1. © Copyright, The Joint Commission Accreditation Panel – Your Success Factors from The Joint Commission Michael Kulczycki Executive Director Ambulatory Care Accreditation Program 4.26.12

3. MNASCA AnnEdConf.0412 - 3 © Copyright, The Joint Commission Overview of topics  About The Joint Commission  Tips for success in coordinating a successful survey experience  Patient tracers…focus your staff on patient safety every day  Resources available

4. MNASCA AnnEdConf.0412 - 4 © Copyright, The Joint Commission Joint Commission Model  Background –Not-for-profit organization –Accredits over 19,500 total organizations –Awards The Gold Seal of Approval™  Accrediting ambulatory since 1975: –ASCs = single-largest segment –Wide variety of other ambulatory settings –AHC program now accredits over 2,000 organizations with 6,500 sites of care

5. MNASCA AnnEdConf.0412 - 5 © Copyright, The Joint Commission Collaborate with ASC customers  Input to Joint Commission strategic issues via Surgery Advisory Council  Input to Ambulatory standards via Board committee, for example: –Ambulatory Surgery Center Association –American Society of Anesthesiologists / Society for Ambulatory Anesthesia –American Society for Cataract & Refractive Surgery –American Society for Gastrointestinal Endoscopy –Association of periOperative Registered Nurses

6. MNASCA AnnEdConf.0412 - 6 © Copyright, The Joint Commission Joint Commission Model… =  Accreditation partnership = –Independent, outside evaluation –Components = continuous compliance with ambulatory care standards: –On-site survey, every 3 years –Annual self-assessment during interim –Focus on processes for ensuring patient (and staff) safety

7. MNASCA AnnEdConf.0412 - 7 © Copyright, The Joint Commission Partnership = service  Partnership means more than promise of customer service  Live phone coverage & e-mail response at each phase of accreditation  Pre-application via Business Development  Application & pre-survey via Ambulatory- specific Account Executive  Post-survey & thru accreditation cycle  Enterprise expectations for customer responsiveness

8. MNASCA AnnEdConf.0412 - 8 © Copyright, The Joint Commission …Model  Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working as part-time surveyors –Survey 30-100+ organizations annually –Sources of consultation & education  Patient-centered accreditation process

9. MNASCA AnnEdConf.0412 - 9 © Copyright, The Joint Commission Dispelling Joint Commission Myths…  Only for hospitals –ASCs = largest customer segment & segment has doubled in 8 years –Offer ASC-specific & Endoscopy-specific standards –Account handled by Ambulatory-specific team of account executives  Don’t understand ASCs –Accrediting ambulatory providers since 1975

10. MNASCA AnnEdConf.0412 - 10 © Copyright, The Joint Commission …Dispelling Myths…  Survey process only focus on policies –Since 2004, over 60% survey time focuses on patient care thru patient tracer method –Most ASC staff, including surgeons & anesthesiologists, engaged in survey process –Standards clearly indicate documentation requirements (language & icon )

11. MNASCA AnnEdConf.0412 - 11 © Copyright, The Joint Commission …Dispelling Myths  Post-survey process lengthy & complicated –Report with summary of findings delivered ON-SITE –Preliminary decision posted to extranet < 48 hours –Web-based submission of corrections from ASC –Final decision posted <10 days from ASC corrections date

12. MNASCA AnnEdConf.0412 - 12 © Copyright, The Joint Commission Overview of topics  About The Joint Commission  Tips for success in coordinating a successful survey experience  Patient tracers…focus your staff on patient safety every day  Resources available

13. MNASCA AnnEdConf.0412 - 13 © Copyright, The Joint Commission Tips for success…  Submit application 3-6 months in advance, with deposit  Select “ready date” & communicate closely with your account executive  “Ready to go” with your list: Link: http://bit.ly/fZCkcnhttp://bit.ly/fZCkcn  For Medicare “deemed status”, provide copy of Medicare 855B approval letter or Intermediary approval link

14. MNASCA AnnEdConf.0412 - 14 © Copyright, The Joint Commission …Tips for success…  Use educational resources: –Get answers to your standards questions via phone/e-mail –Live & distance education via JCR –Published list of “challenging” ambulatory standards in Perspectives –Network with others (QualityCheck)  Tap experiences of others captured by ASC media (see resources)

15. MNASCA AnnEdConf.0412 - 15 © Copyright, The Joint Commission …Electronic Standards…  Available: > E-dition electronic standards option > All accredited customers & applicants receive one free E-dition & one hardcopy CAMAC standards manual See: www.jcrinc.com/e-dition/www.jcrinc.com/e-dition/ 15Kaiser Perm March, 2012

16. MNASCA AnnEdConf.0412 - 16 © Copyright, The Joint Commission …Tips for success  Get comfortable with standards  Use E-dition electronic product to organize your approach  Understand model for surveyors – how will they engage with your ASC  Prepare by using “mock surveys”  Preliminary, onsite report outlines your immediate next steps to final accreditation decision

17. MNASCA AnnEdConf.0412 - 17 © Copyright, The Joint Commission ASC Medicare survey changes (since 2009)  Adds a day for ASCs over 600 cases/yr  Adds survey session/activities: –Increased record review –CDC Infection Control Worksheet  Changes one patient tracer process –Observe operative case beginning to end

18. MNASCA AnnEdConf.0412 - 18 © Copyright, The Joint Commission Joint Commission Surveyor “Tips” for the Survey  It’s OK…not to know the answer, but know who does  We are reviewing systems, not individuals  Please ask questions; survey should be interactive and educational  Surveyors will minimize disruptions to your delivery of patient care  We will notice things you have never seen  If changes are needed in the agenda, please ask  Time will go by very quickly  There are no surprises at the closing

19. MNASCA AnnEdConf.0412 - 19 © Copyright, The Joint Commission 2011 – Top 10 Survey Challenges  Top 10 ‘Requirements for Improvement’ scored in 2011  Prioritizes “challenges” for customers  Benchmarking opportunity!

20. MNASCA AnnEdConf.0412 - 20 © Copyright, The Joint Commission Overview  About The Joint Commission  Tips for success in coordinating a successful survey experience  Patient tracers…focus your staff on patient safety every day  Resources available

21. MNASCA AnnEdConf.0412 - 21 © Copyright, The Joint Commission On-site Survey Process  Accommodates ASCs normal operational systems & schedules  Few formal interviews –More attention to caregivers & direct patient care  Tracer method allows customization: –Settings / Services / Patients

22. MNASCA AnnEdConf.0412 - 22 © Copyright, The Joint Commission Patient Tracer Method  Used since 2004, engages surveyor directly with staff, surgeons, patients  Accounts for nearly 2/3 of survey time  Customized to ASC services  More focused on execution -- actual delivery of care / services  Frontline staff…what they do, and why do they do it that way  Connects the dots for your ASC staff

23. MNASCA AnnEdConf.0412 - 23 © Copyright, The Joint Commission …Patient Tracer  Traces 3-4 patients through ASCs entire process & facility  Use patient chart as “road map”  Identify performance issues in one or more steps of the process – or between processes  Systems tracer includes dialogue on: –data use, infection prevention & medication management

24. MNASCA AnnEdConf.0412 - 24 © Copyright, The Joint Commission Individual Tracer Activities Can include:  Pre-operative information  Patient reception & intake  Pre-procedural assessment  Intra-operative processes  Post-procedure monitoring  Emergency procedures  Room and equipment turnover  Patient discharge from facility  Patient follow up  Data collection Can involve:  Patient  Family  Surgeon  Anesthesiologist  Nursing  Support staff  Vendors  Contractors 24

25. MNASCA AnnEdConf.0412 - 25 © Copyright, The Joint Commission Overview  About The Joint Commission  Tips for success in coordinating a successful survey experience  Patient tracers…focus your staff on patient safety every day  Resources available (see also Resources section)

26. MNASCA AnnEdConf.0412 - 26 © Copyright, The Joint Commission New ‘Value Adds’ for Joint Commission Customers  Leading Practices Library  Center for Transforming Healthcare www.centerfortransforminghealthcare.org 26

27. MNASCA AnnEdConf.0412 - 27 © Copyright, The Joint Commission Summary  Dispel Joint Commission myths  Provide tips on achieving a successful ASC accreditation survey  Patient tracer process  Value-added services for customers = Resources

28. © Copyright, The Joint Commission What are your questions?

29. MNASCA AnnEdConf.0412 - 29 © Copyright, The Joint Commission Available for assisting MNASCA members For more information call or E-Mail:  Michael Kulczycki, Executive Director, Business Development 630.792.5290 mkulczycki@jointcommission.org mkulczycki@jointcommission.org  Mike Dye, Senior Associate Director, 630.792.5259 mdye@jointcommission.org  Darrell Anderson, Senior Specialist, 630.792.5292 danderson@jointcommission.org

30. MNASCA AnnEdConf.0412 - 30 © Copyright, The Joint Commission Supplemental Resource materials  Sample survey agenda  Detail on accreditation fees  Detail on: –Targeted Solutions Tools –Leading Practice Library  Features of Joint Commission model  What others say: –Customers –ASC media resources

31. MNASCA AnnEdConf.0412 - 31 © Copyright, The Joint Commission The Joint Commission The Joint Commission Sample 2-day Survey Agenda for (small/start-up) ASC/Deemed Survey Day 1  8:00 – 9:00 a.m.Surveyor Arrival & Planning Session  9:00 – 10:00 a.m.Opening Conference & Orientation to Organization  10:00 – 10:30 a.m.Cont. Surveyor Planning Session  10:30 – 12 :30 p.m.Individual Tracer Activity  12:30 – 1:00 p.m.Lunch  1:00 – 2:00 p.m.Individual Tracer Activity  2:00 – 3:00 p.m.Life Safety Code  —Building Assessment  3:00 – 4:00 p.m.System Tracer – Data Management  4:00 – 4:30 p.m.Surveyor Planning Session

32. MNASCA AnnEdConf.0412 - 32 © Copyright, The Joint Commission …..Survey Agenda Day 2  8:00 – 8:30 a.m.Daily Briefing  8:30 – 9:30 a.m.Leadership Session  9:30 – 11:30 p.m. Individual Tracer  11:30 – 12:30 p.m.Environment of Care, Equipment & Emergency Management  12:30 – 1:00 p.m.Lunch  1:00 – 2:00 p.m.Competence Assessment & Credentialing/Privileging  2:00 – 3:30 p.m.Surveyor Report Preparation  3:30 – 4:30 p.m.CEO Exit Briefing & Organization Exit Conference

33. MNASCA AnnEdConf.0412 - 33 © Copyright, The Joint Commission Dispelling Myths about fees…  Accreditation too costly –Only accreditor with transparent & publicly posted pricing –Only accreditor with fees spread across 3-year accreditation cycle –Only accreditor with published fees covering ALL costs, including if deemed status option is used –Typical ASC < $10,000 for three years, or less than $9.00 per day

34. MNASCA AnnEdConf.0412 - 34 © Copyright, The Joint Commission Pricing for ASCs (deemed ) – A 3-year plan YearCase Volume 1 - 600Case Volume 601 - 5000 Year 1 Fees $1,700 deposit with application (credit, NOT additional fee) $1,950 annual fee, offset by $1,700 deposit credit, balance due = $250 On-site survey = $4,150 $1,700 deposit with application (credit, NOT additional fee) $1,950 annual fee, offset by $1,700 deposit credit, balance due = $250 On-site survey = $5,475 Year 2 Fees$1,950 Year 3 Fees$1,950 Total Fees $10,000$11,325

35. MNASCA AnnEdConf.0412 - 35 © Copyright, The Joint Commission Center for Transforming Healthcare (CTH) Targeted Solutions Tools 1.Hand washing 2.Wrong site surgery 3.Hand off communications 4.Surgical site infections

36. MNASCA AnnEdConf.0412 - 36 © Copyright, The Joint Commission

37. MNASCA AnnEdConf.0412 - 37 © Copyright, The Joint Commission TST Benefits  TST is accessible via accredited customers’ Joint Commission Connect extranet – at no additional cost  Saves time and resources and uses organization’s current staff  Provides robust process improvement* (RPI) tools to organizations that do not have the necessary resources to implement their own RPI process *Robust process improvement (RPI) is a way to improve business performance by focusing on specific processes of production

38. MNASCA AnnEdConf.0412 - 38 © Copyright, The Joint Commission See: http://bit.ly/CTH_WSS

39. MNASCA AnnEdConf.0412 - 39 © Copyright, The Joint Commission

40. MNASCA AnnEdConf.0412 - 40 © Copyright, The Joint Commission Coverage of WSS project  See April 2011 issue, for full story: http://bit.ly/SurgStrat_Center http://bit.ly/SurgStrat_Center

41. MNASCA AnnEdConf.0412 - 41 © Copyright, The Joint Commission Leading Practices Library  Launched as web-based service, free to customers  Offers customer-generated “library”: –Sample policies –Patient satisfaction survey –Safety risk assessment  Sorted by program or by standards chapters  Share your own leading practices with others

42. MNASCA AnnEdConf.0412 - 42 © Copyright, The Joint Commission Library is web-based resource

43. MNASCA AnnEdConf.0412 - 43 © Copyright, The Joint Commission Features of Joint Commission Accreditation Accredited Ambulatory Care Organization Periodic Performance Review (PPR) On-site Evaluation Unannounced Surveys & Tracer Methodology Experienced Ambulatory Surveyors Standards Interpretation Education Customer Account Executive Operational Tools for Good Management Lessons Learned -- Leading Practices Library Electronic Manual Risk Reduction Process NPSGs State-of- the Art Standards

44. © Copyright, The Joint Commission Ambulatory Health Care Accreditation Accreditation timeframe – all evaluations produce a 3-year accreditation decision Uses “Employee” Surveyors – ambulatory professionals both employed in ambulatory settings AND working as part-time surveyors Accreditation Report – provided on-site, final decision < 5 days from post-survey steps

45. MNASCA AnnEdConf.0412 - 45 © Copyright, The Joint Commission Ambulatory Service Ambulatory Care Accreditation Timely scheduling & customer service from exclusive Ambulatory team Fully electronic process – from application to post-survey steps Defined, fixed pricing – include all costs, billed over three-years Name recognition -- Gold Seal of Approval ™

46. MNASCA AnnEdConf.0412 - 46 © Copyright, The Joint Commission Tips for success….ASC media  Tap experiences of others captured by ASC media: –SurgiStrategies Aug. 2010, “Accreditation: A Roadmap to Success” http://bit.ly/AccredRoadmap8Z2XEq http://bit.ly/AccredRoadmap8Z2XEq –SurgiStrategies July 2010, “Raising the Bar” http://bit.ly/RaiseBar http://bit.ly/RaiseBar – Outpatient Surgery July 2010, “Accreditation Services: Finding Right Fit” http://bit.ly/RightFit_2010 http://bit.ly/RightFit_2010

47. MNASCA AnnEdConf.0412 - 47 © Copyright, The Joint Commission What others say:  “… share what a “pleasant” experience the survey was. Now that is a strange term for a survey, but the surveyor helped. We learned from her and she listened to us. She took the stress away, and we felt like all our hard work was validated. So our thanks to Joint Commission for changing the “aura” that used to surround your surveys.” ~ Illinois ASC  “Administrator said surveyor made her feel that TJC wants the organization to succeed (and not just find problems as had been past experience).” ~ Kansas City ASC

48. MNASCA AnnEdConf.0412 - 48 © Copyright, The Joint Commission …Others say:  “I could not be more delighted with the service from The Joint Commission: – Account executive has been professional, direct and informative with every interaction – Our survey was timely as promised yet retained the requirements of CMS and the rigors of the TJC standards – Surveyor was knowledgeable, collaborative, direct, professional and courteous. – Our report was posted immediately…the next morning. – TJC was a more cost effective survey fee, and in ability to begin doing Medicare patient procedures” ~ COO, ASC management firm