going for the gold seal - joint commission€¦ · builds the structure required for a systematic...
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Going for the Gold SealJoint Commission Chest Pain
Certification
September 30, 2015David Eickemeyer
Associate Director, Certification
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The Joint Commission
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Today’s Objectives
Review benefits of achieving CertificationDefine three core components of Chest Pain
CertificationProvide resources for obtaining Chest Pain
Clinical Practice GuidelinesProvide examples of Chest Pain Certification
Performance MeasuresQ & A Session
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Benefits of Certification Builds the structure required for a systematic approach
to clinical care Reduces variability and improves the quality of patient
care Pushes you to look at yourself more closely Creates a loyal, cohesive clinical team Provides an objective assessment of clinical excellence Differentiates clinical care program in the marketplace
Promotes achievement to community
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Certification by the Numbers3,198 certified programs
– In all 50 states, DC and Puerto Rico– 1,355 organizations– 101 disease programs
Hackensack University Medical Center has 24 certified programs!
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Chest Pain & Related Disease Certifications33 certified AMI programs 12 certified ACS programs 11 certified Chest Pain programs
– ~20 more in application/scheduling processFor a complete list:
www.jointcommission.org/certified
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Accreditation vs. CertificationAccreditation Surveys
– Organization-wide evaluation of care processes and functions
Certification Reviews– Product or service-specific evaluation
of care and outcomes
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Certification Eligibility Any disease-specific care program that has
– Formal program structure– Standardized method of clinical care delivery
based on clinical guidelines/ evidence-based practice
– Organized approach to performance measurement
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Core Program Components
Guidelines
Sa
MeasuresStandardsClinicalPractice
Guidelines
Performance Measures
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Core Program Components
Standards
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Disease-Specific Care StandardsProgram Management
7 standards
Delivering or Facilitating Clinical Care6 standards
Supporting Self-Management3 standards
Clinical Information Management5 standards
Performance Improvement and Measurement6 standards
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Core Program Components
ClinicalPractice
Guidelines
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Clinical Practice Guidelines
Clinical care based on guidelines/evidence-based practice
Review validates:– Rationale for selection/modification– Implementation of CPGs– Monitoring & improving adherence
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Clinical Practice Guidelines: Chest Pain ExamplesNational Institute for Health & Clinical
Excellence (NICE) Institute for Clinical System Improvement (ICSI)American College of Cardiology (ACC)American Heart Association (AHA)
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www.guideline.gov
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Performance Measurement Criteria
Four process or outcome measures to monitor on an ongoing basis – Select existing measures; or– Create new measures
At least two of the measures must be clinical
Up to two measures may be non-clinical: administrative, utilization, financial, patient satisfaction, etc.
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What Makes a Good Performance Measure?
Results can be used for improvementRelates to current medical evidenceDefined specificationsData collection is consistent and logical
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http://www.qualitymeasures.ahrq.gov
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Performance Measures:Chest Pain Examples
Door to EKGDoor to balloonDoor to transfer time for STEMIOrdered to resulted troponin timeLipid profile prior to discharge or within 30 days
of presentationDischarge instructions (cardiac diet, medications,
follow up)Patient satisfaction
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Challenges of CertificationConsistent implementation of Clinical
Practice Guidelines– Most frequently cited issue is related to missing
or inconsistent CPGs Involvement of all physiciansData collection on performance measures
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Certification Logistics
Pre• Gap analysis to standards and guidelines; resolution of any gaps• Apply 4-6 months before desired review date• Data Collection (four months at a minimum)
Visit• 30 days advance notice of date• One reviewer for one day
Post• Data collection and submission• Intracycle conference call 12 months after visit• Apply for recertification
Visit• Recertification visit occurs 2 years after initial visit• To be scheduled within 90 day window around anniversary date• 7 days advance notice of date
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Why Get Certified?Structure clinical programs of excellenceImprove processes of careCulture change: communication, loyalty,
teamwork“Toot your horn” to consumers
– Attract more patients
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Advertise Your Achievement
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ResourcesStandards Interpretation Group
www.jointcommission.org/standards_informationPerformance Measure Online Q&A Forum:
manual.jointcommission.org Pricing Unit: 630-792-5115 Initial applications:
David Eickemeyer, 630-792-5697 [email protected]
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Questions?
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Register for our Oct. 19 Webinar
PART 2: Disease-Specific Care Certification Most Cited Standards:Reviewers Insight October 19, 2015 12:00 p.m. - 1:00 p.m. CT 1 CE CREDIT: 1.0 CEU will be offered
for Part 2. www.jointcommission.org/DSC
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The Joint Commission Disclaimer These slides are current as of 09/14/2015. The Joint
Commission reserves the right to change the content of the information, as appropriate.
These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.