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The Accreditation ProcessQuality Reports

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Speaker Information

Frank S. ZibratAssociate Director, Accreditation SystemsIntegration and ORYX, Division of Accreditation and Certification OperationsThe Joint Commission

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Welcome and Introduction

• This module is 1 out of 9 available to help prepare candidates towards the JCCAP exam. Additional webinar modules include:– Organizational Analysis: Developing An Organizational Profile

– Standards: The Essentials for Accreditation Managers

– How to Engage Your Medical Staff into The Joint Commission Accreditation Process

– Environment of Care

– Leadership: The Foundation of Quality and Safety

– Performance Improvement: The Accreditation Manager’s Role

– Focus on Patient Safety

– Understanding the CMS Regulatory and Survey Process for Hospitals

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Welcome and Introduction

• Please note that all modules and Exam Questions related to the JCCAP product line are specifically related to The Comprehensive Accreditation Manual for Hospitals, in addition to CMS related materials

• JCCAP Questions– Please visit www.jcrinc.com/jccap

– Email questions to: jccap@jcrinc.com

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JCCAP Module 1: Understanding The Joint Commission’s Accreditation Process

Disclosure StatementThe following staff and speakers have disclosed that they do not have any

financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity:– Speaker

– Program Manager

– Nurse Planner

– Other planning team member

The following staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation

Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products.

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Publications and Record Restrictions

• The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited.

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Tips for Using Module

• Optimize your experience– Viewers are encouraged to pause your screen at any

time to bring other staff and faculty in to segments that you find appropriate for team building and/or communication

– Take advantage of printing out the slides (pdf available on the left side bar) for easy note taking

– Make sure to review attached links, documents and references mentioned throughout this module (available on the left side bar)

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Quality Report (QR)

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Introduction

• The Joint Commission Quality Report aims to differentiate health care organizations based on accreditation decision categories and other related information. While the accreditation process emphasizes continuous improvement in key areas of safety and quality, the Quality Report reflects information about a hospital’s National Patient Safety Goals, National Quality Improvement Goals and Requirements, as well as special recognitions and achievements.

• This chapter provides an overview of Quality Reports—what they are, how and when they are developed, how organizations can respond to them, and how the public and organizations can access and use them.

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Introduction (Continued)

• For the purpose of readability and ease of use, this chapter is organized in a question and- answer format. The chapter includes information on the following:– A description of the Quality Report and what it contains– A description of The Joint Commission’s Quality Check®

Web site and its special features– Guidelines for submitting a commentary– Marketing and communication guidelines for using

Quality Reports

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What Is The Joint Commission Quality Report?

• The Joint Commission Quality Report provides accreditation information about the hospital as well as comparative information gathered from other accredited hospitals. The Joint Commission provides Quality Reports to your surveyed hospital and makes them available to the public on our Quality Check Web site.

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What Will My Quality Report Contain?• The Quality Report features two major components.• Summary of Quality Information. This section provides the following

information for a hospital:– Accreditation decision including the effective date of the decision. This

portion also identifies any additional programs in the organization that are accredited by The Joint Commission, if applicable.

– Special quality awards/merit badges, which are quality distinctions that have been awarded to applicable organizations. Examples of merit badges include the following:• The John M. Eisenberg Patient Safety and Quality Award—Given by The Joint

Commission and the National Quality Forum, the John M. Eisenberg Patient Safety and Quality Award recognizes major achievements by individuals and organizations in improving patient safety. The annual awards include an individual lifetime achievement award and awards in the categories of advocacy, system innovation, and research.

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What Will My Quality Report Contain? (Continued)

• Magnet Award—The Magnet Award is the highest level of recognition that the American Nurses Credentialing Center awards to organized nursing services. The award recognizes health care organizations that exhibit excellence in nursing services to patients, the existence of an environment that supports professional nursing practice, and the growth and development of nursing staff. Magnet institutions act as “magnets” by attracting and retaining outstanding nurses and creating a work environment that recognizes and rewards professional nursing.

• The Franklin Award of Distinction—This award honors a case management system that demonstrates excellence in building collaboration among the various professional and technical staff in the hospital to focus on case management and performance measurement results having a positive effect on patient care.

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What Will My Quality Report Contain? (Continued)

• Malcolm Baldrige National Quality Award—The Malcolm Baldrige National Quality Award was established by Congress to promote quality awareness, to recognize quality and business achievements of U.S. organizations, and to publicize the award winners’ successful performance strategies. Awards are given in manufacturing, service, small business, education, and health care.

• The American Hospital Quest for Quality Prize—An American Hospital Association Award that honors leadership and innovation in quality, safety, and commitment to patient care by hospitals and/or multi-hospital health systems

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What Will My Quality Report Contain? (Continued)

• Cheers Award—The Institute for Safe Medication Practices (ISMP) presents Cheers Awards to recognize individuals, health care organizations, regulatory agencies, professional organizations, researchers, pharmaceutical, and other health care-related businesses that have set a superlative standard of excellence in following the prevention of medication errors during the award year.

• Recognition by the Health Resources and Services Administration (HRSA) of hospitals with organ donation conversion rates over 75 percent.

• The American Heart Association’s Get With the Guidelines program presents awards in the categories of Coronary Artery Disease Performance Achievement and Stroke Performance Achievement.

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What Will My Quality Report Contain? (Continued)

• ACS Bariatric Surgery Center Network Accreditation Program—The American College of Surgeons Bariatric Surgery Center Network (ACS BSCN) Accreditation Program recognizes as Bariatric Centers, facilities which implement and maintain certain physical resources, human resources, standards of practice, and documentation of outcomes of care to improve quality and facilitate access to care for morbidly obese patients.

• American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)—The ACS NSQIP is a nationally validated, risk adjusted, outcomes-based program to measure and improve the quality of surgical care.

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What Will My Quality Report Contain? (Continued)

• Department of Veterans Affairs National Surgical Quality Improvement Program (VA NSQIP)—The VA NSQIP is the first nationally validated, risk adjusted, outcomes-based program to measure and improve the quality of surgical care.• Patient-Centered Designation Program—The Patient-

Centered Designation Program recognizes hospitals that have successfully implemented a comprehensive approach to patient-centered care.

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What Will My Quality Report Contain? (Continued)

• Quality Indicators. Quality Indicators are measures that compare hospitals accredited by The Joint Commission. The comparison occurs on both a state and a national level (depending on the Quality Indicator). Quality Indicators for hospitals include the National Patient Safety Goals. All organizations are required to comply with the National Patient Safety Goals in which relevant services are provided. See Figure 1 for the legend of Quality Indicators symbols. The Joint Commission also selects National Quality Improvement Goals for key treatments that affect tens of thousands of patients every year. The report tracks outcomes for ORYX core measure sets such as heart attack, heart failure, perinatal, pneumonia, children’s asthma, and the Surgical Care Improvement Project (SCIP) for infection prevention, cardiac, and venous thromboembolism.

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What Will My Quality Report Contain? (Continued)

• Currently, hospitals that submit National Quality Improvement Goal data are required to report on four of the six measure sets. Organizations such as pediatric, psychiatric, and small rural hospitals are not required to submit core measure data due to their size and/or patient population. Detailed information on each National Quality Improvement Goal and the symbols used to report results are available online at Quality Check (http://www.qualitycheck.org) in the “Quality Report User Guide: Hospitals.”

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What is Quality Check?

• Quality Check is a directory of the more than 19,000 Joint Commission–accredited and certified health care organizations and programs throughout the United States. You can access Quality Check at http://www.qualitycheck.org.

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What is Quality Check? (Continued)

• These features are included on Quality Check:– Hospital performance results of the Centers for Medicare &

Medicaid Services (CMS) 30-day mortality measures for heart attack, heart failure, pneumonia, and readmission rates. Patient mortality is one of the most important outcomes of care. Incorporating this information into Quality Check supports consumer health care decision making and the transparency of reporting efforts. Derived from CMS reports, the mortality measures are from more than 4,500 hospitals across the country. These measures are endorsed by the National Quality Forum, a voluntary standard-setting, consensus building organization representing providers, consumers, purchasers, and researchers.

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What is Quality Check? (Continued)

– Performance results from the CMS Hospital Consumer Assessment of Healthcare Providers and Systems survey data. Derived from the patient’s perception of their hospital experience, this is a standardized publicly reported survey instrument and data collection methodology that allows valid comparisons to be made across hospitals locally, regionally, and nationally.

– Enhanced search functionality that allows the user to search for a health care organization by its Joint Commission–assigned organization number.

– Consumer search functionality that allows the user to search for a health care organization by name within a state, by zip code (within 250 miles), or by city and state. When searching by state or zip code, the search can be narrowed by type of service or type of provider/certification.

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What is Quality Check? (Continued)

– Search by Service—Quality Check includes a search option for accredited and certified organizations by the type of service provided. An inventory of services provided and type of health care providers is displayed within a geographic area. This allows organizations to be identified by a specific type of service. When a type of service is selected, the health care organizations displayed can be filtered by type of provider, setting of care, or health care population.

– Search by Type of Provider—Quality Check includes a search option that allows users to search for a health care provider type. Provider types include certified programs, home care providers, hospitals, laboratories, mental health, substance abuse, foster care, nursing homes, office-based surgery facilities, and outpatient/ ambulatory care.

– The name search option utilizes the organization’s main site name, which is the name consumers are most likely to know.

– A search results page that displays one main entry by organization and the sites within the entry.

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Is a Quality Report Available for My Accredited Hospital?

• Yes. The amount of information available on the report depends on the type of hospital surveyed. A complete directory of all Joint Commission–accredited organizations is available through Quality Check’s Web site (http://www.qualitycheck.org).

• Historical Quality Reports (when applicable) can also be accessed at Quality Check. For reports before 1996, please call The Joint Commission’s Customer Service Department at 630/792-5800. Customer Service can also address queries about Quality Report availability for an organization and can provide lists of all available reports.