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J o i n
t C o m m i s s i o n I n t e r n a t i o n a l
CLINICAL CARE PROGRAM
CERTIFICATION (CCPC)
Paul vanOstenberg, DDS, MS, Senior AdvisorJoint Comm ission Internat ional
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J o i n
t C o m m i s s i o n I n t e r n a t i o n a l
OVERVIEW
General Introduction to CCPC
Publication of 3rd Edition of Standards
Comparison to Hospital Surveys
Eligibility and Program Design
Standards and Chapters
Sample Survey Agenda
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What is Clinical Care Program
Certification?
CCPC is designed toevaluate diseasemanagement and/orcondition –specific care
programs that areprovided in hospitals andother settings
CPGs are used by thosewho demand more
rigorous processes toensure that care is basedon the best availableresearch evidence.
Clinical
Practice
Guidelines
Performance
Measures
JCIStandards
Quality Outcomesfor the
Population
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Value of CCPC Certification
Achieving JCI Certification can validate the quality of
care and services to the patient population through the
program’s ability to demonstrate excellent clinical care
management:
Compliance with consensus-based international
standards, including patient self-management.
Effective use of established evidence based clinical
practice guidelines to manage and optimize care. An organized approach to performance
measurement and improvement activities.
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Accreditation VS Certification
Certification differs from accreditation in that:
Accreditation focuses on an organization's overall
commitment to quality through organization-wide,
patient-centered and health care organization
management systems and processes.
Certification demonstrates excellence within a
single specialty program in fostering better
outcomes for treatment of a specific disease (such
as Diabetes Mellitus ), condition (such as AcuteMyocardial Infarction), or clinical care service (such
as Joint Replacement).
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J o i n
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CCPC and Hospital Survey
Differences More depth to evaluation of actual clinical care
delivered
Standardized care processes//adherence to the CPG
Detailed assessment of performance improvement
activities
Specific wording of and suggested changes to chosen
performance measures
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CCPC and Hospital Survey
Similarities Tracer Methodology
Assessment and Care requirements
Medical Records Requirements
SQE Requirements
International Patient Safety Goals
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J o i n
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Changes in 3rd Edition
Published 1 July 2014
Effective 1 January 2015
Open to more than the 15 programs of the 2nd Edition
Host must now be accredited
The concept of a “Center” introduced
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Eligible Programs for CCPC
Survey
The program is one of the following 15 JCI-approved clinical care programs (examples)
– Acute myocardial infarction
– Heart failure – Primary stroke
– Diabetes Mellitus (type 1 and/or type 2)
– Chronic kidney disease (Stage 1 through IV)
– End stage renal disease
– Palliative care (all types)
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Eligible Programs (continued)
– Traumatic brain injury
– HIV/AIDS management
– Cancer (all types)
– Pain management
– Asthma
– Joint replacement (all types)
– Transplantation (all types) – Chronic obstructive pulmonary disease
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Eligibility for CCPC Survey
Designed and implemented for the population served
Minimum 25 patients meet eligibility and are enrolled in
the program
4 month track record for initial survey compliance
Clinical Practice Guideline are evidence-based and:
– Are sponsored or supported by professional associations or
societies, public or private organizations, government agencies,
etc.
– Are not self-developed by the program staff
– Include evidence if modified to meet the population served
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Eligibility for CCPC Survey
(continued)
Performance measures meet requirements:
– Appropriate and consistent with program’s intent & CPG
– Collected 4 months of data
– Monitored at least four measures Host or parent organization is JCI (no longer any
options in 3rd Edition)
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Organization of
Chapters/Standards International Patient Safety Goals
Program structure and leadership Support
Delivering care
Encouraging patients/families to self-manage diseases
Managing clinical information
Monitoring performance measures for areas of
improvement
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International Patient SafetyGoals (IPSG)
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International Patient Safety
Goals (IPSG)
Goal 1: Identify Patients Correctly
Goal 2: Improve Effective Communication
Goal 3: Improve the Safety of High-Alert
Medications Goal 4: Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
Goal 5: Reduce Risk of Health Care-Associated
Infections Goal 6: Reduce the Risk of Patient Harm
Resulting from Falls
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Program Leadership andManagement (PLM)
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PLM Areas of Focus
Designing and implementing program
Evaluating program
Providing adequate access to care
Conducting program in an ethical manner
Supplying reference resources to staff
Facility safety issues
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Delivering or FacilitatingClinical Care (DFC)
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DFC Areas of Focus
Using qualified, oriented, competent, trained staff
Evaluation of care provided
Delivering care using evidence-based CPG
Individualizing care to meet patient’s needs
Management of co-morbidities/concurrent conditions
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Supporting Self-Management (SSM)
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SSM Areas of Focus
Involving patients and families in making
decisions
Evaluating patient and family’s learning needs,
and ability to learn
Educational materials
Lifestyle changes that support self-management
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Clinical InformationManagement (CIM)
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CIM Areas of Focus
Protecting patient information
Identifying those authorized to access records
Use of standardized documentation Internal and external information needs
Gathering and providing information across
continuum
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Performance Measurementand Improvement (PMI)
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CCPC Agenda Issues
1 surveyor for 2 days, or 2 surveyors for 1 day
Surveyors will have reviewed the CPG and your
performance measurement data
Surveyor may request documents to be available upon
arrival in country to enable the survey to go faster
Interview program staff during tracer activities
Interview program patients in a group
On-site suggestions and education for the program
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CCPC Agenda Issues
Opening conference, overview of program services,
and discussion of PI measures and data use. Agreement
on four measures to be tracked after the survey.
Unit visits and patient tracers---no trick questions
Closed medical records review
SQE
Program patient interviews
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Mid Cycle Review
Requirements Submitted18 months after survey
Monthly results of 4 performance measures with
analysis and plans for improvements
Any changes to the CPG or program design/scope?
Any changes to program leadership or staff?
Progress update on all findings in original survey
report
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J o i n t C o m m i s s i o n I n t e r n a t i o n a l
Grazie
ie ie
o jeh Tak
tesekkür
ederim