1. The Nuts and Bolts of Joint Commission Accreditation: Changes for 2006 AARC 51 st International Respiratory Congress Bob Floro, RRT Associate Director Joint Commission Home Care Accreditation Program December 6, 2005

2. Today Requirement Changes and Additions - 2006 Requirement Changes and Additions - 2006 –APR’s –NPSG’s –Standards Accreditation and Survey Processes Accreditation and Survey Processes Unannounced Surveys and Annualization Plans Unannounced Surveys and Annualization Plans

3. Requirement Changes and Additions - 2006

4. Accreditation Participation Requirements

5. APR’s APR 1 Official records and reports APR 1 Official records and reports APR 2 Report changes in application information APR 2 Report changes in application information APR 3 Permits surveys APR 3 Permits surveys APR 10 Misrepresentation of information APR 10 Misrepresentation of information APR 11 Misrepresentation of accreditation status APR 11 Misrepresentation of accreditation status APR 12 Surveyor not used for accreditation- related counseling services APR 12 Surveyor not used for accreditation- related counseling services APR 13 Survey observation by surveyor management staff APR 13 Survey observation by surveyor management staff

6. Accreditation Participation Requirements APR 8 Public notice APR 8 Public notice –EP 1 – If individual has any concerns about patient care or safety, individual is encouraged to contact organization’s management New 2006

7. APR 14 (Revised) Effective January 1, 2006 Addresses annual requirements for Periodic Performance Review New 2006

8. APR 17 (New) Effective July 1, 2005 Effective July 1, 2005 –EP 1 - Staff educated that any employee who has concerns about safety or quality of care may report these concerns to Joint Commission –EP 2 - Staffed informed that no disciplinary action taken if they report –EP 3 - Organization demonstrates commitment by taking no retaliation disciplinary actions against employees who report

9. APR 18 (New) Effective July 1, 2005 Organization adheres to Joint Commission published guidelines for describing information in its Quality Report –Truthful –Accurate

10. APR 19 (New) Effective June 1, 2005 Meet all requirements for timely submission of data and information to Joint Commission

11. 2006 National Patient Safety Goals for HME

12. Joint Commission 2006 National Patient Safety Goals (NPSGs) for HME 1. Patient identification 2. Communication among caregivers 7. Health care-associated infections 8. Medication reconciliation 9. Patient falls 13. Patient involvement in safety

13. Goal 1Improve the accuracy of patient identification. 1AUse at least two patient identifiers whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. 1AUse at least two patient identifiers whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. Clinical Respiratory Services ONLY

14. Goal 2Improve the effectiveness of communication among caregivers. 2AFor verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result. 2AFor verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result. 2BStandardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. 2BStandardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. 2CMeasure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. (CRS RT only) 2CMeasure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. (CRS RT only)

15. 2EImplement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. 2EImplement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. Goal 2Improve the effectiveness of communication among caregivers. New 2006

16. Goal 7Reduce the risk of health care-associated infections 7AComply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. 7AComply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. 7BManage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care- associated infection. 7BManage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care- associated infection.

17. Goal 8Accurately and completely reconcile medications across the continuum of care. 8AImplement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's entry to the organization and with the involvement of the patient. This process includes a comparison of the medications ordered for the patient while under the care of the organization to those on the list. CRS ONLY 8AImplement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's entry to the organization and with the involvement of the patient. This process includes a comparison of the medications ordered for the patient while under the care of the organization to those on the list. CRS ONLY New 2006

18. Goal 9Reduce the risk of patient harm resulting from falls. 9BImplement a fall reduction program and evaluate the effectiveness of the program 9BImplement a fall reduction program and evaluate the effectiveness of the program New 2006

19. Goal 13Encourage the active involvement of patients and their families in the patient's care as a patient safety strategy. 13ADefine and communicate the means for patients and their families to report concerns about safety and encourage them to do so. 13ADefine and communicate the means for patients and their families to report concerns about safety and encourage them to do so. New 2006

20. NPSG Interpretive Guidelines On Joint Commission Website www.jcaho.org On Joint Commission Website www.jcaho.org www.jcaho.org Program-specific Program-specific Used by surveyors Used by surveyors Promotes consistency Promotes consistency

21. For More Information on the NPSGs

22. The Home Care Accreditation Manual and Standards (New for 2006)

23. Standards Review and Rewrite All standards extensively reviewed and modified every 2 years All standards extensively reviewed and modified every 2 years –Internal Evaluation  Standards  Research  Accreditation Operations  Surveyor management & Development  Home Care Program –External Evaluation  Advisory Councils  Professional and Technical Advisory Committee (PTAC)  Standards and Survey Process (SSP)  Board of Commissioners

24. Components of 2006 Standards Standards are statements defining performance expectations, structures and processes. Standards are statements defining performance expectations, structures and processes. Rationale is background, purpose and educational information Rationale is background, purpose and educational information Elements of performance (EPs) are specific statements of expectations and are the only scorable part of the standard. Elements of performance (EPs) are specific statements of expectations and are the only scorable part of the standard.

25. 111 Home Medical Equipment Standards - 2006 RI (19) RI (19) RIGHTS, ETHICS AND RESPONSIBILITIES PC (18) PROVISION OF CARE, TREATMENT AND SERVICES MM (8) MEDICATION MANAGEMENT (CRS ONLY) IC (5) INFECTION SURVEILLANCE PREVENTION CONTROL PI (6) IMPROVING ORGANIZATION PERFORMANCE LD (21) LEADERSHIP EC (23) ENVIRONMENTAL SAFETY AND EQUIPMENT MANAGEMENT HR (7) MANAGEMENT OF HUMAN RESOURCES IM (10) MANAGEMENT OF INFORMATION

26. Sample Standard Standard RI.2.30 Patients are involved in decisions about care, treatment, and services provided. The standard above applies to the following services: HMECRSRT RI.2.30XXX Rationale for RI.2.30 Making decisions about care, treatment, and services sometimes presents questions, conflicts, or other dilemmas for the [organization] and the [patients], family, or other decision makers. These dilemmas may involve issues about admission; care, treatment, and services; or discharge. The [organization] works with [patients], and when appropriate their families, to resolve such dilemmas.

27. Sample Standard Elements of Performance for RI.2.30 Elements of Performance for RI.2.30 The elements of performance below apply to the following services: The elements of performance below apply to the following services: HME HME CRS CRS RT RT EP 1 X X X EP 2 X X X EP 3 X X X EP 4 X X X EP 5 X X X

28. (M) C 1. Patients are involved in decisions about their care, treatment, and services. treatment, and services. (M) C 2. Patients are involved in resolving dilemmas about care, treatment, and services. treatment, and services. (M) C 3. A surrogate decision maker, as allowed by law, is identified when a patient cannot make decisions about his or her care, treatment, and service. and service. (M) C 4. The legally responsible representative approves care, treatment, and service decisions. (M) C 5. The family, as appropriate and as allowed by law, with permission of the [patient] or surrogate decision maker, is involved in care, treatment, and service decisions. Sample Standard

29. Ethics, Rights and Responsibilities RI.1.20 Potential conflicts {PROBLEMATIC} RI.1.20 Potential conflicts {PROBLEMATIC} RI.2.40 - Informed Consent RI.2.40 - Informed Consent –Implementation issues –Consent for care vs. consent for treatment

30. Ethics, Rights and Responsibilities RI.2.90 – Informed of unanticipated outcomes RI.2.90 – Informed of unanticipated outcomes –implementation issues –Reviewable Sentinel Events RI.2.160 Right to pain management RI.2.160 Right to pain management –No longer applicable for HME, Clinical Respiratory, or Rehab Technology

31. Provision of Care, Treatment, Services –PC.2.20 The organization defines assessment activities  Understand applicable bullets  EP 11 - No longer applicable for Clinical Respiratory

32. Provision of Care, Treatment, Services PC.5.20 Physician orders {COMPLIANCE PROBLEM #2 FOR HME} PC.5.20 Physician orders {COMPLIANCE PROBLEM #2 FOR HME} PC.5.50 – Care provided in an interdisciplinary and collaborative manner PC.5.50 – Care provided in an interdisciplinary and collaborative manner –How to implement with limited resources

33. Medication Management Nothing applicable for HME only Nothing applicable for HME only To be discussed in Clinical Respiratory Services section To be discussed in Clinical Respiratory Services section

34. Surveillance, Prevention, and Control of Infection (New Chapter for 2005) IC.1.10 IC Program IC.1.10 IC Program IC.2.10 Identifying risks {Surveillance implementation issues} IC.2.10 Identifying risks {Surveillance implementation issues} IC.3.10 Priorities based on risks IC.3.10 Priorities based on risks IC.4.10 Strategies to implement goals IC.4.10 Strategies to implement goals IC.5.10 Program evaluation IC.5.10 Program evaluation

35. Surveillance, Prevention, and Control of Infection IC.6.10 Influx of infectious patients {Implementation issues for HME} IC.6.10 Influx of infectious patients {Implementation issues for HME} IC.7.10 Qualified individuals IC.7.10 Qualified individuals IC.8.10 Collaboration IC.8.10 Collaboration IC.9.10 Adequate resources IC.9.10 Adequate resources

36. Improving Organization Performance Categories within PI chapter Categories within PI chapter –PI.1.10 Data collection  EP 4 – Med Management - Applicable to Clinical Respiratory  EP 5 – Blood products - Not applicable to any HME

37. Improving Organization Performance Categories within PI chapter Categories within PI chapter –PI.2.10 Data aggregation and analysis {COMPLIANCE PROBLEM #6 FOR HME} –PI.2.20 Undesirable trends analyzed –PI.2.30 Processes for sentinel events –PI.3.10 Data use for performance improvement

38. PI.3.20 Process to identify and reduce safety risks – new in 2005 PI.3.20 Process to identify and reduce safety risks – new in 2005 –EP 1 -Selecting high risk process –EP 2 -Describing process –EP 3 -Identifying process breakdowns –EP 4 -Effects of breakdowns –EP 5 -Prioritize breakdowns Improving Organization Performance

39. PI.3.20 Process to identify and reduce safety risks (cont’d) PI.3.20 Process to identify and reduce safety risks (cont’d) –EP 6 – Determine why occurred –EP 7 – Redesign –EP 8 – Test and implement –EP 9 – Monitor effectiveness of redesign Improving Organization Performance

40. Leadership LD.3.20 Issues regarding same level of care LD.3.20 Issues regarding same level of care LD.3.50 Contracts and contract management {Compliance problem} LD.3.50 Contracts and contract management {Compliance problem} LD.3.90 Written P&P requirement for patient care LD.3.90 Written P&P requirement for patient care

41. Leadership LD.4.40 Integrated patient safety program – not a new concept LD.4.40 Integrated patient safety program – not a new concept –EP 1 - Assignment to manage –EP 2 - Definition of scope –EP 3 - Incorporate organization wide –EP 4 - Procedures to respond

42. Leadership LD.4.40 (cont’d) LD.4.40 (cont’d) –EP 5 - Systems for reporting –EP 6 -Responses to unanticipated adverse events and proactive risk assessment / reduction –EP 7 -Staff support system –EP 8 -Report to governance

43. Environmental Safety and Equipment Management –EC.4.10 Emergency management addressed {COMPLIANCE PROBLEM #1 FOR HME}  EP 1 – Rewrite to exclude HVA language  EP 2 - Eliminated link to county or region command structure –EC.4.20 Regular drills to test emergency management {COMPLIANCE PROBLEM #7 FOR HME} {COMPLIANCE PROBLEM #7 FOR HME} –EC.5.10 - Fire safety  New EPs 11 & 12 – Fire-safe environment in buildings - Applicable to HME all services

44. EC (cont.) Patient equipment management Patient equipment management –EC.6.30 Plans for selection, delivery, setup, and maintenance –EC.6.40 Delivery –EC.6.50 Setup –EC.6.60 Maintenance, testing, inspection {COMPLIANCE PROBLEM #5 FOR HME}}

45. EC (cont.) Patient equipment management (cont.) Patient equipment management (cont.) –EC.6.70 Emergency maintenance –EC.6.80 24 hr emergency services –EC.6.90 Backup –EC.6.100 Storage –EC.6.110 Tracking Organization equipment management Organization equipment management –EC.6.120 to 6.130 Equipment used by staff –EC.7.10 Not applicable for Clinical Respiratory

46. Management of Human Resources HR.1.10 Staffing adequacy – implementation and survey prep issue HR.1.10 Staffing adequacy – implementation and survey prep issue HR.1.20 Qualifications consistent with job responsibilities HR.1.20 Qualifications consistent with job responsibilities –EP 3 – Verification of licensure if only required by organization –EP 4 – Primary Source verification if required by organization HR.3.10 Competency program HR.3.10 Competency program {COMPLIANCE PROBLEM #3 FOR HME} {COMPLIANCE PROBLEM #3 FOR HME}

47. Management of Information IM.2.10 Privacy and confidentiality of information – addresses HIPAA IM.2.10 Privacy and confidentiality of information – addresses HIPAA –Major rewrite and numbering of EPs IM.2.30 IM.2.30 –New EP 4 - Business continuity plan is implemented if systems are interrupted IM.6.20 Patient-specific information {COMPLIANCE PROBLEM #4 FOR HME} IM.6.20 Patient-specific information {COMPLIANCE PROBLEM #4 FOR HME} –New EP 9 - Individuals/organization (from EP 8)

48. Clinical Respiratory Services (CRS) 12 Possible Additional Standards Additional Interpretations in Others

49. CRS Standards RI.2.80 – End of life decisions RI.2.80 – End of life decisions PC.4.10 – POC PC.4.10 – POC PC.5.10 – Correct order and verification PC.5.10 – Correct order and verification MM.1.10 - Patient specific information MM.1.10 - Patient specific information MM.3.20 - Clear orders MM.3.20 - Clear orders MM.5.10 – Safe administration MM.5.10 – Safe administration

50. CRS Standards (cont’d) MM.6.10 – Monitoring meds administered MM.6.10 – Monitoring meds administered MM.6.20 – Response to ADRs MM.6.20 – Response to ADRs MM.7.10 – High risk/high alert process MM.7.10 – High risk/high alert process MM.7.40 – Investigational meds MM.7.40 – Investigational meds MM.8.10 – Evaluate med management plan MM.8.10 – Evaluate med management plan PI.2.20 - Undesirable trends analyzed PI.2.20 - Undesirable trends analyzed

51. Accreditation and Survey Processes New 2006

52. Extranet Application for Accreditation Available on a secure, password-protected web space Available on a secure, password-protected web space Improves quality & consistency of data Improves quality & consistency of data –Pre-population and Update –Same data used by surveyor Allows for efficiency in Joint Commission analysis of organizational information Allows for efficiency in Joint Commission analysis of organizational information

53. Priority Focus Process Process Logic brings consistency to Joint Commission review of pre-survey data Logic brings consistency to Joint Commission review of pre-survey data Shapes survey process Shapes survey process

54. Rules-Driven Priority Focus Process = Previous = Current APS Rules Priority Focus Rules Previous On-site Survey Data Standards Complement Length PFP Output: PFA CSG Relevant Standards, Survey Activity E-App External Data: PMS & publicly available data Surveyor Feedback Loop Fee APS = Application Processing System

55. Priority Focus Areas Top 4 assigned –Assessment and Care/Services –Communication –Credentialed Practitioners –Equipment Use –Infection Control –Information Management –Medication Management –Organization Structure –Orientation and Training –Rights and Ethics –Physical Environment –Quality Improvement Expertise and Activity –Patient Safety –Staffing

56. Clinical Service Groups Assigned as appropriate Home Medical Equipment Home Medical Equipment HME with Clinical Respiratory Services HME with Clinical Respiratory Services HME with Rehabilitation Technology HME with Rehabilitation Technology HME with CRS and RT HME with CRS and RT

57. Tracer Methodology Process surveyors use during on-site survey Process surveyors use during on-site survey Follow patients through organization’s processes and services experienced by patient Follow patients through organization’s processes and services experienced by patient Review systems that support care Review systems that support care Surveyed across programs Surveyed across programs

58. Unannounced Surveys and Annualization Plans New 2006

59. Unannounced Surveys in 2006 Value: Value: –Organizations stop preparing to be surveyed and start preparing to embed quality –Organizations report periodically as they conduct their own tracer activities - PPR –Scores are eliminated –Validation of continual standards compliance

60. Unannounced Changes Advanced mailing of applications for 2006 Advanced mailing of applications for 2006 12 month cycle for application updates in future 12 month cycle for application updates in future New APRs for prompt submission and informing public New APRs for prompt submission and informing public Advanced application processing by Joint Commission staff Advanced application processing by Joint Commission staff Additional application questions refine organizational information Additional application questions refine organizational information

61. Unannounced Changes (cont.) Extranet posting of PFP, introductory letter, bio’s, and surveyor photographs on morning of survey Extranet posting of PFP, introductory letter, bio’s, and surveyor photographs on morning of survey Elimination of pre-survey billing, notification letters, and surveyor phone calls Elimination of pre-survey billing, notification letters, and surveyor phone calls Window widens for scheduling Window widens for scheduling Initial, PPR, small organization, and ESO surveys will remain announced Initial, PPR, small organization, and ESO surveys will remain announced

62. Unannounced Changes (cont.) Initial, PPR, and ESP surveys will remain announced Initial, PPR, and ESP surveys will remain announced –Extension new program surveys are unannounced Agenda change: Surveyor planning session moved to first activity followed by opening conference Agenda change: Surveyor planning session moved to first activity followed by opening conference Communicate special events (e.g. KY Derby, Daytona 500, national political convention, etc.) Communicate special events (e.g. KY Derby, Daytona 500, national political convention, etc.) Use your 10 “avoid dates” wisely – skip federal holidays Use your 10 “avoid dates” wisely – skip federal holidays Don’t assume (due date +/- 45 days, same geography, etc) Don’t assume (due date +/- 45 days, same geography, etc)

63. Annualization Plans Timing Events Due Survey end date + 12 months Application update Application update BBI BBI PPR update PPR update Survey end date + 24 months Application update Application update BBI update BBI update PPR update PPR update Survey end date + 36 months Application update Application update BBI update BBI update PPR update PPR update

64. Subscription Billing Supports annual activities Supports annual activities Two components Two components –Annual Fees – Billed every January – about 20% of current fees –Survey Fees – Billed every 3 years about 30 days after survey – about 40% of current fees Fees will be posted to extranet Fees will be posted to extranet

65. Random Unannounced Surveys Continue in 2006 at 5% of annual volume Continue in 2006 at 5% of annual volume Eligibility remains at 9-30 months Eligibility remains at 9-30 months Focus is on program Priority Focus Areas Focus is on program Priority Focus Areas –Assessment and Care –Infection Control –Patient safety –National Patient Safety Goals

66. Complex Organization Surveys HCOs accredited under more than one Joint Commission accreditation manual HCOs accredited under more than one Joint Commission accreditation manual Replaced “tailored survey” Replaced “tailored survey” Integrated and streamlined process Integrated and streamlined process Customized, focused, efficient, educational Customized, focused, efficient, educational Common standards surveyed once across HCO Common standards surveyed once across HCO Program-specific surveyors survey specialty standards Program-specific surveyors survey specialty standards

67. Corporate Survey Protocol Corporate Survey Process Corporate Survey Process –“Orientation” approach –One day –Multiple surveyors –Multiple surveyor disciplines –Variable services –Where and when –Sequencing of subsequent surveys

68. “The success of Joint Commission accreditation will be measured by our ability to assist HME organizations in embracing quality patient services and safe provision of care as an integral element of their corporate and organizational culture.” “The success of Joint Commission accreditation will be measured by our ability to assist HME organizations in embracing quality patient services and safe provision of care as an integral element of their corporate and organizational culture.” Philosophy

69. Joint Commission Home Care Accreditation Program Central Office – 630-792-5000 (www.jcaho.org) Central Office – 630-792-5000 (www.jcaho.org)www.jcaho.org Program office – 630-792-7441 Program office – 630-792-7441 Bob Floro – 630-792-5741 (rfloro@jcaho.org) Bob Floro – 630-792-5741 (rfloro@jcaho.org)rfloro@jcaho.org Account Representative – 630-792-3004 Account Representative – 630-792-3004 Standards Interpretation – 630-792-5900 Standards Interpretation – 630-792-5900