you have.
We won't directly be submitting it, you have access to all that information
so when your visits come due, you are able to do so.
If you have any questions, though,
when things are coming up or at the time of that,
you can always contact us
to make sure you're able to get the correct information
so you can present that to our friends with The Joint Commission.
(Diane) And just to piggyback off of that as well,
once you get that data from ASR,
you'll be able to put it into the Connect portal,
through The Joint Commission Connect portal.
And you can always reach out to your Associate Director
or your Account Executive to assist with that process.
(Loren) Another question that just came in here,
I'll answer this one.
It says, "If you apply for Advanced Certification
and you do not pass,
can you still get the Core Certification?"
So great question.
If you pursue the Advanced Certification
and the reviewer is there on site for the two-day review
and there's quite a few findings that come up,
or the reviewer feels that maybe the facility isn't suited right now
for the Advanced Certification,
they may be able to turn it into a Core Certification review at that time,
or the other option is turning it into an educational visit.
It really depends on the timing for the reviewer,
if it occurs on day one or day two.
So it is kind of a case-by-case basis on that front.
So there is a possibility that you guys could have a Core Certification review
at that time.
It would just depend, like I said,
on a case-by-case basis with that reviewer.
All right. Well, it looks like that is the end of our questions.
I just want to give a big thank you to all of our guest speakers today.
Thank you so much for your participation,
and I want to thank everyone who's on the line here
who attended the webinar,
we appreciate you taking the time out of your day.
If you have any questions,
feel free to reach out to the email addresses
that were provided in the webinar.
Again, you will be getting a copy of this presentation
along with the webinar recording.
So if you have any other questions, feel free to reach out to us.
And I hope everyone has a great day. Thank you so much.