1 the accreditation process part 2: before, during, after and between the surveys

1 The Accreditation Process Part 2: Before, During, After and Between the Surveys

2 Speaker Information Mark E. Schario, MS, RN, FACHE Field Director Accreditation and Certification Operations The Joint Commission

3 BEFORE THE SURVEY

4 Eligibility for Preliminary Accreditation The Early Survey Policy is available to any organization that is currently not accredited, except an organization that has been denied accreditation. An organization must declare during the application process that it wishes to be surveyed under this policy. The First Survey When an organization chooses to be surveyed under the Early Survey Policy, The Joint Commission conducts two on-site surveys, both of which will be announced, unless the organization is using accreditation to meet deemed status purposes. The Joint Commission can conduct the first survey as early as two months before the organization begins its operations, provided that the organization meets the following criteria: It is licensed, or, has a provisional license according to applicable law and regulation.

5 Eligibility for Preliminary Accreditation (Continued) The building in which the services will be offered or from which the services will be coordinated is identified, constructed, and equipped to support such services; It has identified its CEO or administrator, its director of clinical or medical services, and its nurse executive, if applicable; It has identified the date it will begin operations. Generally, the first survey uses a limited set of standards and assesses only the organizations physical facilities, policies and procedures, plans, and related structural considerations. For this reason, organizations surveyed under this policy are not recognized by CMS to meet the requirements for Medicare certification.

6 Eligibility for Preliminary Accreditation (Continued) Preliminary Accreditation Decision The Joint Commission grants Preliminary Accreditation to an organization that is in satisfactory compliance with a limited set of the standards and their EPs assessed in the first survey (See the Early Survey Policy Option chapter). An organization that is not in satisfactory compliance must reapply and begin the accreditation process again. The Preliminary Accreditation decision includes assignment of an additional announced survey against the full set of applicable standards within six months of the first survey. (Note: The survey will be unannounced for organizations seeking to meet CMS deemed status requirements.) The survey assesses the organizations compliance with all applicable EPs.

7 Eligibility for Preliminary Accreditation (Continued) For an organization that has begun its operations when the survey is conducted, if it does not receive any RFIs, the effective date for its Preliminary Accreditation decision is the day after the survey is conducted. If the organization receives at least one RFI and therefore must submit an acceptable ESC report that resolves all RFIs, the effective date for Preliminary Accreditation is the date of the acceptable ESC submission. For an organization not in operation at the time of the survey, if it does not receive any RFIs, the effective date for its Preliminary Accreditation decision is the day after it begins its operations. If the organization receives at least one RFI and therefore must submit an acceptable ESC report that resolves all RFIs, the effective date for Preliminary Accreditation is the date of the acceptable ESC submission. (Note: Any organization not in operation at the time of survey must confirm in writing the date it begins operating.)

8 Eligibility for Preliminary Accreditation (Continued) A Preliminary Accreditation decision remains in effect until the organization has completed a second, full survey or until The Joint Commission has withdrawn the Preliminary Accreditation. Organizations may stay in Preliminary Accreditation for one year. The Joint Commission may withdraw Preliminary Accreditation in the following situations: If an organization that was not providing services at the time of the first survey does not begin providing services when expected If an organization does not meet the survey eligibility criteria If an organization fails to accept the date of the second survey and If an organization is found to be not in satisfactory compliance with the applicable standards and their EPs In any of these cases, the organization must begin the accreditation process again.

9 Eligibility for Preliminary Accreditation (Continued) The Second Survey The second survey under the Early Survey Policy is an announced full accreditation survey. (Note: The second survey will be unannounced for organizations seeking to meet CMS deemed status requirements.) The Joint Commission conducts this survey at either of the following times: Approximately six months after the first survey At a time frame selected by the organization within six months of the acceptance of its first ESC for organizations seeking to meet CMS deemed status requirements Based on survey results, the organizations accreditation decision then changes to one of the following: Accredited Accreditation with Follow-up Survey Contingent Accreditation Preliminary Denial of Accreditation Denial of Accreditation (See Accreditation Decision Categories on page ACC-64 for descriptions of these decisions in the CAMH)

10 Eligibility for Preliminary Accreditation (Continued) The effective date of the accreditation decision is the day after the second survey if the organization does not receive any RFIs. If the organization receives at least one RFI and therefore must submit an acceptable ESC report that resolves all RFIs, the effective date for Preliminary Accreditation is then set retroactively to the date of the acceptable ESC submission. The organizations accreditation cycle begins the day after the second survey was conducted, unless The Joint Commission reached a decision to deny accreditation.

11 Electronic Application for Accreditation When an organization notifies The Joint Commission that it wants to become accredited, The Joint Commission provides the organization with information explaining how to access and complete the E-App on the organizations secure Joint Commission Connect site. Initial applications are valid for one year. An organization needs to complete and submit its E-App upon initial application for survey, and will be asked to verify the information annually. An organization can provide updates to the E-App at any time, as it can access the E-App 24 hours a day, 7 days a week. (See Changes Affecting E-App Information on page ACC-85 in the CAMH)

12 Accuracy of the Application Information The Joint Commission schedules surveys based on information provided in an organizations E-App. Based on the information provided, The Joint Commission determines the number of days required for a survey and the number and type of surveyors. Inaccurate or incomplete information in the E-App may necessitate an additional survey, which could delay the processing of survey findings and rendering of an accreditation decision. It may also cause the organization to incur additional survey charges.

13 Accreditation Contract and Business Associate Agreement Organizations seeking Joint Commission accreditation for the first time or reaccreditation with The Joint Commission must submit a signed accreditation contract and a signed Business Associate Agreement. The contract outlines the responsibilities of both the organization and The Joint Commission relative to the accreditation process. This contract is separate from the E-App. Contracts are available for printing and approval via each organizations secure Joint Commission Connect site. Governmental organizations may enter into unique contracts with The Joint Commission in accordance with the scope of services available from The Joint Commission and the laws for contracting that bind that government entity.

14 Priority Focus Process (PFP) An important component of the Joint Commissions accreditation process is the PFP, which guides the surveyor(s) in planning and conducting the on-site survey. It focuses survey activities on the organization-specific issues that are most relevant to safety and quality of care (referred to as priority focus areas or PFAs). PFP can be considered a process for standardizing the PFAs for review during survey. PFP uses an automated tool, which takes available data from a variety of sourcesincluding the E-App, previous survey findings, complaint data, and publicly available external dataand integrates them to identify clinical/service groups (CSGs) and PFAs for the hospital. PFP converts these data into information that focuses survey activities, increases consistency in the accreditation process, customizes the accreditation process to make it specific to a given hospital, guides tracer activities (see Tracer Methodology on page ACC-50 in the CAMH)

15 Priority Focus Process (PFP) (Continued) Each hospital will receive PFP information for its top PFAs and CSGs on its Joint Commission Connect site. Complex organizations that are surveyed under more than one accreditation program will receive accreditation program-specific PFP information and organization-level PFP information that summarizes all accreditation programs data and information. From these sources, the PFP identifies for each hospital the PFAs on which the surveyor(s) will focus during the initial part of the on-site survey. The surveyor(s) will use the PFP in the following ways: The surveyor(s) assigned to the hospital will have access to the hospitals PFP information via the surveyor extranet. The surveyor(s) will review the PFP information for hospital-specific PFAs as well as for hospital-specific CSGs. As part of the survey planning process, the surveyor(s) will begin to assess and plan his or her tracer activities.

16 Priority Focus Process (PFP) (Continued) During the on-site survey, the surveyor(s) will use the hospitals active patient list to select tracer patients. As the survey progresses, the surveyor(s) may find other priority areas that need to be addressed and may begin to focus less on the PFP suggested list and more on what he or she is finding. The PFP will also be used for a hospital undergoing its initial survey. For initial surveys, The Joint Commission will only be able to feed E-App data, external data (as applicable), and Office of Quality Monitoring data (as applicable) into the PFP.

17 Priority Focus Process (PFP) (Continued) After these data are transformed to become the PFP information, the process for initial surveys is no different from the process for any other type of survey. The data will be aggregated in the same manner to determine the PFAs and CSGs for the hospital. PFP data are updated quarterly, as changes warrant. (Note: Organizations will receive an updated report only if there is a change to one or more PFAs and/or CSGs in their programs since the previous PFP Summary Report. Due to the systems nature of the PFAs and CSGs, it is possible that there may not be a change from one quarter to the next.) The PFP Reports are shared with surveyors before the on-site survey to focus the survey and can also be used by organizations to support continuous performance improvement activities.

18 Priority Focus Areas (PFAs) PFAs are processes, systems, or structures in a health care organization that significantly impact safety and/or the quality of care, treatment, and services provided. The PFAs provide a consistent yet customized approach to providing an initial focus for the on-site survey process, and they may assist the health care organization at the time of its PPR.

19 Priority Focus Areas (PFAs) (Continued) PFAs guide the surveyor with assessing standards compliance in relation to the individual tracer activities. Outside formal conferences/interviews, much of the survey will consist of reviewing issues in the form of tracers. The tracer methodology incorporates the use of the PFP information, follows the care, treatment, or service experience for individuals initially identified by CSGs, and allows the surveyor to identify performance issues that may be related to PFAs for your organization (see Tracer Methodology on page ACC- 50 in the CAMH). Definitions for each of the PFA categories follow.

20 Priority Focus Areas (PFAs) (Continued) Assessment & Care/Services Assessment & Care/Services for patients comprise the execution of a series of processes that are fluid in nature to accommodate needs of patients including, as relevant, screening; assessment; planning care, treatment, and/or services; provision of care; ongoing reassessment of care; and discharge planning, referral for continuing care, or discontinuation of services.

21 Priority Focus Areas (PFAs) (Continued) Successful implementation of improvements in Assessment & Care/Services relies on the full support of leadership. Subprocesses of Assessment & Care/Services include the following: Screening Assessment Planning care, treatment, or services Provision of care, treatment, or services Reassessment Discharge planning or discontinuation of services

22 Priority Focus Areas (PFAs) (Continued) Communication Communication is the process by which information is exchanged between individuals, programs/services, or organizations. Effective Communication successfully permeates every aspect of a health care organization, from the provision of care, treatment, and services to performance improvement, resulting in a marked improvement in the quality of care delivery and functioning. Subprocesses of Communication include the following: Provider and/or staffpatient communication Patient and family education Staff communication and collaboration Information dissemination Multidisciplinary teamwork

23 Priority Focus Areas (PFAs) (Continued) Credentialed Practitioners Credentialed Practitioners are health care professionals whose qualifications to provide care, treatment, and services have been verified and assessed, resulting in the assignment of clinical responsibilities. The Credentialed Practitioners category varies from organization to organization and from state to state. It includes licensed independent practitioners and others who are permitted to provide care, treatment, and services to patients under the direction of a sponsoring physician. Licensed independent practitioners are permitted by law and the health care organization to provide care, treatment, and services without clinical supervision or direction within the scope of their license and consistent with individually assigned clinical responsibilities or individually granted privileges.

24 Priority Focus Areas (PFAs) (Continued) Equipment Use Equipment Use incorporates the selection, delivery, setup, and maintenance of equipment and supplies to meet the needs of patients and staff. It generally includes movable equipment, as well as management of supplies that staff members use (for example, gloves, syringes). (Equipment Use does not include fixed equipment such as built-in oxygen and gas lines and central air conditioning systems; such items are included in the Physical Environment PFA.) Equipment Use includes planning and selecting; training and orientation; maintaining, testing, and inspecting; educating and providing instructions; delivery and setup; and risk prevention related to equipment and/or supplies. Subprocesses of Equipment Use include the following: Selection Maintenance strategies Periodic evaluation Orientation and training

25 Priority Focus Areas (PFAs) (Continued) Infection Control Infection Control includes the prevention, surveillance/identification, and control of infections among patients, employees, physicians and other licensed independent practitioners, contract service workers, volunteers, students, and visitors. Infection Control is a systemwide, integrated process that is applied to all programs, services, and settings. Subprocesses of Infection Control include the following: Prevention and control Surveillance/identification Reporting Measurement

26 Priority Focus Areas (PFAs) (Continued) Information Management Information Management is the interdisciplinary field concerning the timely and accurate creation, collection, storage, retrieval, transmission, analysis, control, dissemination, and use of data or information, both within an organization and externally, as allowed by law and regulation. In addition to written and verbal information, supporting information technology and information services are also included in Information Management. Subprocesses of Information Management include the following: Planning Procurement Implementation Collection Recording

27 Priority Focus Areas (PFAs) (Continued) Subprocesses of Information Management continued: Protection Aggregation Interpretation Storage and retrieval Data integrity Information dissemination

28 Priority Focus Areas (PFAs) (Continued) Medication Management Medication Management encompasses the systems and processes used to provide medication to individuals served by the organization. Usually a multidisciplinary, coordinated effort of health care staff who implement, evaluate, and constantly improve the processes of selecting, procuring, storing, ordering, transcribing, preparing, dispensing, administering (including self- administering), and monitoring the effects of medications throughout the patients continuum of care. Medication Management involves educating patients and, as appropriate, their families about each medication, its administration and use, and potential side effects.

29 Priority Focus Areas (PFAs) (Continued) Subprocesses of Medication Management include the following: Selection Procurement Storage Prescribing or ordering Preparing Dispensing Administration (including self-administration) Education Monitoring

30 Priority Focus Areas (PFAs) (Continued) Organizational Structure Organizational Structure is the framework for an organization to carry out its vision and mission. Implementation is accomplished through corporate bylaws and governing body policies, organization management, compliance, planning, integration and coordination, and performance improvement. Organizational Structure includes the organizations governance, as well as business ethics, contracted organizations, and management requirements. Subprocesses of Organizational Structure include the following: Management requirements Corporate bylaws and governing body plans Organization management Compliance Planning Business ethics Contracted services

31 Priority Focus Areas (PFAs) (Continued) Orientation & Training Orientation is the process of educating newly hired staff in health care organizations to organization wide, department, program, service, and job-specific competencies before they provide care, treatment, or services to patients. Newly hired staff includes, but is not limited to, regular staff employees, contracted staff, agency (temporary) staff, float staff, volunteer staff, students, housekeeping, and maintenance staff.

32 Priority Focus Areas (PFAs) (Continued) Training refers to the development and implementation of programs that foster staff development and continued learning, address skill deficiencies, and thereby help ensure staff retention. More specifically, training entails providing opportunities for staff to develop enhanced skills related to revised processes that may have been addressed during orientation, new care techniques for patients, or expanded job responsibilities. Whereas orientation is a one-time process, training is a continuous one. Subprocesses of Orientation & Training include the following: Organizationwide orientation Program/service orientation Job-specific orientation Training and continuing or ongoing education

33 Priority Focus Areas (PFAs) (Continued) Patient Safety Patient Safety entails a framework for proactively identifying the potential and actual risks to safety, identifying the underlying cause(s) of the potential or actual risk, and making the necessary improvements to reduce risk. Also entails establishing processes to respond to sentinel events, identifying risks through root cause analysis, and making necessary improvements. Involves a systems-based approach that examines all activities within an organization that contribute to maintaining and improving patient safety, including performance improvement and risk management, to ensure that the activities work together, not independently, to improve care and safety.

34 Priority Focus Areas (PFAs) (Continued) This systems-based approach is driven by organization leadership; anchored in the organizations mission, vision, and strategic plan; endorsed and actively supported by medical staff and nursing leadership; implemented by directors; integrated and coordinated throughout the organizations staff; and continuously re-engineered using proven, proactive performance improvement modalities. Effective reduction of errors and other factors that contribute to unintended adverse outcomes in an organization requires an environment in which patients, their families, and organization staff and leaders can identify and manage actual and potential risks to safety.

35 Priority Focus Areas (PFAs) (Continued) Subprocesses of Patient Safety include the following: Planning and designing services Directing services Integrating and coordinating services Reducing and preventing errors Using Sentinel Event Alerts The Joint Commissions National Patient Safety Goals Clinical practice guidelines, if available Actively involving patients in their care, treatment, or services

36 Priority Focus Areas (PFAs) (Continued) Physical Environment The Physical Environment refers to a safe, accessible, functional, supportive, and effective physical environment for patients, staff members, workers, and others. This is accomplished by: managing physical design; construction and redesign; maintenance and testing; planning and improvement; and risk prevention, defined in terms of utilities, fire protection, security, privacy, storage, and hazardous materials and waste. Physical Environment may include the home in the case of in-home programs and foster care.

37 Priority Focus Areas (PFAs) (Continued) Subprocesses of Physical Environment include the following: Physical design Construction and redesign Maintenance and testing Planning and improvement Risk prevention

38 Priority Focus Areas (PFAs) (Continued) Quality Improvement Expertise/Activities Quality Improvement Expertise/Activities identifies the collaborative and interdisciplinary approach to the continuous study and improvement of the processes of providing health care services to meet the needs of consumers and others. Quality Improvement Expertise depends on understanding and revising processes on the basis of data and knowledge about the processes themselves. Quality Improvement Activities involve identifying, measuring, implementing, monitoring, analyzing, planning, and maintaining processes to ensure they function effectively. Examples of Quality Improvement Activities include designing a new service, flowcharting a clinical process, collecting and analyzing data about performance measures or patient outcomes, comparing the organizations performance to that of other organizations, selecting areas for priority attention, and experimenting with new ways of carrying out a function.

39 Priority Focus Areas (PFAs) (Continued) Subprocesses of Quality Improvement Expertise/Activities include the following: Identifying issues and establishing priorities Developing measures Collecting data to evaluate status on outcomes, processes, or structures Analyzing and interpreting data Making and implementing recommendations Monitoring and sustaining performance improvement

40 Priority Focus Areas (PFAs) (Continued) Rights & Ethics Rights & Ethics includes patient rights and organizational ethics as they pertain to the care of patients. Rights & Ethics addresses issues such as patient privacy, confidentiality, and protection of health information, advance directives (as appropriate), organ procurement, use of restraints, informed consent for various procedures, and the right to participate in care decisions. Subprocesses of Rights & Ethics include the following: Patient rights Organizational ethics pertaining to patient care Organizational responsibility Consideration of patient Care sensitivity Informing patients and/or family

41 Priority Focus Areas (PFAs) (Continued) Staffing Effective staffing entails providing the number of competent personnel with the appropriate skills mix to meet the needs of a health care organizations patients based on the organizations mission, values, and vision. As such, it involves defining competencies and expectations for all staff. Subprocesses of Staffing include the following: Competency Skill mix Number of staff

42 DURING THE SURVEY

43 During the Survey During an accreditation survey, The Joint Commission evaluates an organizations performance of functions and processes aimed at continuously improving patient outcomes. The survey process focuses on assessing performance of important patient centered and organization functions that support the safety and quality of care, treatment, and services. This assessment is accomplished through evaluating an organizations compliance with the applicable standards in this manual, based on the following activities and information: Tracing the care, treatment, and services delivered to patients Verbal and written information provided to The Joint Commission On-site observations and interviews by Joint Commission surveyors Review of documents provided by the organization

44 During the Survey (Continued) The Joint Commissions accreditation process seeks to help organizations identify and correct problems and improve the safety and quality of care, treatment, and services provided. A survey is designed to be individualized to each organization, to be consistent, and to support the organizations efforts to improve performance. The Joint Commission determines the length of a survey based on information supplied in the E-App that describes the organizations size and scope of services. Joint Commission surveyors may conduct some survey activities on evenings, nights, and weekends, as necessary, for full surveys of three or more days. These off-shift visits do not occur before the opening conference at the start of the survey.

45 The On-Site Survey This section includes information relevant to an organization that has applied for an accreditation survey and is ready for the survey process. It provides an overview of the survey process, including use of the PFP. The Joint Commissions accreditation process focuses on systems critical to the safety and the quality of care, treatment, or services. It represents a shift from a focus on survey preparation to a focus on continuous operational improvement by encouraging hospitals to incorporate the standards as a guide for routine operations. Under this accreditation process, the unannounced full survey is the on- site evaluation piece of a continuous process. The accreditation process encourages organizations to embed the standards into routine operations to achieve and maintain excellent operational systems on an ongoing basis. Initiatives such as the continuous PPR and the sharing of PFP information facilitate this.

46 Unannounced Surveys The Joint Commission generally conducts surveys in an unannounced fashion except for situations in which it would not be logical or feasible to conduct an unannounced survey. Table 1, on page ACC-43, outlines specific exceptions to unannounced surveys and the length of advance notice. An organization can undergo an unannounced survey between 18 and 36 months after its previous full survey. Predetermined criteria based on PFP data across multiple quarters as well as trends in the performance of these data will determine the timing of an organizations full unannounced survey.

47 Unannounced Surveys (Continued) With an unannounced survey, an accredited organization will receive no notice of its survey date prior to the start of the survey. In concert with the unannounced survey process, the following procedures will be implemented: Accredited organizations are able to identify up to 15 days in their survey eligibility range (between 18 and 36 months after their last full unannounced survey) in which an unannounced survey should be avoided. These 15 days should not include federal holidays but may include regional events during which it may be difficult to conduct a survey. The Joint Commission will make every effort to accommodate the organization regarding avoiding these 15 days. However, The Joint Commission reserves the right to conduct a survey during an avoid period if the reason(s) given to avoid a survey at that time is such that a survey can be reasonably accomplished.

48 Unannounced Surveys (Continued) An organization is required to demonstrate how it communicates on an ongoing basis to its public that if members of the public have any quality-of-care or safety concerns, they should notify The Joint Commission (see APR.09.01.01 in the APR chapter). On the day of the unannounced survey, by 7:30 A.M. in the organizations local time zone (for organizations within the United States and its territories), The Joint Commission will post on the organizations secure Joint Commission Connect site the letter of introduction, the survey agenda, and the biography and picture of each surveyor assigned to conduct the survey. For organizations outside of these locations, notifications will be posted by 7:00 A.M. eastern time.

49 Unannounced Surveys (Continued) If an organization knows of a surveyor who works (or has worked) at the organization or a competing organization, or, has had personal experience with the surveyor that represents a potential conflict, the organization is asked to identify the individual(s) in its E-App or notify The Joint Commission via phone or e-mail as soon as possible so that another surveyor may be assigned.

50 Survey Team Composition Based on the size and complexity of the organization being surveyed, an accreditation survey may be conducted by one surveyor or a team of surveyors. The composition of an organizations survey team is based on the information provided in its E-App. On surveys with more than one surveyor, one of the surveyors is designated as the team leader. The team leader is responsible for integration, coordination, and communication of on-site survey activities. In addition to being one of the surveyors conducting the survey, the team leader serves as the primary point of on-site contact between the organization and The Joint Commission. Among other responsibilities, the team leader leads the opening conference and the daily and exit briefings.

51 Life Safety Code Specialist Scope of Service A Life Safety Code Specialist will be part of the survey for a minimum of two days on all surveys. The Life Safety Code Specialist is responsible for evaluating specific environment of care and Life Safety Code accreditation criteria and educating the organization during the survey about related compliant and not compliant areas, opportunities for improvement, and remedial action that may be required.

52 ISO Certification Option The Joint Commission and SGS Group now offer hospitals in the United States the option of pursuing both accreditation and certification to various ISO (International Organization for Standardization) and industry best practice standards. SGS is a worldwide verification, inspection, certification, and testing company that provides independent certification and quality assurance services. This program combines The Joint Commissions health care quality and safety standards, survey process, and accountability performance measures with SGS management system audits, including certification to the ISO 9001 quality management system standards. The combination of accreditation and ISO certification offers hospitals the tools to maintain best practices and lower costs across the entire operation while remaining focused on their core service: delivering quality health care to patients.

53 ISO Certification Option (Continued) While The Joint Commission accreditation decision and the SGS ISO certification decision are separate, the survey activities of SGS and The Joint Commission can be combined during the organizations routine accreditation survey approximately every three years. A surveillance or recertification audit is then annually conducted by SGS. The ISO option can be customized. Health care organizations can pursue certification at the system level, the hospital level, or the department (such as radiology, laboratory, pharmacy, food service, or health information management) level. All areas of an organization are eligible to be certified. In addition, hospitals can select from a menu of certifications and testing including ISO 9001 (quality management system), ISO 14001 (environmental management), ISO 27001 (information security), OHSAS 18001 (occupational health and safety), ISO 17025 (testing and calibration laboratories), and food safety testing and certification.

54 Survey Agenda The Joint Commission reviews the data in a hospitals E-App and posts a sample agenda on the organizations secure Joint Commission Connect site. Also available on the secure site is the organizations Survey Activity Guide, which includes a list of initial materials that the surveyor will request to review at the onset of the survey. The organizations Joint Commission account executive will contact the hospital and provide the anticipated number of days and number of surveyors that will be assigned for the on-site survey. On the first day of an on-site survey, surveyors will work with the hospital to ensure the schedule considers the organizations operations and needs. During the survey, the surveyor will work with the hospital to determine the best time for scheduling survey activities so they coincide more effectively with patient care and administrative operations. The on-site survey process focuses on continuous operational improvement in support of safe, high-quality care, treatment, and services. The survey agenda will include the elements described in the following slides.

55 Survey Agenda (Continued) Surveyor Planning Session During this session, the surveyor(s) will review data and information about the hospital to plan the survey agenda. This will include any information from previously conducted Joint Commission activities, such as MOS generated from a full PPR, Option 1 or Option 2, and other hospital documents that have been gathered for review. The surveyor(s) will select the first patients for tracing based on what they learn from the review of data and information during this session. Opening Conference and Orientation to the Organization. During the opening conference, the surveyor(s) describes the structure and content of the survey to organization staff, while the organization staff provides the surveyor(s) with information about the organization. At this time, the hospital will briefly explain its structures, mission, vision, and relationship with the community. This provides the surveyor(s) with baseline information about the organization that can help focus subsequent survey activities.

56 Survey Agenda (Continued) Surveyor Team Meeting On surveys conducted by more than one surveyor, scheduled team meetings provide an opportunity for the surveyor(s) to share information and observations, plan for upcoming survey activities, and plan for communication and coordination with the organization. Individual Tracer Activity During the individual tracer activity, the surveyor(s) will do the following: Follow the course of a type of care, treatment, or service provided to the patient by the hospital Assess the interrelationships among disciplines and services/programs and the important functions in the care, treatment, or services provided Evaluate the performance of processes relevant to the care, treatment, or service needs of the patient, with particular focus on the integration and coordination of distinct but related processes Identify vulnerabilities in the care processes See Tracer Methodology on page ACC-50 in the CAMH for more information.

57 Survey Agenda (Continued) Program-Specific Tracers Program-specific tracers will be conducted if they apply to the organization being surveyed and at the surveyors discretion. These program-focused activities take place during time noted on the agenda for individual tracer activity. See Tracer Methodology on page ACC-50 for more information. System Tracers System tracers are interactive sessions with the surveyor(s) and organization staff that explore the performance of important patient-related functions that cross the organization. The surveyor(s) will explore critical risk points with organization staff and provide education when indicated during the system tracer sessions. System tracers may include the following: Data management Infection control Medication management, if within the scope of the organization

58 Survey Agenda (Continued) As surveyors perform individual tracers to determine standards compliance as it relates to care delivered to the selected patient, they also begin to learn about the organizations overall systems. Information gathered during individual tracers is then considered from a multi-patient, cross-organization perspective during system tracers for high-risk processes. See Tracer Methodology on page ACC-50 in the CAMH for more information.

59 Survey Agenda (Continued) Daily Briefings During the daily briefing session, surveyors will communicate to organization staff their observations on the previous days survey findings and any significant patterns or trends that are becoming evident in the survey, if requested to do so. During the daily briefing, the surveyor(s) will do the following: Facilitate leaders understanding of the survey process and the findings that contribute to the accreditation decision Report on findings from the previous days survey activities Emphasize patterns or trends of significant concern that could lead to noncompliance determinations Highlight any positive findings or exemplary performance Allow the hospital to provide information that may have been missed during the previous survey day Allow the organization to supply additional information that would demonstrate compliance with a standard that a surveyor has indicated may be an RFI

60 Survey Agenda (Continued) Review the agenda for the survey day ahead and make any necessary adjustments based on hospital needs or the need for more intensive assessment of an issue If the organization has additional information that would demonstrate compliance with a standard that a surveyor has indicated may be an RFI, the organization should supply that information to the surveyor(s) as soon as possible. Special Issue Resolution This session provides an opportunity for the surveyor(s) to follow up on potential findings that could not be resolved in other survey activities.

61 Survey Agenda (Continued) Competence Assessment and Medical Staff Credentialing and Privileging This activity will help the hospital and the surveyor(s) identify specific issues and do the following: Evaluate the process the hospital uses to collect relevant data for decisions for credentialing and privileging Evaluate the consistent implementation of the credentialing and privileging process Evaluate processes for the granting of and the appropriate delineation of privileges Determine whether practitioners practice within the limited scope of delineated privileges Link results of peer review and focused monitoring to the credentialing and privileging process Identify vulnerabilities in the credentialing, privileging, and appointment process Evaluate ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) processes

62 Survey Agenda (Continued) Environment of Care Session This session is an opportunity for the surveyor and hospital to review and evaluate the following: The processes in place for managing risk in the physical environment (for example, safety and security, fire safety, hazardous materials and wastes, medical equipment) Emergency Management Session This survey activity will allow the organization and the surveyor(s) to do the following: Discuss the four emergency management categories: mitigation, planning, response, and recovery Review and discuss organization plans for managing critical areas of their operations so that they can effectively respond regardless of the emergency Review emergency management processes, such as identifying risks, interactions with other health care organizations, interactions and communication with the community, and drills, critiques, and performance improvement

63 Survey Agenda (Continued) Life Safety Code Building Assessment This session, as applicable, will help the organization and the surveyor(s) do the following: Identify areas of concern in the organizations processes for designing buildings to Life Safety Code** requirements Identify areas of concern in the organizations processes for maintaining buildings to Life Safety Code requirements Identify areas of concern in the organizations processes for identifying and resolving Life Safety Code problems Determine the organizations degree of compliance with relevant Life Safety Code requirements Identify or determine the action(s) necessary to address any identified Life Safety Code problems

64 Survey Agenda (Continued) Leadership Session During the leadership session, surveyors discuss the following with leaders: Information gathering and baseline assessment of leadership-level, system issuessystem standards, management oversight and direction, and other leadership responsibilities Ongoing initiatives to improve delivery of health care Safety program and National Patient Safety Goals Oversight by governance or the board Surveyor Report Preparation The surveyor(s) will use this time to compile, analyze, and organize the data he or she has collected throughout the survey into a Summary of Survey Findings Report reflecting the organizations compliance with standards (see page ACC-58).

65 Survey Agenda (Continued) Exit Briefing and Organization Exit Conference During the Exit Briefing the surveyor(s) will review the outcome of the survey with the most senior leader, usually the CEO or administrator, or the leadership team. The surveyor will present the survey findings and review the Summary of Survey Findings Report, discuss any concerns senior leaders have with the report, and determine the need for any special arrangements for the Organization Exit Conference. (A written report is not provided at the completion of a for-cause unannounced survey.) During the Organization Exit Conference the surveyor(s) will report the outcome of the survey and present the survey findings (if desired by senior leaders), review the issues of standards compliance that have been identified during the survey, allow the hospital a final on-site opportunity to question the survey findings or provide additional material regarding standards compliance, and review required follow-up actions, as applicable.

66 Tracer Methodology The tracer methodology is the cornerstone of The Joint Commission on-site survey. The tracer methodology incorporates the use of PFP information to follow the experience of care, treatment, or services for a number of individuals (initially identified by CSGs) through the organizations entire health care process. Tracers allows the surveyor(s) to identify performance issues (that may be related to PFAs) in one or more steps of the process, or in the interfaces between processes. The three types of tracers are described in the following sections.

67 Program-Specific Tracers The goal of the program-specific tracer activity is to identify safety concerns within different levels and types of care, treatment, or services. Program-specific tracers bring a targeted focus on important issues relevant to the following information: Types of care, treatment, or services offered by the organization Programs being surveyed The organizations PFAs Topics for the program-specific tracers were identified through a review of expert literature, research, input from the field, and subject matter expertise. Accreditation programspecific tracers evaluate program-specific issues and compliance with relevant standards that impact patient safety. Table 2 on page ACC-51 contains hospital-specific tracer activities, including applicability and objectives. Note: Program-specific tracers will only be conducted if they apply to the specific organization being surveyed. Program-specific tracers occur during survey time designated for Individual Tracer Activity.

68 Individual Tracer Activity The individual tracer activity is conducted during an on-site survey and is designed to trace the care experiences that a patient had while at the hospital. The tracer methodology is a way to analyze a hospitals system of providing care, treatment, or services using actual patients as the framework for assessing standards compliance. The surveyor(s) will use the following general criteria to select initial individual tracers: Patients in top CSGs for that organization Patients who cross programs (for example, home care patients discharged from a hospital or individuals served by behavioral health care organizations who present at an ambulatory care facility in complex organizations) Patients related to individual-based system tracer topics (see System Tracer Activity following), such as infection control or medication management Patients receiving complex services, such as surgery or treatment in an intensive care unit Please see the Survey Activity Guide on the Joint Commission Connect for more detailed information on other program-specific criteria for tracer selection.

69 Individual Tracer Activity (Continued) Patients selected for initial individual tracer activity will most likely be those identified in the hospitals PFP information as listed in the CSGs. Based on identified CSGs, the surveyor(s) will identify individual tracers and follow specific patients through the hospitals processes. A surveyor will not only examine the individual components of a system but will also evaluate how the components of a system interact with each other. In other words, a surveyor will look at the care, treatment, or services provided by each department/unit/program and service, as well as how departments/units/programs and services work together. The surveyor(s) may start where the patient is currently located. He or she can then move to where the patient first entered the organizations systems; an area of care provided to the patient that may be a priority for that organization; or to any areas in which the patient received care, treatment, or services. The location and order will vary. Along the way, the surveyor(s) will speak with the health care staff member(s) who actually provided the care to that individual tracer patientor, if that staff member(s) is not available, will speak with another staff member(s) who provides the same type of care, treatment, or services.

70 Individual Tracer Activity (Continued) Surveyors use individual patient tracers and systems tracers to review patient medical records. For hospitals seeking deemed status, surveyors will review records for 10% of the average daily census or a minimum of 30 inpatient records or 20 for small general acute care hospitals (but not for surgical or other specialty hospitals) with an average daily census of 20 patients or fewer. Based on the findings of the surveyor(s), he or she may select similar patients to trace. The tracer methodology permits surveyors to further investigate if there is a reason to believe that an issue needs further exploration.

71 System Tracer Activity System tracers explore one specific system or process across the organization, focusing, when possible, on the experiences of specific patients or activities relevant to specific patients. This differs from individual tracers in that during individual tracers, the surveyor(s) follows a patient through his or her course of care, evaluating all aspects of care as opposed to a system. During the system tracer sessions, the surveyor(s) evaluates the system or process, including the integration of related processes and the coordination and communication among disciplines and departments in those processes. A system tracer includes an interactive session (involving a surveyor and relevant staff members) in tracing a system within the organization based on information from individual tracers. Points of discussion in the interactive session include the following: The flow of the process across the hospital, including identification and management of risk points, integration of key activities, and communication among staff/units involved in the process

72 System Tracer Activity (Continued) Strengths in the process and possible actions to be taken in areas needing improvement Issues requiring further exploration in other survey activities A baseline assessment of standards compliance Education by the surveyor, as appropriate The three topics evaluated with system tracers are Data use, infection control, and medication management. Whether all system tracers are conducted varies based on survey length, but the data use system tracer is performed on every hospital survey. If survey length does not permit the conduct of an infection control or medication management system tracer, the given area is assessed through other survey activities.

73 System Tracer Activity (Continued) Data Management. The data management system tracer focuses on how the hospital collects, analyzes, interprets, and uses or manages data to improve patient safety and care. Infection Control. The infection control individual-based system tracer explores the hospitals infection control processes. The goals of this session are to assess the hospitals compliance with the relevant infection control standards, identify infection control issues that require further exploration, and determine actions that may be necessary to address any identified risks and improve the safety of patients. Medication Management. The medication management individual-based system tracer explores the hospitals medication management processes while focusing on subprocesses and potential risk points (such as handoff points). This tracer activity helps the surveyor(s) evaluate the continuity of medication management from procurement of medications through the monitoring of their effects on patients.

74 Patient Flow Tracer The patient flow tracer addresses potential treatment delays, medical errors, and unsafe practices that may occur during periods of patient congestion and if patient flow does not occur smoothly throughout the hospital. The only standard that specifically includes the words patient flow is Leadership Standard LD.04.03.11. However, patient flow problems stress the hospitals entire system. When this occurs, noncompliance with many Joint Commission standards, core measures, and National Patient Safety Goals may be evident.

75 Patient Flow Tracer (Continued) Patient flow Standard LD.04.03.11 details leadership responsibilities for evaluating patient flow, accepting responsibility, and making necessary changes to improve throughput. Leaders must develop and implement plans to evaluate patient flow in the entire organization. They must identify problems in the hospital and take action to prevent barriers to patient flow. If patient flow problems are identified during the survey, the surveyor will interview hospital leaders about actions they have taken to mitigate consequences of patient congestion, how they have shared accountability with medical staff, evidence of their shared accountability, inpatient flow indicators throughout the hospital, how indicator results are reported to leadership, and how this information has been used to improve patient flow.

76 Patient Flow Tracer (Continued) When evaluating patient flow, Joint Commission surveyors will look for compliance with all standards and requirements. Standard LD.04.03.11 addresses patient flow from a performance improvement perspective. Surveyors will ensure that a hospital is not just looking at one area (for example, emergency department, laboratory, or radiology), but at its processes in its entire system. Literature shows that patient flow problems emerge in various departments and units in different hospitals; therefore, the hospital needs to evaluate all of its areas to identify where it needs to focus. In addition to Standard LD.04.03.11, there are many other standards and EPs that can be cited when the flow of patient care is disrupted.

77 Second Generation Tracers As part of a natural evolution of the current tracer process, second generation tracers are a deep and detailed exploration of a particular area, process, or subject. A surveyor conducting any type of tracer at a hospital might notice something involving a high-risk area that requires a more in- depth look. The following are seven high-risk topics in hospitals that surveyors might need to explore in more detail: Cleaning, disinfection, and sterilization Patient flow across the care continuum Contracted Services Diagnostic imaging Ongoing professional practice (OPPE) and focused professional practice evaluation (FPPE) Assessment Staffing

78 The Role of Staff in Tracer Methodology To help the surveyor(s) in the tracer methodology process, staff will be asked to provide the surveyor(s) with a list of active patients, including the patients names, current locations in the hospital, and diagnoses/conditions, as appropriate. The surveyor(s) may request assistance from hospital staff for selection of appropriate tracer patients. As the surveyor(s) moves around a hospital, he or she will ask to speak with the staff members who have been involved in the tracer patients care, treatment, or services if available. If those staff members are not available, the surveyor(s) will ask to speak to another staff member who would perform the same function(s) as the member who has cared for or is caring for the tracer patient. Although it is preferable to speak with the direct caregiver, it is not mandatory because the questions that will be asked are questions that any caregiver should be able to answer in providing care, treatment, or service to the patient being traced.

79 Immediate Threat to Health or Safety The Joint Commission defines Immediate Threat to Health or Safety as a threat that represents the most immediate risk and has or may potentially have serious adverse effects on the health or safety of the patient, resident, or individual served. Such a situation may occur anywhere in an organization. (See Accreditation Participation Requirement [APR].09.04.01.) If a surveyor identifies any condition that he or she believes poses a serious threat to public or patient health or safety, he or she will notify the organizations CEO and Joint Commission headquarters staff immediately. The president of The Joint Commission, or his or her designee if the president is unavailable, can then issue an expedited Preliminary Denial of Accreditation decision based on the threat. An organization notified of a Preliminary Denial of Accreditation decision due to an Immediate Threat to Health or Safety situation does not have a right to clarify the survey findings relative to the situation. Since a Preliminary Denial of Accreditation is an official accreditation decision category, the decision is posted on Quality Check.

80 Immediate Threat to Health or Safety (Continued) The organizations CEO and appropriate governmental authorities are informed of this decision and the findings that led to this action. After notification of the Preliminary Denial of Accreditation decision, an organization has up to 72 hours to do the following: Eliminate the Immediate Threat to Health or Safety situation entirely Or If the situation is such that it will take the organization more time to fully eliminate it (such as situations involving building construction), then the organization must implement emergency interventions to abate the risk to patients (for example, cease performing a certain procedure, implement additional safety measures) within 72 hours. If the situation is not fully eliminated within 72 hours, the organization will have a maximum of 23 days to do so.

81 Immediate Threat to Health or Safety (Continued) The Accreditation Committee of the Joint Commission Board of Commissioners confirms or reverses the Preliminary Denial of Accreditation decision at its next meeting. The Accreditation Committee may take into consideration an organizations corrective actions or responses to a serious threat situation. The organization can provide information to demonstrate that a serious threat to health or safety has been corrected prior to the Accreditation Committees consideration of the Preliminary Denial of Accreditation decision. In these situations, the corrective action is considered when a single issue leads to the adverse finding and the organization demonstrates that it did the following: Took immediate action to completely remedy the situation Prepared a thorough and credible root cause analysis Adopted systems changes to prevent a future recurrence of the problem

82 Immediate Threat to Health or Safety (Continued) If the organization demonstrates that it has taken corrective action, The Joint Commission will conduct an abatement survey to validate the implementation of the corrective action and that the immediate threat situation is no longer present. If the abatement survey confirms the absence of the Immediate Threat to Health or Safety situation, The Joint Commission will remove the Preliminary Denial of Accreditation decision (assuming there are no other reasons for the Preliminary Denial of Accreditation). Therefore, the sooner an organization eliminates the Immediate Threat to Health or Safety situation, the shorter the period of time the organization will be in Preliminary Denial of Accreditation.

83 Immediate Threat to Health or Safety (Continued) Upon resolution of an Immediate Threat to Health or Safety situation, the organizations accreditation status will change from Preliminary Denial of Accreditation to Contingent Accreditation and remain as such until an accreditation follow-up survey is conducted to assess the organizations sustained implementation of appropriate corrective actions. See Figure 2 on page ACC-58 for a visual representation of the process flow for Immediate Threat to Health or Safety situations.

84 The Summary of Survey Findings Report Following evaluation of an organizations performance of functions and processes, the surveyor (or survey team) reviews the results of integrated individual findings. The surveyor (or survey team) produces the organizations Summary of Survey Findings Report. The surveyor (or survey team leader) meets with the organizations CEO prior to the closing conference and provides him or her with a copy of the preliminary report. The CEO determines whether this report is distributed at the closing conference. The surveyor (or survey team) uses the report contents in making closing conference presentations.

85 The Summary of Survey Findings Report (Continued) Shortly after a survey, an organizations report of survey findings is posted on the organizations secure Joint Commission Connect site. The report includes RFIs, as appropriate. If a hospital does not receive any RFIs, its accreditation decision is rendered at the same time that the hospitals Summary of Survey Findings Report is available, and it is effective the day after the completion of the survey. If a hospital receives RFIs, then the hospitals accreditation decision is rendered following the submission of an acceptable ESC report. (See Accreditation Effective Date on page ACC-66 and Evidence of Standards Compliance [ESC] Process on page ACC-67 in the CAMH for more information.)

86 AFTER THE SURVEY

87 How Accreditation Decisions Are Made The Joint Commission defines criticality as the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement (for example, an EP, National Patient Safety Goal, Universal Protocol). The four levels of criticality are as follows: Immediate Threat to Health or Safety Situational Decision Rules Direct Impact Requirements Indirect Impact Requirements

88 How Accreditation Decisions Are Made (Continued) Reference pyramid on pg 61 in the CAMH Immediate Threat to Health or Safety The top (sharp end) of the pyramid represents the most immediate risk (marked with a in the manual). This component of the model represents a risk that currently exists Immediate Threat to Health or Safety situations that are identified on site have or may potentially have serious adverse effects on the health or safety of patients. Upon resolution of an Immediate Threat to Health or Safety situation, the organizations accreditation status will change from Preliminary Denial of Accreditation to Contingent Accreditation and remain as such until a follow-up survey is conducted to assess the organizations sustained implementation of appropriate corrective actions.

89 How Accreditation Decisions Are Made (Continued) Situational Decision Rules The second level of the pyramid includes situations (marked with a in the manual) that automatically trigger a recommendation for Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey based on such issues as loss of facility licensure, provision of care by unlicensed individuals who require such a license, and failure to implement corrective action in response to identified Life Safety Code deficiencies. In follow-up to these situations, organizations must demonstrate resolution of the situation through the ESC process. An on-site survey is conducted to validate implementation of corrective action.

90 How Accreditation Decisions Are Made (Continued) Direct Impact Requirements The third level of the pyramid involves direct impact requirements (a standard, EP, National Patient Safety Goal, or APR marked with A). Such requirements have a direct impact on patients if noncompliance is likely to create an immediate risk to patient safety or quality of care, treatment, and services. The immediate risk usually results because there are no or few processesor no or few protective defenses intervening between the noncompliance and the impact on the safety or quality of a patients care, treatment, and services.

91 How Accreditation Decisions Are Made (Continued) Indirect Impact Requirements The requirements at the bottom (blunt end) of the pyramid pose less immediate risk to patient care or safety than direct impact requirements, but noncompliance increases risk to patient safety or quality of care, treatment, or services over time. If there are no direct impact EPs out of compliance, any remaining indirect impact Eps under that standard must be addressed in an ESC submission within 60 days. The organizations accreditation decision will be held in abeyance pending submission of ESC within the established time frames. As with the direct impact requirements, failure to resolve instances of partial compliance or insufficient compliance with indirect impact requirements will lead to progressively more adverse accreditation decisions.

92 Accreditation Decision Categories The Joint Commission revised its decision categories to better distinguish organizations with serious patterns and trends in the provision of care, treatment, or serviceswhich require follow-up more quicklyfrom those with less serious compliance issues. There are six categories of accreditation that an organization can achieve based on a Joint Commission survey. See Figure 4 on page ACC-66 in the CAMH for the continuum of accreditation decisions now possible following a full or other survey activity.

93 Accreditation Decision Categories (Continued) The Joint Commissions six accreditation decision categories are as follows: 1.Preliminary Accreditation. The organization demonstrates compliance with selected standards in the surveys conducted under the Early Survey Policy. 2.Accredited. The organization is in compliance with all standards at the time of the on-site survey or has successfully addressed all RFIs in an ESC within 45 or 60 days following the posting of the Accreditation Survey Findings Report and does not meet any other rules for other accreditation decisions. 3.Accreditation with Follow-up Survey. The organization is not in compliance with specific standards that require a follow-up survey within 30 days to 6 months.

94 Accreditation Decision Categories (Continued) 4.Contingent Accreditation The organization has: Successfully abated an Immediate Threat to Life (ITL) situation through direct observation or other method, Fails to successfully address all requirements of the Accreditation with Follow-up Survey decision, shows some evidence of engaging in possible fraud or abuse, demonstrates patterns or trends of noncompliance at an initial survey, and/or is not recommended for certification by CMS after undergoing its first Joint Commission survey for deemed status or Medicare recognition purposes. In most cases, a follow-up survey in 30 days will be required to show resolution of the issues that led to the decision. If an organization receives this decision because it was not recommended for certification by CMS or demonstrates systemic patterns or trends of noncompliance at an initial survey, the organization will remain in Contingent Accreditation until the organization can be recommended for certification or it meets a rule for Preliminary Denial of Accreditation or Denial of Accreditation.

95 Accreditation Decision Categories (Continued) 5.Preliminary Denial of Accreditation. There is justification to deny accreditation to the organization as evidenced by: An Immediate Threat to Health or Safety to patients or the public, and/or Submission of falsified documents or misrepresented information, and/or Lack of a required license or similar issue at the time of survey, and/or Failure to resolve the requirements of Contingent Accreditation, and/or Significant noncompliance with Joint Commission standards. The decision is subject to review and appeal by the organization prior to the determination to deny accreditation. (See Review and Appeal Procedures on page ACC-97.) 6.Denial of Accreditation. The organization has been denied accreditation. All review and appeal opportunities have been exhausted

96 Accreditation Effective Date The effective date of the accreditation decision varies based on the type of and acceptance of follow-up activities. (See Evidence of Standards Compliance [ESC] Process on page ACC-67 in the CAMH) For organizations that do not receive any RFIs, the accreditation decision will be effective the day after the last day of survey. Otherwise, an accreditation decision is rendered following the submission of the ESC report resolving all RFIs, which is retroactive to the day after the last day of the full survey For organizations undergoing an initial survey, the accreditation decision becomes official the day of the Accreditation Committee meeting or an acceptable ESC resolving all RFIs is submitted (if that occurs after the Accreditation Committee meeting). For organizations receiving Preliminary Denial of Accreditation or Denial of Accreditation, the decision becomes effective the day the decision is rendered by the Accreditation Committee. When an organizations accreditation decision becomes official, it is publicly disclosable and is posted on Quality Check.

97 Corrective ESC An acceptable corrective ESC report must detail the following: Action(s) that the organization took to bring itself into compliance with a requirement The title of the person(s) responsible for implementing the corrective actions or approving a revised policy, procedure, or process Compliance at the EP level and include an MOS, if applicable An acceptable ESC report is due within 45 or 60 calendar days (depending on whether the EP relates to a direct or indirect impact requirement) following the posting of the Accreditation Survey Findings Report. The required time frame will be specified in the survey report. Following a successful submission of the ESC report, the organization receives an accreditation decision. However, the organizations accreditation decision is retroactive to the day after the last day of the survey, unless the organization is undergoing its first Joint Commission survey. In that case, the effective date for accreditation is the date on which the acceptable ESC is submitted.

98 Corrective ESC (Continued) The organizations ESC submission(s) will be evaluated by Central Office using the same scoring guidelines used by the surveyors at the time of survey and by health care organizations when they conduct their PPR (see the Sample Sizes section that follows). The Joint Commission will consider the ESC acceptable when the hospital has demonstrated resolution of all RFIs. If the hospital has not met a rule for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation and the ESC submission(s) is determined to be acceptable, its decision will be Accredited, and it will be required to submit the data for applicable MOS for each EP, if required, four months later.

99 Corrective ESC (Continued) On-Site ESC Usually, the ESC will be an electronic submittal to The Joint Commission, but there will be times when an ESC also will be conducted on site by a surveyor. If an on-site evaluation is required to assess compliance with the relevant standards, a copy of the hospitals electronic ESC is provided to the surveyor conducting the on-site ESC. The on-site ESC process provides the opportunity to evaluate the organizations success in correcting the issues. It also allows the surveyor to provide coaching and guidance to the organization supporting its efforts to achieve and maintain compliance with the standards. A final decision letter will be posted to the hospitals secure, password-protected Joint Commission Connect site when its ESC has been reviewed and an accreditation decision has been rendered. A Quality Report will then be posted on Quality Check on The Joint Commissions website. For more information, see The Joint Commission Quality Report (QR) chapter.

100 Corrective ESC (Continued) Sample Sizes If, during an on-site survey, your hospital has been found to be not compliant, or partially compliant, with one or more EPs, you must demonstrate ESC for each standard that is not compliant. The ESC must address compliance at the EP level. When an EP within a not compliant standard requires an MOS, your hospital must demonstrate whether each MOS identified in the organizations ESC report was met. Assessment of MOS compliance is conducted for a four-month period following the date of ESC approval. Your hospital should select records as a part of its sample following the date of ESC approval and use the required sample sizes. MOS percentage compliance rates are derived from the average of all four months.

101 Corrective ESC (Continued) You need an average of 90% or higher compliance over 4 months for a successful ESC. When demonstrating an ESC, the following percentages determine your EP score: 90% through 100% of your sample size is in compliance = score 2 80% through 89% of your sample size is in compliance = score 1 Less than 80% of your sample size is in compliance = score 0 Note: Hospitals are encouraged, but not required, to use the same percentages when conducting a PPR. However, an MOS cannot be accepted in a PPR if it does not meet requirements.

102 Measure of Success (MOS) Report An MOS ( M ) is a numerical or quantifiable measure, usually related to an audit to determine if an action was effective and sustained, due four months after notification of an acceptable ESC. The MOS report should demonstrate whether each MOS identified in the hospitals ESC report was reached. Central Office will evaluate the MOS results. If the MOS results are acceptable, no further action will be required of the hospital. If it is determined that a hospitals MOS submission is unacceptable, its accreditation decision may be changed to Accreditation with Follow-up Survey and/or the hospital may be required to submit a second set of MOS results in another four months.

103 Measure of Success (MOS) Report (Continued) If the hospitals first ESC submission is determined to be acceptable and the second MOS submission is determined to be acceptable, its accreditation decision will be changed to Accredited, and no further action will be required of the hospital. If the second MOS submission is determined to be unacceptable, a recommendation for Accreditation with Follow-up Survey will be presented to the Accreditation Committee. The organizations ESC submission and sustained implementation of it, including the MOS, are subject to review in random unannounced surveys.

104 The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation If an organization is notified that a recommendation is to be made to the Joint Commissions Accreditation Committee for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation, the organization has 10 calendar days to provide information to clarify any of the RFIs cited in its Accreditation Survey Findings Report through its ESC report and demonstrate that it was in fact in compliance with one or more standards in question at the time of survey. A Clarification Validation Survey (CVS) may be conducted to ensure that the organization was, in fact, in compliance with Joint Commission standards at the time of survey rather than relying solely on information submitted by the organization. (See Clarification Validation Survey on page ACC-90 in the CAMH for more information.)

105 The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation (Continued) Whenever an organization submits written or electronic information after receiving a Preliminary Denial of Accreditation decision, The Joint Commission may conduct a CVS to validate the information and assure compliance with Joint Commission standards before making a final decision to remove the organization from the Preliminary Denial of Accreditation decision.

106 The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation (Continued) If the organization does not meet a rule for Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey, it will be awarded accreditation (if it is compliant with all standards) or it will be required to submit an ESC (if it still has RFIs). if the organization continues to meet a decision rule for Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey, The Joint Commission will recommend to the Accreditation Committee that the organization remain in Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey. The organization will have 5 business days from receipt of notification to submit a written response directly to the Accreditation Committee.

107 Preliminary Denial of Accreditation for Organizations Without Proper License, Certificate, or Permit Without Proper License, Certificate, or Permit If a hospital does not possess a license, certificate, and/or permit, when required by applicable law and regulation, to provide the health care services for which the hospital is seeking accreditation, Joint Commission staff may initiate the Preliminary Denial of Accreditation process under decision rule PDA04. (see 2012 Accreditation Decision Rules on page ACC-92 in the CAMH)

108 Preliminary Denial of Accreditation for Organizations Without Proper License, Certificate, or Permit (Continued) The process for Preliminary Denial of Accreditation in such circumstances is as follows: If at the time of survey the hospital does not have a required license, certificate, or permit, the hospital will be notified that it meets a rule for Preliminary Denial of Accreditation, and The Joint Commission will initiate such action. If it obtains the required license, certificate, or permit or is able to provide proof of application during the clarification process, PDA04 will be removed, but the RFI will remain in the survey report. The hospital will not be presented to the Accreditation Committee unless it meets a decision for Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey based on another decision rule.

109 Plan of Action (POA) A POA is a detailed description of how a hospital plans to bring into compliance any standard identified as not compliant in the PPR. The POA must include the planned action to be taken and target implementation dates. If the EP requires an MOS when lack of compliance exists, you must also describe the MOS or how you plan to measure your successful implementation of your POAs.

110 BETWEEN SURVEYS

111 Sentinel Event Follow Up Accredited hospitals are expected to identify and respond appropriately to all sentinel events as defined by the hospital. The hospital is required to conduct a thorough and credible root cause analysis develop an action plan in a manner and time frame acceptable to The Joint Commission as specified in the Sentinel Event Policy, and Submit to The Joint Commission or otherwise provide evidence of an acceptable response to the sentinel event. (See the Sentinel Events [SE] chapter in the CAMH for more information.)

112 Accreditation Status of Organizations That Cease Services After a Disaster The Joint Commission will discontinue the accreditation of hospitals that have been closed or out of service for more than six months as a result of a disaster. The complete process for determining the accreditation status of hospitals that cease services after a disaster follows: Up to 30 Days. For hospitals that resume services within the first 30 days after a disaster and/or the hospitals decision to cease operations, the hospitals original Joint Commission accreditation status will stay in effect. The time frame for complying with any outstanding Joint Commission requirements (such as the PPR or ESC) will pause until the hospital resumes operation. In most cases, The Joint Commission will not need to survey the affected hospital to reassess its level of standards compliance. If The Joint Commission decides to conduct a survey, the hospitals accreditation decision will be driven by the interim survey findings.

113 Accreditation Status of Organizations That Cease Services After a Disaster (Continued) Up to 90 Days. For hospitals that resume services from 31 to 90 days after a disaster, The Joint Commission will conduct an extension survey to determine the hospitals accreditation status. The circumstances surrounding the hospitals closure will determine the surveys length and scope. Up to Six Months. For hospitals that resume services from 91 days up to six months after a disaster, The Joint Commission will require an on-site survey to assess the environment of care. This survey will preferably take place one to two weeks after services are resumed. These hospitals must receive clearance to operate from the fire marshal and other local/state authorities before resuming services. In addition, The Joint Commission will conduct a second on-site survey approximately four months after services have been resumed to evaluate sustained compliance with Joint Commission standards and requirements. The track record requirement for demonstrating standards compliance will be four months.

114 Accreditation Status of Organizations That Cease Services After a Disaster (Continued) More Than Six Months. For hospitals that do not resume services within six months after a disaster or decide to cease operations, The Joint Commission will discontinue its accreditation. If the hospital resumes services, it must reapply to become accredited. In such cases, the accreditation process will involve at least two surveys. The first survey will be conducted at the hospitals request and will assess the hospitals ability to provide safe patient care. The hospital may qualify for an accreditation award as a result of this survey. However, at this point the hospital will not be recognized by CMS to meet the requirements for Medicare certification. The second survey will be conducted approximately four months later to assess sustained compliance with Joint Commission requirements. The track record requirement for demonstrating standards compliance will be four months.

115 Accreditation Status of Organizations That Cease Services After a Disaster (Continued) The Joint Commission will continue to list all affected hospitals as Accredited up to six months after a disaster, unless interim survey findings dictate otherwise. While working with affected hospitals in the aftermath of a catastrophic event, The Joint Commission will be sensitive to these hospitals needs and will work with responsible state and federal agencies to help reestablish the hospitals operations as well as their qualification for accreditation. If your hospital is affected by a natural disaster, please notify your hospitals account executive as soon as possible. Once notified, The Joint Commission can cancel any accreditation-related events and offer assistance, if needed. If you dont know who serves as your hospitals assigned account executive, call 630-792-3007.

116 Accreditation Status of Organizations That Cease Provision of Services for a Period of Time Accredited Joint Commission hospitals may stop providing care, treatment, and services to patients or may not have any patients for a period of time for reasons other than natural or man-made disasters. The Joint Commission will discontinue the accreditation of hospitals that have ceased providing care, treatment, and services for more than six months. The complete process for determining the accreditation status of such hospitals follows: Up to 60 Days. If a hospital does not have any patients for up to 60 days, The Joint Commission will continue the hospitals current accreditation status.

117 Accreditation Status of Organizations That Cease Provision of Services for a Period of Time (Continued) Up to Six Months. If a hospital does not have any patients from 60 days to less than six months, but then resumes patient services within six months, The Joint Commission will continue the hospitals current accreditation status only if the hospital has an extension survey. This extension survey would generally take place within a week of the hospitals request. The purpose of this survey is to evaluate the hospitals capability for resuming services and whether it is performing at current accreditation levels. More Than Six Months. If a hospital does not have any patients for six months or longer, The Joint Commission will consider the hospital no longer accredited. If the hospital resumes services, it will have to apply for a full survey in order to evaluate its current compliance with Joint Commission standards.

118 Reentering the Accreditation Process For a previously accredited hospital to be designated as new, it must not have participated in the accreditation process during the previous four months. If a hospital is reentering the accreditation process before four months have passed, it must demonstrate a continuous 12-month track record of compliance with the standards.

119 Extension Surveys The Joint Commission conducts an extension survey when an accredited hospital acquires a new service, program, or site for which The Joint Commission has

1 the accreditation process part 2: before, during, after and between the surveys

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organizations compliance

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