Roadmap to Accreditation

Transcription

1 Roadmap to Accreditation September 17, 2014 Peggy Lavin, LCSW, DCSW, ACSW Senior Associate Director Megan Marx, MA, MPA Associate Director Allison Kikilas, MA, CRC, LPC Operations Account Executive

2 If you are NOT hearing us To access the audio for this webinar, please use a phone to call: Dial in Number: Pass Code:

3 What is Accreditation? Accreditation is the process of inviting outside experts to conduct a review of your organization to validate and improve the safety and quality of care, treatment and services. 3

4 Selecting an Accrediting Body Reputation National Recognition Accreditation Requirements Surveyor Cadre Assistance & Resources Accreditation Process 4

5 What do our accredited organizations say? "Joint Commission s accreditation process is unmatched in the industry. The support they give us is unparalleled, whether it s communication over the phone, on their website, or the various tools they provide us." David Fetterman Quality Improvement/Compliance Manager New Vitae Mental Health Center, Quakertown PA 5

6 Joint Commission Behavioral Health Care Accreditation Accrediting Behavioral Health organizations since 1969 Accredited over 2000 Behavioral Health organizations Range of settings/services 6

7 The Joint Commission Difference: Widely respected as a mark of distinction by payers, consumers, and referral sources Aligns the organization with the health care community to take advantage of health care reform Helps your organization validate and improve the quality of care provided and expand their opportunities 7

8 Joint Commission Accreditation: What will it do for your organization? Demonstrates the organization s commitment to quality and safety Provides a management outline for leadership Supports a culture of excellence Integrates data use into daily operations Recognized by referral sources 8

9 Joint Commission Accreditation: What will it do for your organization? (Cont d) Supports board members in meeting their fiduciary responsibilities Helps meet state authority / 3 rd party payer requirements May reduce liability insurance premiums For a list of insurance providers, see 9

10 Behavioral Health Accreditation Program National and State Recognitions Federally deemed by SAMHSA as an approved provider of opioid treatment program accreditation Approved accreditation provider for state requirements or regulatory relief by 196 distinct administrative agencies within 49 states and the District of Columbia 10

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12 Joint Commission Accreditation Requirements Guidance for Good Practices 12

13 Joint Commission Accreditation Requirements Requirements found in Comprehensive Accreditation Manual for Behavioral Health Care(CAMBHC) online via E-dition Based on Recovery/Resilience and Trauma concepts Applicability of standards determined by settings, services, programs, and specific populations 13

14 Joint Commission Surveyor Cadre Experienced behavioral health care professionals Trained, mentored, and monitored to deliver consistently valuable surveys Sensitivity training for diversity (i.e. cultural, gender preferences, etc) Licensed clinicians Diverse cadre Experience Cultures/Ethnicity Geography 14

15 Joint Commission Surveyor Cadre Each surveyor surveys an average of times per year Average length of service is 11 years Surveying is a skill set that needs to be exercised Sharing good practices Helping organizations in their commitment to provide safe and high quality care, treatment and services 15

16 What do our accredited organizations say? I am always impressed by the experience, patience and thoroughness of our surveyors. With The Joint Commission as a partner in treatment, I feel like we have a wise mentor prodding us to do better, to think more clearly, and to be more efficient. Dustin Tibbitts, L.M.F.T. Executive Director InnerChange New Haven RTC, Provo, UT 16

17 Assistance and Resources Behavioral Health Care team Complimentary webinars Monthly tips (contact Online tools to aid in the accreditation process Publications and educational opportunities available through Joint Commission Resources 17

18 Preparing for Accreditation 1. Obtain and review the accreditation requirements 2. Identify the standards which are applicable to your organization by using the service profile sorting function 3. Conduct an analysis to identify areas that are not in compliance, and make necessary changes before the onsite survey 18

19 Applying for Accreditation 1. Request an application for accreditation 2. Complete and submit electronic application for accreditation 3. Identify a Ready Date for the on-site survey Indicate in the application which month and date during the next 12 months you think that you ll be ready for your survey 4. Submit the non-refundable $1700 accreditation deposit, which will be credited towards your accreditation fees 19

20 Your Own Joint Commission Account Executive An accreditation coach who will: Help you to fill out your application Schedule and coordinate your initial on-site survey Guide you through accreditation policies and procedures as you prepare for your survey Assist you with any post-survey activities 20

21 Technical Assistance Standards Interpretation Group (SIG) Group composed of Joint Commission engineer, clinical social worker, behavioral health care advanced nurse practitioner Answer questions about accreditation requirements Interpretation of accreditation requirements Compliance issues Applicability of standards and elements of performance Provide examples from similar agencies/organizations Call or submit online 21

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23 Other Considerations Do it yourself vs. hiring a consultant Time frames Cost Human resources Other resources to consider Peer organizations State or national associations 23

24 Tip: Name an Accreditation Champion Can provide: Leadership support Establish expertise and credibility Inspire staff Communicate value and benefit of accreditation Embed accreditation into organization culture and daily operations 24

25 Tip: Mining For Gold Gold = Policies, procedures, practices, processes already in place that demonstrate full compliance with accreditation requirements Quick Fixes = Policies, procedures, practices, processes that demonstrate partial compliance with accreditation requirements Gaps = Lack of any policies, procedures, practices, processes to demonstrate compliance 25

26 The Initial On-Site Survey At least thirty days notice of the actual on-site survey date is given once it is scheduled Be in compliance with all applicable accreditation requirements by your survey date Use your organization s unique password-secured extranet site Undergo your initial on-site survey 26

27 After your Survey Generally days to resolve any noncompliance areas found Work with your Account Executive Seek advice Account Executive Standards Interpretation Group Final Accreditation Decision posted upon resolution of non-compliance areas Don t forget to make use of the free publicity kit posted on our web site to publicize your new status: 27

28 What do our accredited organizations say? We find that The Joint Commission provides state of the art guidance. And it helps our organization maintain state of the art treatment for our consumers. Patricia Novak Director of Quality Improvement Adult and Child Community Mental Health Center, Indianapolis 28

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30 Joint Commission Behavioral Health Care Accreditation The Joint Commission s Gold Seal of Approval TM means your organization has reached for and achieved the highest level of performance recognition available in the behavioral health field. 30

31 2014 Upcoming Events* November 5 webinar -Strategies for a Successful On-Site Survey December 3 webinar Best Practices and New Standards in Medication-Assisted Opioid Treatment * Already conducted webinars posted at jointcommission.org/bhcs 31

32 Assistance and Resources Joint Commission Behavioral Health Care Annual Conference October 15-16, 2014 Rosemont, IL An opportunity for a deep dive into the accreditation experience with our experts To Register: 32

33 Behavioral Health Care Accreditation Team Tracy Griffin Collander, LCSW Executive Director 630 / Peggy Lavin, LCSW Senior Associate Director plavin@jointcommission.org 630 / Megan Marx, MPA Associate Director mmarx@jointcommission.org 630 / Darrell Anderson, BA Senior Accreditation Specialist danderson@jointcommission.org 630 / Merlin Wessels, LCSW Standards Interpretation Group 630 / Cynthia Leslie, APRN, BC, MSN Standards Interpretation Group 630 /

34 What do our accredited organizations say? Our organization chose The Joint Commission because it helps us learn about best practices from other organizations, and it helps us establish protocols in development of our own best practices. Denise Dunn Standards and Compliance Manager Hazelton, Center City MN 34