2015 Joint Commission Update Joint Commission Resources Custom Education Program for the Hawaii Hospital Education and Research Foundation

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1 2015 Joint Commission Update Joint Commission Resources Custom Education Program for the Hawaii Hospital Education and Research Foundation Dates Thursday, January 8 and Friday, January 9, am 4:30 pm both days Location Hawaii Prince Hotel Waikiki Mauna Kea Ballroom 100 Holomoana Street, Honolulu, HI Cost The cost per person for the full two day session is: $680 for members of the Healthcare Association of Hawaii (HAH) $820 for non members $730 for facilities in Guam, CNMI and American Samoa Meals Continental breakfast is provided on both days. Lunch will be the responsibility of each attendee. Parking Full parking validation at the Hawaii Prince or Marina Parking Structure is included with registration. If the Hawaii Prince Hotel parking garage becomes full, alternate validated parking will be available at the Marina Parking Structure (use entrance next to Red Lobster). We do not validate for the Ilikai Hotel. Registration Please complete the following registration form and return by , mail or fax by December 9. This is to allow sufficient time for Joint Commission Resources to ship resource materials to us. Once we receive the number of attendees from your facility, an invoice will be sent to you. Upon receipt of the invoice, please make check payable to HHERF and send to 707 Richards St, PH2, Honolulu, HI Cancellations will not be accepted; however, substitutions will be permitted. Hotel Rooms at Hawaii Prince A discounted rate is available for our group from Jan 7 9: $179 per night for Hawaii residents and $199 for non residents (plus tax). A block of rooms will be held at these rates until December 8. Thereafter all rooms and rates are based on space available. Please call (800) for reservations and say you are attending the Joint Commission Update Conference. CEUs CEU credits are included in the registration price. Continuing Education Hours/Units are being applied for as follows: Contact Hours for CEs are being applied for ACCME, ANCC, ACHE, and ACPE. Units for CEUs are being applied for IACET. Two days of attendance are required for Continuing Education Hours/Units. We will give more information on CEUs as it becomes available. To give a rough guide, last year Continuing education credits were available for ANCC, ACCME and ACHE and ACPE. Questions? Please contact Adria Estribou at (808) or aestribou@hah.org

2 FACULTY BIOS Laurel McCourt, M.D. Consultant, Joint Commission Resources Laurel McCourt, MD is a board certified family physician. She received her MD degree from Northeastern Ohio Universities College of Medicine in Her residency training was at Aultman Hospital in Canton, Ohio. In addition, Dr. McCourt is an honorary member of the Medina General Hospital Medical Staff in Medina, Ohio. Her initial career in medicine began in a staff model HMO where she held the position of staff physician until From , she served as the Medical Director of Brunswick Medical Care Center, a satellite facility of Medina General Hospital. From , she held the position of Physician Quality Liaison at Medina General Hospital. In 2004, she began her career as a hospital surveyor for The Joint Commission. For the first five years, she continued to practice medicine as well. Since that time, she has become further trained in the Manual for Office Based Surgery and in the Primary Medical Home Accreditation Process. In addition, Dr. McCourt has served in the Special Survey Unit to investigate complaints for The Joint Commission. She has served as a team leader for both deemed and non-deemed hospital systems and has surveyed the range of organizations from rural community hospitals to large academic medical centers. In her career at The Joint Commission, Dr. McCourt has been active in the speaker s bureau. She has given numerous presentations to a variety of audiences including several national meetings. Her topics include the hospital accreditation standards and the survey process. Roberta Fruth, RN, MS, PhD, FAAN, CJCP Senior Consultant, Joint Commission Resources, Inc. Roberta Fruth has more than 35 years of experience in health care operations, clinical practice, education and research in hospital, ambulatory, and international settings. Her expertise in operations, patient safety, performance improvement and leadership establishes her strong foundation as a consultant. Dr. Fruth offers demonstrated experience as a nurse executive and educator in academic and community hospital settings. She has faculty appointments at Rush University and the University of St. Francis. As a consultant, she brings educational and operational expertise in data management, performance improvement, clinical safety, survey readiness, and team development to help organizations achieve their goals. She consults domestically and internationally and serves as a faculty member for JCR/JCI education programs. In her international consulting role she has experience in Asia, Europe, the Middle East, and South America. Dr. Fruth s faculty and lecturing experiences contribute to her ability to present content to a variety of audiences with case examples that support application to clinical settings. Her experiences in clinical operations provide the framework to integrate evidencebased practices and standards into the clinical world. Her seasoned and practical approach to process changes and the realities of today s dynamic health care scene add the element of workability to her consulting practice. Dr. Fruth received her associate s degree in nursing from Belleville Area College, Belleville, Illinois; her bachelor s of science in nursing from St. Louis University, St. Louis, Missouri; her master s of science from Rush University, Chicago, Illinois; and her doctorate from the University of Illinois at Chicago, Chicago, Illinois. She is a Joint Commission certified Yellow Belt. In 2013, she earned the new Certified Joint Commission Professional (CJCP) credential for knowledge in accreditation compliance, survey readiness, and performance improvement.

3 Please return registration form by December 9 Joint Commission Resources Custom Education Program January 8 9, 2015 Name of Facility: Joint Commission Project Director for your facility Name: Title: Phone: Name(s) of Attendee(s): Please type or print legibly. Check box Indication required for CEUs: Total number attending from your $680 each [HAH $820 each [non $730 each [CNMI, Guam, American Samoa] Please send this form to Gail Coleman by gcoleman@hah.org or fax it to (808)

4 2015 Joint Commission Hospital Accreditation Update A JCR Custom Education Program for The Healthcare Association of Hawaii January 8-9, 2015 Draft Agenda Thursday, January 8th Time* Topic 7:30 8:00 am Registration 8:00 8:15 am Welcome and Review of Objectives 8:15 9:45 am Updates to The Joint Commission s Accreditation Process Improving the Accreditation Process o Survey Process/Changes o Focused Standards Assessment o Tracers: Individual, System, Disease-Specific, 2 nd Generation CMS Update for :45 10:00 am Break 10:00 11:00 am 2015 National Patient Safety Goals 2014 Trends and Challenges 2015 Goals and Requirements Compliance Tips for the Most Challenging Standards 11:00 12:00 Noon Medical Staff FPPE/OPPE Telemedicine 12:00 pm 1:00 pm Lunch 1:00 pm 2:30 pm Environment of Care Life Safety 2:30 2:45 pm Break 2:45 3:30 pm Emergency Management 3:30 4:15 pm Performance Improvement 4:15 4:30 pm Q&A 4:30 pm Adjournment * Times are approximate and fluid based on audience questions and discussions

5 2015 Joint Commission Hospital Accreditation Update A JCR Custom Education Program for The Healthcare Association of Hawaii January 8-9, 2015 Draft Agenda Friday, January 9th Time* Topic 8:00 8:30 am Rights and Responsibilities of the Individual 8:30 9:30 am Medication Management 9:30 9:45 am Break 9:45 10:45 am Provision of Care, Treatment and Services Waived Testing Transplant Safety 10:45 12:00 Noon Infection Prevention and Control 12:00 pm 1:00 pm Lunch Human Resources 1:00 pm 1:45 pm Record of Care, Treatment, and Services 1:45 2:45 pm Leadership 2:45 3:00 pm Break Information Management 3:00 4:00 pm Tips for a Successful Survey 4:00 4:30 pm Q&A 4:30 pm Adjournment * Times are approximate and fluid based on audience questions and discussions

6 Objectives At the conclusion of this program, participants will be able to: 1. Translate the changes related to the Joint Commission s standards and survey process for 2015 into your organization s ongoing survey readiness activities. 2. Apply appropriately the relationship between The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) as to distinguish between accreditation and deemed status in your healthcare setting(s). 3. Incorporate the use of tracers to analyze your organization s systems and processes. 4. Implement strategies for complying with new and challenging standards in your practice setting(s).