March 2011 - PowerPoint PPT Presentation

Loading...

PPT – March 2011 PowerPoint presentation | free to download - id: 3b213d-ZjdlZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

March 2011

Description:

San Antonio APIC MARCH 2011 THE JOINT COMMISSION SURVEY PROCESS OVERVIEW * * * * * AGENDA TJC Survey Process (hospitals) TJC Chapter Requirements Periodic Performance ... – PowerPoint PPT presentation

Number of Views:125
Avg rating:3.0/5.0
Slides: 32
Provided by: apicsanan
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: March 2011


1
San Antonio APIC
  • March 2011
  • The Joint Commission Survey Process Overview

2
AGENDA
  • TJC Survey Process (hospitals)
  • TJC Chapter Requirements
  • Periodic Performance Review (PPR)
  • Survey Readiness
  • Infection Control Prevention Chapter
  • Resources
  • Discussion Questions

3
OBJECTIVES
  • Provide an overview of TJC Survey Process
    (hospitals)
  • Review the TJC Chapter Requirements Infection
    Control Prevention Chapter
  • Discuss Periodic Performance Review (PPR)
    Survey Readiness
  • Share TJC Survey Related Resources

4
TJC SURVEY PROCESS
  • Unannounced Survey Process
  • Posted on TJC secure extranet site by 730 a.m.
  • Survey window 18 to 39 months after previous
    full survey
  • Strategic Surveillance System (S3- past survey
    findings, ORYX core measure data, data from the
    Office of Quality Monitoring (complaints and
    non-self reported sentinel events), data from an
    organizations electronic application, and HCAHPS
    data.
  • TJC Survey Team Composition (based on size
    complexity of your organization) -gt Lead
    Surveyor, Administrator, Nurse, Generalist,
    Specialist (e.g. lab), Life Safety Code
    Specialist

5
TJC SURVEY PROCESS
  • Opening Session (Leadership) survey overview
    orientation to organization
  • Document Review Policies, Plans, Meeting
    Minutes, Census
  • Individual Tracer Activity Isolation Patient,
    Surgical Patient
  • System Tracers depends on the size/complexity
    of your organization
  • Infection Control Prevention
  • Medication Management
  • Data Use
  • Program Specific Tracers suicide prevention,
    patient flow, lab integration
  • Competency Medical Staff Credentialing
    Privileging

6
TJC SURVEY PROCESS
  • Infection Control Prevention System Tracer
  • Composition of Team (IC members -gt Employee
    Health, Pharmacy, Lab, EVS, Facilities
    Management, Nursing, Procedure Areas)
  • Scheduled after Document Review Individual
    Tracers
  • Discussion - review of accomplishments and
    opportunities
  • Exit Briefing Exit Summary - Summary of Survey
    Findings Report
  • Direct Impact Standards
  • Condition of Participation Deficiencies -gt
    Central Office Review
  • Indirect Impact Standards

7
Infection Control Prevention System Tracer
  • IP Program Assessment Plan
  • Population Demographics ? Annual Plan
  • MDROs -gt Lab (culture result tracking), Pharmacy,
    Dietary, EVS, NPSG, tracking
  • SSIs -gt Health Optimization Prior to Elective
    Surgery, types of procedures monitored, Joint,
    Cardiac and Bariatric Surgery
  • Device Related Infections -gt CLABSI, VAP, CAUTI
  • Review of a patient in isolation as a table top
    tracer
  • Type of isolation
  • Education of staff, patient, visitors
  • Tracking Notification

8
TJC SURVEY PROCESS
  • Potential Accreditation Decision Accreditation
    Survey Findings Report posted on secure extranet
    site includes the potential accreditation
    decision (within 2 days usually)
  • Central Office Review COP, Immediate Threat,
    Situational Decision Rules
  • Final Accreditation Decision Evidence Standards
    Compliance (ESC)
  • Immediate Threat to Health or Safety
  • Situational Decision Rules
  • Direct Impact Standards (45 days)
  • Indirect Impact Standards (65 days)
  • MOS 4 months

9
Continuum of survey activity outcomes
Reports that meet a decision rule that
automatically triggers a PDA, Cont or AFS or a
report with a CMS Condition level or APR
deficiency will be reviewed by TJC Central
Office. Reminder CMS conducting validation
surveys
10
TJC CHAPTER REQUIREMENTS
  • Chapter NPSG, EC, EM, HR, IC, LD, MS,PI,TS
  • Standard (Requirement) statements that define
    the performance expectations and/or structures or
    processes
  • Rational background, justification, additional
    information
  • Element of Performance (EP) identify
    performance expectations
  • References help to identify related
    standards/EPs
  • Icons

11
TJC CHAPTER REQUIREMENTS
  • Numbering Requirements
  • Standard six digit number broken down into three
    sets of two numbers each
  • For Example, IC.02.04.01
  • First two letters are the chapter acronym
  • First two digits refer to the Roman numeral in
    the outline
  • Second two digits refer to the letter under the
    Roman numeral in the outline
  • Last two digits refer to the standard number

12
TJC CHAPTER OUTLINE - IC
  • I. Planning
  • A. Responsibility (IC.01.01.01)
  • B. Resources (IC. 01.02.01)
  • C. Risks (IC.01.03.01)
  • D. Goals (IC. 01.04.01)
  • E. Activities (IC. 01.05.01)
  • F. Influx (IC. 01.06.01)
  • II. Implementation
  • A. Activities (IC.02.01.01)
  • B. Medical Equipment, Devices, and Supplies
    (IC.02.02.01)
  • C. Transmission of Infection (IC. 02.04.01)
  • III. Evaluation and Implementation (IC. 03.01.01)

13
TJC Glossary of Terms
What is the time line for resolution of
non-compliant findings?
What is the immediacy of risk to the patient?
Short
High
Low
Long
14
Example Scoring and Icons
Scoring Category
Documentation
Scoring Scale
Criticality Tag 3
MOS
15
TJC Periodic Performance Review
  • Tool for self-assessing compliance with
    standards and requirements between on-site
    surveys
  • Process to identify potential areas of concern,
    and opportunities to make ongoing adjustments.

16
PERIODIC PERFORMANCE REVIEW
  • Organizations self assessment with chapters,
    standards and EPs
  • Noncompliant Standard Plan of Action(POA)
    Measure of Success (MOS)
  • Completed annually one year after survey
  • Several Options for submission
  • Full PPR and 3 other options

17
PERIODIC PERFORMANCE REVIEW
Review using resources
Questions Contact Facility Administrator
18
TJC Survey Readiness
  • PPR self assessment POAs/MOS
  • Mock Individual/Patient, Progam Tracers IP and
    Team
  • Infection Prevention Control related examples
  • Isolation Patient Tracers MDROs, Precautions
  • Surgical Patient
  • Instrument handling and reprocessing
  • Biohazard Waste
  • Food and Nutrition Services
  • Environment of Care
  • Practice Infection Control System Tracer

19
TJC Survey Readiness
20
Infection Control Prevention Chapter Summary -
Planning
  • IC.01.01.01 Identifies individual(s)
    responsible for program
  • IC.01.02.01 Leaders allocate needed resources
    for program
  • IC.01.03.01 Hospital identifies risks for
    acquiring and transmitting infections
  • IC. 01.04.01 Based upon risks hospital sets
    goals to minimize possibility of transmitting
    infection
  • IC. 01.05.01 Hospital has an IP and Control
    Plan
  • IC. 01.06.01 Hospital prepares to respond to an
    influx of potentially infectious patients

21
Infection Control Prevention Chapter Summary -
Implementation
  • IC.02.01.01 Hospital implements its IP and
    Control program
  • IC.02.02.01 Hospital reduces the risk of
    infections associated with medical equipment,
    devices, and supplies
  • IC.02.03.01 Hospital works to prevent
    transmission among patients, LIPs and staff
  • IC. 02.04.01 Hospital offers vaccination
    against influenza to LIPs and staff

22
Infection Control Prevention Chapter Summary
Evaluation Improvement
  • IC.03.01.01 Hospital evaluates the
    effectiveness of its IP and Control Plan

23
National Patient Safety Goals
  • Goal 7 Reduce the risk of health-care
    associated infections
  • Meeting Hand Hygiene Guidelines
  • Preventing MDROs
  • Preventing CLABSI
  • Preventing SSI
  • 2012 VAPs and CAUTI
  • Sentinel Events separate chapter

24
2010 Challenging Standards - IC
  • Identify risks for acquiring/transmitting
    infection. IC.01.02.01/EP12 (Identify
    prioritize risks based on location, community,
    and services provided)
  • Reduce the risk of infections associated with
    medical equipment, devices, supplies.
    IC.02.02.01/EPs 1,2, 4 (Implement infection
    prevention and control activities when cleaning,
    performing disinfection, sterilizing, and
    storing) DIRECT IMPACT

25
(No Transcript)
26
Resources Available
  • JCR TJC Publications Perspectives
  • Infection Prevention Control Publications
  • TJC Hospital E-dition 2011 (updated July and
    before January)
  • TJC website (www.jointcommission.org/Standards/FAQ
    s)
  • BoosterPak
  • R3 Report
  • TJC Leading Practice Library
  • Joint Commission Center for Transforming
    Healthcare
  • (www.centerfortransforminghealthcare.org/)
  • IP Networking

27
TJC BoosterPak(As of January 2011 two
BoosterPaks Published)
28
R3 Report (As of January 2011 One Report
Published)
29
Leading Practice Library
30
Leading Practice Library
31
(No Transcript)
About PowerShow.com