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March 2011 The Joint Commission Survey Process Overview
San Antonio APIC March 2011 The Joint Commission Survey Process Overview
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TJC Survey Process (hospitals) TJC Chapter Requirements
AGENDA TJC Survey Process (hospitals) TJC Chapter Requirements Periodic Performance Review (PPR) Survey Readiness Infection Control & Prevention Chapter Resources Discussion & Questions
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Provide an overview of TJC Survey Process (hospitals)
OBJECTIVES Provide an overview of TJC Survey Process (hospitals) Review the TJC Chapter Requirements & Infection Control & Prevention Chapter Discuss Periodic Performance Review (PPR) & Survey Readiness Share TJC Survey Related Resources
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TJC SURVEY PROCESS Unannounced Survey Process
Posted on TJC secure extranet site by 7:30 a.m. Survey window – 18 to 39 months after previous full survey Strategic Surveillance System (S3- past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data. TJC Survey Team Composition (based on size & complexity of your organization) -> Lead Surveyor, Administrator, Nurse, Generalist, Specialist (e.g. lab), Life Safety Code Specialist
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TJC SURVEY PROCESS Opening Session (Leadership)– survey overview & orientation to organization Document Review – Policies, Plans, Meeting Minutes, Census Individual Tracer Activity– Isolation Patient, Surgical Patient System Tracers – depends on the size/complexity of your organization Infection Control & Prevention Medication Management Data Use Program Specific Tracers – suicide prevention, patient flow, lab integration Competency & Medical Staff Credentialing & Privileging
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TJC SURVEY PROCESS Infection Control & Prevention System Tracer
Composition of Team (IC members -> Employee Health, Pharmacy, Lab, EVS, Facilities Management, Nursing, Procedure Areas) Scheduled after Document Review & Individual Tracers Discussion - review of accomplishments and opportunities Exit Briefing & Exit Summary - “Summary of Survey Findings Report” Direct Impact Standards Condition of Participation Deficiencies -> Central Office Review Indirect Impact Standards
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Infection Control & Prevention System Tracer
IP Program Assessment & Plan Population Demographics Annual Plan MDROs -> Lab (culture result tracking), Pharmacy, Dietary, EVS, NPSG, tracking SSIs -> Health Optimization Prior to Elective Surgery, types of procedures monitored, Joint, Cardiac and Bariatric Surgery Device Related Infections -> CLABSI, VAP, CAUTI Review of a patient in isolation as a table top tracer Type of isolation Education of staff, patient, visitors Tracking & Notification
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TJC SURVEY PROCESS Potential Accreditation Decision – “Accreditation Survey Findings Report” posted on secure extranet site includes the potential accreditation decision (within 2 days usually) Central Office Review – COP, Immediate Threat, Situational Decision Rules Final Accreditation Decision – Evidence Standards Compliance (ESC) Immediate Threat to Health or Safety Situational Decision Rules Direct Impact Standards (45 days) Indirect Impact Standards (65 days) MOS – 4 months
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Continuum of survey activity outcomes
PA/ A Preliminary Accreditation (Applicable to the Early Survey Policy - 1st time accreditation of new organization) Accredited (Compliance with all standards or successfully addresses RFIs in an ESC within 45 or 60 days) AFS Accreditation with Follow-up Survey (not in compliance with specific standards that require a follow-up survey in 30 days to 6 months – ESC still applicable) Cont Contingent Accreditation (fails Accreditation with Follow-up Survey or does not have a required license, follow-up survey in 30 days) PDA Preliminary Denial of Accreditation (Immediate Threat to Health or Safety, Failure to resolve requirements of AFUS after two opportunities or CA; or Significant Standard Non-compliance) DA Denial of Accreditation Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or a report with a CMS Condition level or APR deficiency will be reviewed by TJC Central Office. Reminder: CMS conducting validation surveys
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TJC CHAPTER REQUIREMENTS
Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TS Standard (Requirement) – statements that define the performance expectations and/or structures or processes Rational – background, justification, additional information Element of Performance (EP) – identify performance expectations References – help to identify related standards/EPs Icons
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TJC CHAPTER REQUIREMENTS
Numbering Requirements Standard six digit number broken down into three sets of two numbers each For Example, IC First two letters are the chapter acronym First two digits refer to the Roman numeral in the outline Second two digits refer to the letter under the Roman numeral in the outline Last two digits refer to the standard number Chapter Roman Numeral Letter in Outline Standard Number IC 02 04 01 Infection Prevention and Control II (section – Implementation) D
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TJC CHAPTER OUTLINE - IC
I. Planning A. Responsibility (IC ) B. Resources (IC ) C. Risks (IC ) D. Goals (IC ) E. Activities (IC ) F. Influx (IC ) II. Implementation A. Activities (IC ) B. Medical Equipment, Devices, and Supplies (IC ) C. Transmission of Infection (IC ) III. Evaluation and Implementation (IC )
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Situational Decisional Rules / Contingent Accreditation
TJC Glossary of Terms EP Element of Performance M Measure of Success required D Written Documentation required 2/3 EP Criticality Tag: 2=Situational Decisional Rule; 3=Direct Impact A/C Scoring Category: A=Y/N; C=3 strikes out What is the time line for resolution of non-compliant findings? What is the immediacy of risk to the patient? Immediate Threat Situational Decisional Rules / Contingent Accreditation Direct Impact Indirect Impact Short High EP Scoring Scale Insufficient Compliance 1 Partial Compliance 2 Satisfactory Compliance Low Long
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Example – Scoring and Icons
Scoring Category Documentation Scoring Scale Criticality Tag 3 MOS
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TJC Periodic Performance Review
Tool for self-assessing compliance with standards and requirements between on-site surveys Process to identify potential areas of concern, and opportunities to make ongoing adjustments.
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PERIODIC PERFORMANCE REVIEW
Organization’s self assessment with chapters, standards and EPs Noncompliant Standard – Plan of Action(POA); Measure of Success (MOS) Completed annually one year after survey Several Options for submission Full PPR and 3 other options
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PERIODIC PERFORMANCE REVIEW
PPR ASSESSMENT BY CHAPTER CHAMPION CHAPTER CHAMPION completes Scoring Facility Administrator concurs/revises scoring Submission to TJC Action Plans MOS OFI Review using resources Questions: Contact Facility Administrator
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TJC Survey Readiness PPR – self assessment & POAs/MOS
Mock Individual/Patient, Progam Tracers – IP and Team Infection Prevention & Control related examples Isolation Patient Tracers – MDRO’s, Precautions Surgical Patient Instrument handling and reprocessing Biohazard Waste Food and Nutrition Services Environment of Care Practice Infection Control System Tracer
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TJC Survey Readiness Facility TJC Readiness Regional Mock Tracers
Scorecard & Executive Summary Facility & System OFI Follow-up Regional Mock Tracers
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Infection Control & Prevention Chapter Summary - Planning
IC – Identifies individual(s) responsible for program IC – Leaders allocate needed resources for program IC – Hospital identifies risks for acquiring and transmitting infections IC – Based upon risks hospital sets goals to minimize possibility of transmitting infection IC – Hospital has an IP and Control Plan IC – Hospital prepares to respond to an influx of potentially infectious patients
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Infection Control & Prevention Chapter Summary - Implementation
IC – Hospital implements its IP and Control program IC – Hospital reduces the risk of infections associated with medical equipment, devices, and supplies IC – Hospital works to prevent transmission among patients, LIPs and staff IC – Hospital offers vaccination against influenza to LIPs and staff
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Infection Control & Prevention Chapter Summary – Evaluation & Improvement
IC – Hospital evaluates the effectiveness of its IP and Control Plan
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National Patient Safety Goals
Goal 7 – Reduce the risk of health-care associated infections Meeting Hand Hygiene Guidelines Preventing MDRO’s Preventing CLABSI Preventing SSI 2012 – VAPs and CAUTI Sentinel Events – separate chapter
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2010 Challenging Standards - IC
Identify risks for acquiring/transmitting infection. IC /EP#1&2 (Identify & prioritize risks based on location, community, and services provided) Reduce the risk of infections associated with medical equipment, devices, supplies. • IC /EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}
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Resources Available JCR & TJC Publications – Perspectives
Infection Prevention & Control Publications TJC Hospital E-dition 2011 (updated July and before January) TJC website ( BoosterPak R3 Report TJC Leading Practice Library Joint Commission Center for Transforming Healthcare ( IP Networking
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TJC BoosterPak (As of January 2011 two BoosterPaks Published)
Full version available on HITT site.
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R3 Report (As of January 2011 One Report Published)
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Leading Practice Library
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Leading Practice Library
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