transitioning your obs to a licensed asc · 2017. 11. 2. · – lasik –ivf surgical settings we...

Transitioning Your OBS to A Licensed ASC - 1 © C

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Transitioning Your OBS to a Licensed ASC

Oct. 20, 2017

Mike Dye, Senior Business Development SpecialistThe Joint Commission

Linda Welsh, Director of AccreditationIntrepidware


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ASC accreditation applies to variety of surgical providers: – Vascular Surgery– Pain Management– Endoscopy– Plastic/Cosmetic Surgery– Orthopedic– Oral Surgery– Podiatry– ENT– Dermatology– Lasik– IVF

Surgical Settings We Accredit


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Why ASC Accreditation?– Potential for increased reimbursement

for office-based practices that transition to ASCs

– CMS has identified select ‘core’ procedures for increased levels of reimbursement

– Specific reimbursements vary by CMS procedural code – increases range from 22% to 59% depending on procedure

– Bundling of these CMS procedural codes may support your practice’s rationale for ASC accreditation

Reasons to Convert…


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Why Joint Commission?– ASC deemed accreditation

recognized by CMS – Helps meet certain states’

regulatory requirements– Reinforces risk

management efforts– Possible discounts on

liability insurance

– Implements comprehensive framework for patient care

Reasons to Convert…

“I was pleasantly surprised by the quick call-backs, gracious

service, and expedited process The Joint Commission provided.

Alex Rothschild, MS, CMPEAdministrator


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Joint Commission’s Legacy:– Accrediting ASCs since 1976– Over 1,000 Accredited ASCs– ASC Deeming authority** since

1996:– CMS determined The Joint

Commission’s standards & survey process meets or exceeds those established by CMS

…Reasons to Convert

** Effective Dec. 2014 through Dec. 2020, CMS Renews Joint Commission Deeming Authority for Ambulatory Surgery Centers


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Added Value to Our Customers…Partner with you to understand your strategic quality/safety goals & needsNational advocacy with:– CMS– States– Payers

Providing real-world solutions to health care safety and quality issues:– Center for Transforming Healthcare– Sentinel Event Alerts– Quick Safety updates


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…Added Value: What Does That Mean to You?

Joint Commission offers support via:– Designated Account Executive– “Joint Commission Connect”

On-line applicationSurvey schedulingElectronic survey reportE-paymentE-dition (electronic standards)

– Standards Interpretation Group (SIG) FAQsOn-line submissionsPhone call


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…Added Value to Our Customers…

Input to Ambulatory standards from ASC Groups:

Ambulatory Surgery Center Association (ASCA)Association of periOperative Registered Nurses (AORN)American Nephrology Nurses’ Association (ANNA)

Ambulatory Executive Director serves on board of ASC Quality Collaborative Partner with ASCA on pilots for ASC performance improvement projects


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…Added Value to Our CustomersJoint Commission Ambulatory Care team understands importance of speed in entering Medicare process via deemed status

Deemed/ASC applications, scheduling & post-survey processes are “fast-tracked”

Joint Commission Data (2016) Indicators for Deemed/ASC Process:

Avg Turn-Around-Time (TAT) between “ready to schedule” to survey date = 35 days

Avg TAT from survey end to posting report = 1.5 days


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Eligibility– 2 active patients w/10 patients served prior to

on-site survey

Occupancy Expectations– Healthcare Occupancy Rules

Length of Survey– 2-day minimum (2 clinicians, 1 engineer)

Notification Policy– Unannounced for deemed ASCs (morning

posting via JC Connect w/surveyor names & biographies)

ASC Eligibility Expectations


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Healthcare Occupancy Issues:– 2012 Life Safety Code– Healthcare-focused architect or engineer!– Professionally approved Fire Alarm Systems:

Sprinklers, strobes, audibles, fire alarm panelFire-rated walls and doors, fire-rated barriers, self-closing doors

− Hazardous areas− Up-to-date floor plans− Mapped utilities (water, electric, gas)

Intrepidware Advises…

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Joint Commission StandardsEnvironment of CareEmergency ManagementHuman ResourcesInfection Prevention & ControlInformation ManagementLeadershipLife SafetyMedication Management

National Patient Safety Goals (NPSG)Provision of CarePerformance ImprovementRecord of CareRights of the IndividualTransplant SafetyWaived Testing

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One or more clinical surveyors for 2-3 days – Survey length based on

volumeLife Safety Code Surveyor added:− All deemed ASCs− Joins team for 1 day,

provides oral report− Addresses Life Safety Code,

Environment of Care, Emergency Management

What an ASC Survey Looks Like…


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…What an ASC Survey Looks Like

Review Survey Activity Guide (SAG)Surveyor(s) arrival

– Clinician & engineer (1 day)

Opening ConferenceUtilize ‘patient tracer’

– Observe 3-4 procedures

Everything else!!!Daily & closing conferenceOn-site report & findingsPost-survey expectationsIntra-Cycle Monitoring (ICM)Re-survey 3 years


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Joint Commission ASC Pricing

Fees:Initial Deemed ASC (up to 400 patients) = $13,675

Fees spread over 3-year accreditation cycle

(60% - 20% - 20%)Includes $1,700 depositAccess ASC pricing worksheet online


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Steps to ASC Accreditation…


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Gauge Your ASC’s Readiness

Conduct Self-AssessmentPhysically walk through your facility and see how well you meet requirements.

Identify Gaps in ComplianceDocument areas where improvement is needed. This will help target your efforts and prioritize where resources are needed.

Develop Timetable Assign completion dates for each gap identified & select a ready date


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Joint Commission Surveyor “Tips”It’s okay not to know the answer… but know who does!Please ask questions…your survey should be interactive, educational, consultativeSurveyors are reviewing systems, not individualsSurveyors will minimize disruptions to your delivery of patient careIf changes needed on your agenda, please ask!There should be no surprises at end of survey


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Most Common FindingsTop Compliance Issues – 2016

Yellow shading represents percentage of organizations that received Requirements for Improvement (RFIs) for that particular requirement.

Read AmBuzz blog “Top 10 Challenging Standards for 2016” for more insights and tips


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Get the StandardsRequest E-dition Trial Version Standards– Select applicable standards

based on setting– Free 90-day access

Standards Interpretation Group (SIG)www.jointcommission.org/standards– FAQ’s, online form to submit ?’s

Purchase Manuals– www.jcrinc.com– Comprehensive Manual (CAC17)– Abridged Standards (ACS)

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Resources: Educational Offerings

Joint Commission Resources– Webinars: Ambulatory Breakfast

Briefings– E-books:

Checklists, Mock Tracers, Top Compliance Issues, Toolkit

– JCR Consulting Services*: Mock Surveys and other Tools

See Ambulatory Care Offerings for 2017-18

*The use of Joint Commission Resources (JCR) consulting services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards

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Resources: Web SiteWeb site: www.jointcommission.org/AHCProgram1. Accreditation overview and pricing, eligibility2. Request standards/application 3. Twitter Feeds, LinkedIn, Blogs4. More: Quality Check, Other Resources

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…What Do I Do Next?Talk to Business Development– Call 630-792-5286– E-mail: [email protected]

Review ASC Standards via E-dition– Trial version offers 90-day,

free access

Complete E-Application– Online access, save-as-you-go– Submit ready date

Submit Deposit– Easy, on-line payment initiates

scheduling process

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Joint Commission SupportBusiness Development– For initial questions, access

to standards & application for accreditation

– Mike Dye, MPH– Ph. 630.792.5259– [email protected]

Account Executive– Your dedicated operational point of

contact, from application onward

Standards Interpretation Groupwww.jointcommission.org/standards

– Check FAQ’s– Submit questions via on-line form– Reference HCO# if available

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Intrepidware Accreditation Preparation & Support

Director of Accreditation– Linda Welsh RN, BSN– Phone: 347-762-6706– E-Mail: [email protected]– Website: www.intrepidware.com

transitioning your obs to a licensed asc · 2017. 11. 2. · – lasik –ivf surgical settings we...

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