1. © Copyright, The Joint Commission Quality Tools Available for Critical Access Hospitals December 16, 2010 2:00-3:00pm CST

2. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Agenda 1.Targeted Solutions Tool - Developed by the Joint Commission Center for Transforming Healthcare, this tool is an online application that helps accredited critical access hospitals solve some of the most persistent health care quality and safety problems by developing solutions that are best for their unique hospitals. You’ll receive tips and guidance for sustaining a comprehensive process improvement process. 2.Core Measure Solution Exchange - Participants will learn more about the measure-specific “solution exchange”, which enables critical access hospitals to access solutions/interventions successfully used by other hospitals to achieve and sustain high performance on accountability performance measures.

3. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Agenda 3.Leading Practice Library - This online tool contains a library of real life solutions to help with health care safety and quality challenges that critical access hospitals frequently encounter You’ll learn how to browse through specific topics of interest and review as many documents and topics as needed at any time. 4.Critical Access Hospital Updates for 2011 - Learn about what to expect in the New Year. 5.Questions

4. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Critical Access Hospital Updates for 2011  An Engineer Surveyor will be scheduled for two days to all critical access hospital surveys beginning in 2011.  MS.01.01.01 – revised all Elements of Performance for Medical Staff Bylaws effective March 31, 2011  EC.02.01.01 EP 1 – revision to this Element of Performance – clarified expectation  EC.02.06.05 EP1 – revised Element of Performance to address most current version of Guidelines for Design and Construction of Health Care Facilities  LD.04.01.01 – New Elements of Performance for Distinct Part Units related to utilization review (EPs 17 and 18) effective January 1, 2011. Elements of Performance developed to meet CMS’ request that we now need to address utilization review for hospitals as part of deeming.

5. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Critical Access Hospital Updates for 2011  NPSG.01.03.01 EP1 revised regarding verification process prior to blood transfusion  NPSG.07.04.01 EP 11 revised to address literature and endorsement by professional organization  NPSG.07.05.01 EP 7 revised to address literature and endorsement by professional organization  PC.02.01.05 EP 2 For Rehab Distinct Part Unit only – revised timeframe for team conferences to occur (at least once per week) based on change to CoP language

6. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Contact Us  Critical Access Hospitals that are interested in Joint Commission accreditation can e-mail: jconway@jointcommission.org  We will walk you through the entire accreditation process, from submission of the electronic application to your final accreditation decision report.

7. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission  For more information, see:  http://www.centerfortransforminghealth care.org/ http://www.centerfortransforminghealth care.org/  Or call us at (630) 792-5100

8. © Copyright, The Joint Commission Thank you for your participation! Questions?

9. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission APPENDIX

10. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Top Standards Compliance Issues for Critical Access Hospitals in the First Half of 2010  47% EC.02.03.05: The critical access hospital maintains fire safety equipment and fire safety building features.  44% LS.02.01.10: Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.  40% EC.02.05.07: The critical access hospital inspects, tests, and maintains emergency power systems.  33% LS.02.01.20: The critical access hospital maintains the integrity of the means of egress.

11. Quality Tools Available for Critical Access Hospitals © Copyright, The Joint Commission Top Standards Compliance Issues for Critical Access Hospitals in the First Half of 2010  27% EC.02.06.01: The critical access hospital establishes and maintains a safe, functional environment.  27% MM.03.01.01: The critical access hospital safely stores medications.  27% MS.08.01.01: The medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.  27% MS.08.01.03: Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.