The Nuts and Bolts of The Nuts and Bolts of Joint Commission Joint Commission

Accreditation:Accreditation:Changes for 2006Changes for 2006AARC 51AARC 51stst International Respiratory International Respiratory

CongressCongress

Bob Floro, RRTBob Floro, RRTAssociate Director Associate Director

Joint Commission Home Care Accreditation Joint Commission Home Care Accreditation ProgramProgram

December 6, 2005December 6, 2005

TodayToday

Requirement Changes and Additions - Requirement Changes and Additions - 20062006– APR’sAPR’s– NPSG’sNPSG’s– StandardsStandards

Accreditation and Survey ProcessesAccreditation and Survey Processes Unannounced Surveys and Unannounced Surveys and

Annualization Plans Annualization Plans

Requirement Changes Requirement Changes and Additions - 2006and Additions - 2006

Accreditation Accreditation Participation Participation

RequirementsRequirements

APR’sAPR’s APR 1 Official records and reportsAPR 1 Official records and reports APR 2 Report changes in application APR 2 Report changes in application

informationinformation APR 3 Permits surveysAPR 3 Permits surveys APR 10 Misrepresentation of informationAPR 10 Misrepresentation of information APR 11 Misrepresentation of accreditation APR 11 Misrepresentation of accreditation

statusstatus APR 12 Surveyor not used for APR 12 Surveyor not used for

accreditation-related counseling services accreditation-related counseling services APR 13 Survey observation by surveyor APR 13 Survey observation by surveyor

management staffmanagement staff

Accreditation Participation Accreditation Participation RequirementsRequirements

APR 8 Public noticeAPR 8 Public notice– EP 1 – If individual has any concerns EP 1 – If individual has any concerns

about patient care or safety, individual about patient care or safety, individual is encouraged to contact organization’s is encouraged to contact organization’s managementmanagement New 2006

APR 14 (Revised)APR 14 (Revised)

Effective January 1, 2006Effective January 1, 2006

Addresses annual requirements for Addresses annual requirements for Periodic Performance Review Periodic Performance Review

New 2006

APR 17 (New)APR 17 (New)

Effective July 1, 2005Effective July 1, 2005– EP 1 - Staff educated that any EP 1 - Staff educated that any

employee who has concerns about employee who has concerns about safety or quality of care may report safety or quality of care may report these concerns to Joint Commissionthese concerns to Joint Commission

– EP 2 - Staffed informed that no EP 2 - Staffed informed that no disciplinary action taken if they reportdisciplinary action taken if they report

– EP 3 - Organization demonstrates EP 3 - Organization demonstrates commitment by taking no retaliation commitment by taking no retaliation disciplinary actions against disciplinary actions against employees who reportemployees who report

APR 18 (New) APR 18 (New)

Effective July 1, 2005Effective July 1, 2005

Organization adheres to Joint Organization adheres to Joint Commission published guidelines for Commission published guidelines for describing information in its Quality describing information in its Quality ReportReport– TruthfulTruthful– Accurate Accurate

APR 19 (New) APR 19 (New)

Effective June 1, 2005 Effective June 1, 2005

Meet all requirements for timely Meet all requirements for timely submission of data and information to submission of data and information to Joint Commission Joint Commission

2006 National Patient 2006 National Patient Safety Goals for HMESafety Goals for HME

Joint Commission 2006Joint Commission 2006National Patient Safety Goals National Patient Safety Goals

(NPSGs) for HME (NPSGs) for HME

1. Patient identification1. Patient identification

2. Communication among caregivers2. Communication among caregivers

7. Health care-associated infections7. Health care-associated infections

8. Medication reconciliation8. Medication reconciliation

9. Patient falls9. Patient falls

13. Patient involvement in safety13. Patient involvement in safety

Goal 1Goal 1 Improve the accuracy of Improve the accuracy of patient identification.patient identification.

1A1A Use at least two patient Use at least two patient identifiers whenever identifiers whenever administering administering medicationsmedications or blood products; or blood products; taking taking blood samplesblood samples and other specimens and other specimens for clinical testing, or providing any for clinical testing, or providing any other other treatments or procedurestreatments or procedures..

Clinical Respiratory Services ONLYClinical Respiratory Services ONLY

Goal 2Goal 2 Improve the effectiveness Improve the effectiveness of communication among of communication among

caregivers. caregivers. 2A2A For For verbal or telephone ordersverbal or telephone orders or for or for

telephonic telephonic reporting of critical test resultsreporting of critical test results, verify , verify the complete order or test result by having the the complete order or test result by having the person receiving the order or test result "read-person receiving the order or test result "read-back" the complete order or test result.back" the complete order or test result.

2B2B Standardize a list of abbreviations, acronyms Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the and symbols that are not to be used throughout the organization.organization.

2C2C Measure, assess and, if appropriate, take Measure, assess and, if appropriate, take action to improve the action to improve the timeliness of reportingtimeliness of reporting, and , and the timeliness of receipt by the responsible the timeliness of receipt by the responsible licensed caregiver, of licensed caregiver, of critical test resultscritical test results and and values. values. (CRS RT only)(CRS RT only)

2E2E Implement a standardized Implement a standardized approach to "hand off" approach to "hand off" communications, including an communications, including an opportunity to ask and respond to opportunity to ask and respond to questions. questions.

Goal 2Goal 2 Improve the effectiveness Improve the effectiveness of communication among of communication among

caregivers. caregivers.

New 2006

Goal 7Goal 7 Reduce the risk of health Reduce the risk of health care-associated infectionscare-associated infections

7A7A Comply with current Centers for Comply with current Centers for Disease Control and Prevention (CDC) Disease Control and Prevention (CDC) hand hygiene guidelines.hand hygiene guidelines.

7B7B Manage as sentinel events all Manage as sentinel events all identified cases of unanticipated death or identified cases of unanticipated death or major permanent loss of function major permanent loss of function associated with a health care-associated associated with a health care-associated infection.infection.

Goal 8Goal 8 Accurately and completely Accurately and completely reconcile medications across the reconcile medications across the

continuum of care.continuum of care.

8A8A Implement a process for obtaining Implement a process for obtaining and documenting a complete list of the and documenting a complete list of the patient's current medications upon the patient's current medications upon the patient's entry to the organization and patient's entry to the organization and with the involvement of the patient.  This with the involvement of the patient.  This process includes a comparison of the process includes a comparison of the medications ordered for the patient while medications ordered for the patient while under the care of the organization to those under the care of the organization to those on the list. on the list. CRS ONLYCRS ONLY

New 2006

Goal 9Goal 9 Reduce the risk of patient Reduce the risk of patient harm resulting from falls.harm resulting from falls.

   9B9B Implement a fall reduction Implement a fall reduction

program and evaluate the program and evaluate the effectiveness of the programeffectiveness of the program

New 2006

Goal 13Goal 13 Encourage the active Encourage the active involvement of patients and their involvement of patients and their families in the patient's care as a families in the patient's care as a

patient safety strategy.patient safety strategy.

13A13A Define and communicate the Define and communicate the means for patients and their families means for patients and their families to report concerns about safety and to report concerns about safety and encourage them to do so.encourage them to do so.

New 2006

NPSG Interpretive NPSG Interpretive GuidelinesGuidelines

On Joint Commission Website On Joint Commission Website www.jcaho.orgwww.jcaho.org

Program-specificProgram-specific Used by surveyorsUsed by surveyors Promotes consistencyPromotes consistency

For More Information on the For More Information on the NPSGsNPSGs

The Home Care The Home Care Accreditation ManualAccreditation Manual

and Standards and Standards (New for 2006)(New for 2006)

Standards Review and Standards Review and RewriteRewrite

All standards extensively reviewed and All standards extensively reviewed and modified every 2 yearsmodified every 2 years

– Internal EvaluationInternal Evaluation StandardsStandards ResearchResearch Accreditation OperationsAccreditation Operations Surveyor management & DevelopmentSurveyor management & Development Home Care ProgramHome Care Program

– External EvaluationExternal Evaluation Advisory CouncilsAdvisory Councils Professional and Technical Advisory Committee (PTAC)Professional and Technical Advisory Committee (PTAC) Standards and Survey Process (SSP)Standards and Survey Process (SSP) Board of CommissionersBoard of Commissioners

Components of 2006 Components of 2006 StandardsStandards

StandardsStandards are statements defining are statements defining performance expectations, structures and performance expectations, structures and processes.processes.

Rationale Rationale is background, purpose and is background, purpose and educational informationeducational information

Elements of performance (EPs) Elements of performance (EPs) are are specific statements of expectations and specific statements of expectations and are the only scorable part of the standard. are the only scorable part of the standard.

111 Home Medical 111 Home Medical Equipment Standards - 2006Equipment Standards - 2006

RI RI (19)(19) RIGHTS, ETHICS

AND RESPONSIBILITIES

PCPC (18) (18) PROVISION OF CARE,

TREATMENT AND SERVICES

MM MM (8)(8) MEDICATION

MANAGEMENT(CRS ONLY)

IC IC (5)(5)INFECTION

SURVEILLANCEPREVENTION

CONTROL

PI PI (6)(6) IMPROVING

ORGANIZATION PERFORMANCE

LD LD (21)(21)LEADERSHIP

EC EC (23)(23)ENVIRONMENTAL

SAFETY AND EQUIPMENT

MANAGEMENT

HR HR (7)(7)MANAGEMENT OF

HUMAN RESOURCES

IM IM (10)(10)MANAGEMENT OF

INFORMATION

Sample Standard

Standard RI.2.30 Patients are involved in decisions about care, treatment, and services provided.The standard above applies to the following services:

HMEHME CRCRSS

RTRT

RI.2.3RI.2.300

XX XX XX

Rationale for RI.2.30 Making decisions about care, treatment, and services sometimes presents questions, conflicts, or other dilemmas for the [organization] and the [patients], family, or other decision makers. These dilemmas may involve issues about admission; care, treatment, and services; or discharge. The [organization] works with [patients], and when appropriate their families, to resolve such dilemmas.

Sample Standard

Elements of Performance for Elements of Performance for RI.2.30RI.2.30

The elements of performance below The elements of performance below apply to the following services:apply to the following services:

HMEHME CRSCRS RTRT

EP 1EP 1 XX XX XX

EP 2EP 2 XX XX XX

EP 3EP 3 XX XX XX

EP 4EP 4 XX XX XX

EP 5EP 5 XX XX XX

(M) C (M) C 1. Patients are involved in decisions about their care,1. Patients are involved in decisions about their care, treatment, and services.treatment, and services.

(M) C(M) C 2. Patients are involved in resolving dilemmas about 2. Patients are involved in resolving dilemmas about care,care,

treatment, and services.treatment, and services.

(M) C(M) C 3. A surrogate decision maker, as allowed by law, is 3. A surrogate decision maker, as allowed by law, is identified when a patient cannot make decisions about his or identified when a patient cannot make decisions about his or her care, treatment,her care, treatment,

and service.and service.

(M) C(M) C 4. The legally responsible representative approves care, 4. The legally responsible representative approves care, treatment, and service decisions.treatment, and service decisions.

(M) C(M) C 5. The family, as appropriate and as allowed by law, with 5. The family, as appropriate and as allowed by law, with permission of the [patient] or surrogate decision maker, is permission of the [patient] or surrogate decision maker, is involved in care, treatment, and service decisions.involved in care, treatment, and service decisions.

Sample Standard

Ethics, Rights and Ethics, Rights and ResponsibilitiesResponsibilities

RI.1.20 Potential conflicts RI.1.20 Potential conflicts {PROBLEMATIC}{PROBLEMATIC}

RI.2.40 - Informed ConsentRI.2.40 - Informed Consent– Implementation issuesImplementation issues– Consent for care vs. consent for Consent for care vs. consent for

treatmenttreatment

Ethics, Rights and Ethics, Rights and ResponsibilitiesResponsibilities

RI.2.90 – Informed of unanticipated RI.2.90 – Informed of unanticipated outcomesoutcomes– implementation issuesimplementation issues– Reviewable Sentinel EventsReviewable Sentinel Events

RI.2.160 Right to pain management RI.2.160 Right to pain management – No longer applicable for HME, Clinical No longer applicable for HME, Clinical

Respiratory, or Rehab TechnologyRespiratory, or Rehab Technology

Provision of Care, Provision of Care, Treatment, ServicesTreatment, Services

– PC.2.20 The organization defines PC.2.20 The organization defines assessment activitiesassessment activities

Understand applicable bulletsUnderstand applicable bullets

EP 11 - No longer applicable for Clinical EP 11 - No longer applicable for Clinical Respiratory Respiratory

Provision of Care, Provision of Care, Treatment, ServicesTreatment, Services

PC.5.20 Physician orders PC.5.20 Physician orders {COMPLIANCE {COMPLIANCE PROBLEM #2 FOR HME} PROBLEM #2 FOR HME}

PC.5.50 – Care provided in an PC.5.50 – Care provided in an interdisciplinary and collaborative mannerinterdisciplinary and collaborative manner– How to implement with limited How to implement with limited

resourcesresources

Medication ManagementMedication Management

Nothing applicable for HME onlyNothing applicable for HME only

To be discussed in Clinical To be discussed in Clinical Respiratory Services sectionRespiratory Services section

Surveillance, Prevention, and Control of Surveillance, Prevention, and Control of Infection (New Chapter for 2005)Infection (New Chapter for 2005)

IC.1.10 IC ProgramIC.1.10 IC Program IC.2.10 Identifying risks IC.2.10 Identifying risks

{Surveillance implementation {Surveillance implementation issues}issues}

IC.3.10 Priorities based on risksIC.3.10 Priorities based on risks IC.4.10 Strategies to implement IC.4.10 Strategies to implement

goalsgoals IC.5.10 Program evaluation IC.5.10 Program evaluation

Surveillance, Prevention, Surveillance, Prevention, and Control of Infectionand Control of Infection

IC.6.10 Influx of infectious patients IC.6.10 Influx of infectious patients {Implementation issues for HME}{Implementation issues for HME}

IC.7.10 Qualified individualsIC.7.10 Qualified individuals IC.8.10 CollaborationIC.8.10 Collaboration IC.9.10 Adequate resourcesIC.9.10 Adequate resources

Improving Organization Improving Organization PerformancePerformance

Categories within PI chapterCategories within PI chapter– PI.1.10 Data collectionPI.1.10 Data collection

EP 4 – Med Management - Applicable to EP 4 – Med Management - Applicable to Clinical RespiratoryClinical Respiratory

EP 5 – Blood products - Not applicable to EP 5 – Blood products - Not applicable to any HMEany HME

Improving Organization Improving Organization PerformancePerformance

Categories within PI chapterCategories within PI chapter– PI.2.10 Data aggregation and analysis PI.2.10 Data aggregation and analysis

{COMPLIANCE PROBLEM #6 FOR HME} {COMPLIANCE PROBLEM #6 FOR HME} – PI.2.20 Undesirable trends analyzedPI.2.20 Undesirable trends analyzed– PI.2.30 Processes for sentinel eventsPI.2.30 Processes for sentinel events– PI.3.10 Data use for performance PI.3.10 Data use for performance

improvementimprovement

PI.3.20PI.3.20 Process to identify and Process to identify and reduce safety risks – new in 2005reduce safety risks – new in 2005– EP 1 -EP 1 - Selecting high risk processSelecting high risk process– EP 2 -EP 2 - Describing processDescribing process– EP 3 -EP 3 - Identifying process Identifying process

breakdownsbreakdowns– EP 4 -EP 4 - Effects of breakdownsEffects of breakdowns– EP 5 -EP 5 - Prioritize breakdownsPrioritize breakdowns

Improving Organization Improving Organization PerformancePerformance

PI.3.20PI.3.20 Process to identify and Process to identify and reduce safety risks (cont’d)reduce safety risks (cont’d)– EP 6 – Determine why occurredEP 6 – Determine why occurred– EP 7 – RedesignEP 7 – Redesign– EP 8 – Test and implementEP 8 – Test and implement– EP 9 – Monitor effectiveness of redesignEP 9 – Monitor effectiveness of redesign

Improving Organization Improving Organization PerformancePerformance

LeadershipLeadership

LD.3.20 Issues regarding same LD.3.20 Issues regarding same level of carelevel of care

LD.3.50 Contracts and contract LD.3.50 Contracts and contract management management {Compliance {Compliance problem}problem}

LD.3.90 Written P&P requirement LD.3.90 Written P&P requirement for patient carefor patient care

LeadershipLeadership

LD.4.40 Integrated patient safety LD.4.40 Integrated patient safety program – not a new conceptprogram – not a new concept– EP 1 - EP 1 - Assignment to manageAssignment to manage– EP 2 - Definition of scopeEP 2 - Definition of scope– EP 3 - Incorporate organization wideEP 3 - Incorporate organization wide– EP 4 - Procedures to respondEP 4 - Procedures to respond

LeadershipLeadership

LD.4.40 (cont’d)LD.4.40 (cont’d)– EP 5 - Systems for reportingEP 5 - Systems for reporting– EP 6 -EP 6 - Responses to unanticipated Responses to unanticipated

adverse events and proactive risk adverse events and proactive risk assessment / reductionassessment / reduction

– EP 7 -EP 7 - Staff support systemStaff support system– EP 8 -EP 8 - Report to governanceReport to governance

Environmental Safety and Environmental Safety and Equipment ManagementEquipment Management

– EC.4.10 Emergency management EC.4.10 Emergency management addressed addressed {COMPLIANCE PROBLEM #1 {COMPLIANCE PROBLEM #1 FOR HME}FOR HME} EP 1 – Rewrite to exclude HVA languageEP 1 – Rewrite to exclude HVA language EP 2 - Eliminated link to county or region EP 2 - Eliminated link to county or region

command structurecommand structure

– EC.4.20 Regular drills to test EC.4.20 Regular drills to test emergency management emergency management

{COMPLIANCE PROBLEM #7 FOR HME}{COMPLIANCE PROBLEM #7 FOR HME}– EC.5.10 - Fire safetyEC.5.10 - Fire safety

New EPs 11 & 12 – Fire-safe environment New EPs 11 & 12 – Fire-safe environment in buildings - Applicable to HME all servicesin buildings - Applicable to HME all services

EC (cont.)EC (cont.)

Patient equipment management Patient equipment management – EC.6.30 Plans for selection, delivery, EC.6.30 Plans for selection, delivery,

setup, and maintenancesetup, and maintenance– EC.6.40 DeliveryEC.6.40 Delivery– EC.6.50 SetupEC.6.50 Setup– EC.6.60 Maintenance, testing, inspectionEC.6.60 Maintenance, testing, inspection

{COMPLIANCE PROBLEM #5 FOR HME}{COMPLIANCE PROBLEM #5 FOR HME}}}

EC (cont.)EC (cont.) Patient equipment management (cont.) Patient equipment management (cont.)

– EC.6.70 Emergency maintenanceEC.6.70 Emergency maintenance– EC.6.80 24 hr emergency servicesEC.6.80 24 hr emergency services– EC.6.90 BackupEC.6.90 Backup– EC.6.100 StorageEC.6.100 Storage– EC.6.110 TrackingEC.6.110 Tracking

Organization equipment management Organization equipment management – EC.6.120 to 6.130 Equipment used by staffEC.6.120 to 6.130 Equipment used by staff– EC.7.10 Not applicable for Clinical EC.7.10 Not applicable for Clinical

RespiratoryRespiratory

Management of Human Management of Human ResourcesResources

HR.1.10 Staffing adequacy – HR.1.10 Staffing adequacy – implementation and survey prep issueimplementation and survey prep issue

HR.1.20 Qualifications consistent with job HR.1.20 Qualifications consistent with job responsibilitiesresponsibilities

– EP 3 – Verification of licensure if only required EP 3 – Verification of licensure if only required by organizationby organization

– EP 4 – Primary Source verification if required by EP 4 – Primary Source verification if required by organization organization

HR.3.10 Competency programHR.3.10 Competency program {COMPLIANCE{COMPLIANCE PROBLEM #3 FOR HME} PROBLEM #3 FOR HME}

Management of InformationManagement of Information IM.2.10 Privacy and confidentiality of IM.2.10 Privacy and confidentiality of

information – addresses HIPAAinformation – addresses HIPAA– Major rewrite and numbering of EPsMajor rewrite and numbering of EPs

IM.2.30 IM.2.30 – New EP 4New EP 4 - Business continuity plan is - Business continuity plan is

implemented if systems are interrupted implemented if systems are interrupted

IM.6.20 Patient-specific information IM.6.20 Patient-specific information {COMPLIANCE PROBLEM #4 FOR HME} {COMPLIANCE PROBLEM #4 FOR HME} – New EP 9 - Individuals/organization (from EP New EP 9 - Individuals/organization (from EP

8)8)

Clinical Clinical Respiratory Respiratory

ServicesServices(CRS)(CRS)

12 Possible Additional Standards 12 Possible Additional Standards

Additional Interpretations in Additional Interpretations in OthersOthers

CRS StandardsCRS Standards

RI.2.80 – End of life decisionsRI.2.80 – End of life decisions PC.4.10 – POCPC.4.10 – POC PC.5.10 – Correct order and PC.5.10 – Correct order and

verificationverification MM.1.10 - Patient specific MM.1.10 - Patient specific

informationinformation MM.3.20 - Clear ordersMM.3.20 - Clear orders MM.5.10 – Safe administration MM.5.10 – Safe administration

CRS Standards (cont’d)CRS Standards (cont’d)

MM.6.10 – Monitoring meds MM.6.10 – Monitoring meds administeredadministered

MM.6.20 – Response to ADRsMM.6.20 – Response to ADRs MM.7.10 – High risk/high alert processMM.7.10 – High risk/high alert process MM.7.40 – Investigational medsMM.7.40 – Investigational meds MM.8.10 – Evaluate med management MM.8.10 – Evaluate med management

planplan PI.2.20 - Undesirable trends analyzedPI.2.20 - Undesirable trends analyzed

Accreditation Accreditation and Survey Processesand Survey Processes

New 2006

Extranet Application Extranet Application for Accreditationfor Accreditation

Available on a secure, password-Available on a secure, password-protected web spaceprotected web space

Improves quality & consistency of dataImproves quality & consistency of data– Pre-population and UpdatePre-population and Update– Same data used by surveyorSame data used by surveyor

Allows for efficiency in Joint Commission Allows for efficiency in Joint Commission analysis of organizational informationanalysis of organizational information

Priority Focus Process Priority Focus Process ProcessProcess

Logic brings consistency to Joint Logic brings consistency to Joint Commission review of pre-survey Commission review of pre-survey datadata

Shapes survey processShapes survey process

Rules-Driven Priority Focus ProcessRules-Driven Priority Focus Process

= Previous= Current

APS Rules

Priority

Focus Rules

Previous On-site Survey Data

Standards

Complement

Length

PFP Output: •PFA•CSG•Relevant Standards, •Survey Activity

E-App

External Data: PMS & publicly available data

Surveyor Feedback

Loop

Fee

APS = Application Processing System

Priority Focus AreasPriority Focus AreasTop 4 assignedTop 4 assigned

– Assessment and Assessment and Care/ServicesCare/Services

– CommunicationCommunication– Credentialed Credentialed

PractitionersPractitioners– Equipment UseEquipment Use– Infection ControlInfection Control– Information Information

ManagementManagement– Medication Medication

ManagementManagement

– Organization Organization StructureStructure

– Orientation and Orientation and TrainingTraining

– Rights and EthicsRights and Ethics– Physical Physical

EnvironmentEnvironment– Quality Quality

Improvement Improvement Expertise and Expertise and ActivityActivity

– Patient SafetyPatient Safety– StaffingStaffing

Clinical Service GroupsClinical Service GroupsAssigned as appropriateAssigned as appropriate

Home Medical EquipmentHome Medical Equipment HME with Clinical Respiratory HME with Clinical Respiratory

ServicesServices HME with Rehabilitation TechnologyHME with Rehabilitation Technology HME with CRS and RTHME with CRS and RT

Tracer MethodologyTracer Methodology ProcessProcess surveyors use during on-site surveyors use during on-site

surveysurvey

Follow Follow patientspatients through through organization’s processes and organization’s processes and services experienced by patientservices experienced by patient

Review Review systems systems that support carethat support care

Surveyed across programsSurveyed across programs

Unannounced SurveysUnannounced Surveysand Annualization Plansand Annualization Plans

New 2006

Unannounced Surveys in Unannounced Surveys in 20062006

Value: Value: – Organizations Organizations stop preparing to be surveyedstop preparing to be surveyed

and start preparing to embed qualityand start preparing to embed quality

– Organizations Organizations report periodicallyreport periodically as they as they conduct their own tracer activities - PPRconduct their own tracer activities - PPR

– Scores are eliminatedScores are eliminated

– Validation of Validation of continual standards compliancecontinual standards compliance

Unannounced Changes Unannounced Changes Advanced mailingAdvanced mailing of applications for 2006 of applications for 2006

12 month cycle for application 12 month cycle for application updatesupdates in future in future

New APRsNew APRs for prompt submission and informing for prompt submission and informing publicpublic

Advanced Advanced application processingapplication processing by Joint by Joint Commission staffCommission staff

Additional application questionsAdditional application questions refine refine organizational information organizational information

Unannounced Changes Unannounced Changes (cont.)(cont.)

Extranet postingExtranet posting of PFP, introductory letter, of PFP, introductory letter, bio’s, and surveyor photographs on morning of bio’s, and surveyor photographs on morning of surveysurvey

EliminationElimination of pre-survey billing, notification of pre-survey billing, notification letters, and surveyor phone callsletters, and surveyor phone calls

Window widensWindow widens for scheduling for scheduling

Initial, PPR, small organization, and ESO Initial, PPR, small organization, and ESO surveys will remain surveys will remain announcedannounced

Unannounced Changes Unannounced Changes (cont.)(cont.)

Initial, PPR, and ESP surveys will remain Initial, PPR, and ESP surveys will remain announcedannounced– Extension new program surveys are Extension new program surveys are unannouncedunannounced

Agenda change: Surveyor Agenda change: Surveyor planning session movedplanning session moved to first activity followed by opening conferenceto first activity followed by opening conference

Communicate Communicate special eventsspecial events (e.g. KY Derby, (e.g. KY Derby, Daytona 500, national political convention, etc.)Daytona 500, national political convention, etc.)

Use your 10 “Use your 10 “avoid datesavoid dates” wisely – skip federal ” wisely – skip federal holidaysholidays

Don’t assumeDon’t assume (due date +/- 45 days, same (due date +/- 45 days, same geography, etc)geography, etc)

Annualization PlansAnnualization PlansTimingTiming Events DueEvents Due

Survey end date + 12 Survey end date + 12 monthsmonths

Application Application updateupdateBBIBBIPPR updatePPR update

Survey end date + 24 Survey end date + 24 monthsmonths

Application Application updateupdateBBI updateBBI updatePPR updatePPR update

Survey end date + 36 Survey end date + 36 monthsmonths

Application Application updateupdateBBI updateBBI updatePPR updatePPR update

Subscription BillingSubscription Billing Supports annual activitiesSupports annual activities

Two componentsTwo components– Annual Fees – Billed every January – about 20% Annual Fees – Billed every January – about 20%

of current feesof current fees– Survey Fees – Billed every 3 years about 30 Survey Fees – Billed every 3 years about 30

days after survey – about 40% of current feesdays after survey – about 40% of current fees

Fees will be posted to extranetFees will be posted to extranet

Random Unannounced Random Unannounced SurveysSurveys

Continue in 2006 at 5% of annual Continue in 2006 at 5% of annual volumevolume

Eligibility remains at 9-30 monthsEligibility remains at 9-30 months Focus is on program Priority Focus Focus is on program Priority Focus

AreasAreas– Assessment and CareAssessment and Care– Infection ControlInfection Control– Patient safetyPatient safety– National Patient Safety GoalsNational Patient Safety Goals

Complex Organization Complex Organization SurveysSurveys

HCOs accredited under more than one HCOs accredited under more than one Joint Commission accreditation manualJoint Commission accreditation manual

Replaced “tailored survey”Replaced “tailored survey” Integrated and streamlined processIntegrated and streamlined process Customized, focused, efficient, educationalCustomized, focused, efficient, educational Common standards surveyed once across Common standards surveyed once across

HCOHCO Program-specific surveyors survey Program-specific surveyors survey

specialty standardsspecialty standards

Corporate Survey ProtocolCorporate Survey Protocol

Corporate Survey ProcessCorporate Survey Process– ““Orientation” approachOrientation” approach– One dayOne day– Multiple surveyorsMultiple surveyors– Multiple surveyor disciplinesMultiple surveyor disciplines– Variable servicesVariable services– Where and whenWhere and when– Sequencing of subsequent surveys Sequencing of subsequent surveys

““The success of Joint Commission The success of Joint Commission accreditation will be measured by our accreditation will be measured by our ability to assist HME organizations in ability to assist HME organizations in embracing embracing quality patient servicesquality patient services and and safe provision of caresafe provision of care as an as an integral element of their corporate integral element of their corporate and organizational culture.” and organizational culture.”

PhilosophyPhilosophy

Joint Commission Home Care Joint Commission Home Care Accreditation ProgramAccreditation Program

Central Office – 630-792-5000 (Central Office – 630-792-5000 (www.jcaho.orgwww.jcaho.org))

Program office – 630-792-7441Program office – 630-792-7441

Bob Floro – 630-792-5741 Bob Floro – 630-792-5741 ((rfloro@jcaho.orgrfloro@jcaho.org))

Account Representative – 630-792-3004Account Representative – 630-792-3004

Standards Interpretation – 630-792-5900Standards Interpretation – 630-792-5900