The Road to Quality Accreditation Basics for Home Care Organizations: Strategies for Success
Presenters From The Joint Commission: Julia Finken BSN, MBA, CPHQ, CSSBB, Associate Director, Home Care Wayne Murphy RRT, MPS, Field Director, Home Care Dea Greathouse RN, MSHA, Associate Director, Standards Interpretation Group Eboné Wilkerson, Senior Account Representative, Home Care Brenda Lamberti BS, Business Development Specialist, Home Care Wendy Daigle RN, Quality Manager, LHC Group, Inc. November 18, 2014 2
The Joint Commission Independent, not-for-profit organization Accrediting Home Care organizations since 1988 Accredits over 7,000 Home Care programs 3
Today s Discussion includes: First steps for a provider considering accreditation Eligibility requirements How to apply Basics of the accreditation experience Standards to support your quality efforts Strategies to enhance compliance Demonstrating your performance excellence Unique onsite survey experience Sustaining quality and sharing your success Quality distinction within the industry Access to helpful tools and resources 4
Why Joint Commission Accreditation? Our Customers say it best It s the industry s most highly regarded quality framework for delivering consistent best-in-class care. It provides opportunity to learn from the industry s most trusted name in quality and safety on survey, from their Standards team and through their many, free online tools. 5
Home Care Providers Eligible for Accreditation Home Health Hospice Personal Care and Support Pharmacy DMEPOS 6
Pre-application Considerations Available accreditation options: Accreditation Accreditation with federal recognition Deemed status for home health Deemed status for hospice Recognition for DMEPOS providers 7
Eligibility Requirements Satisfy your state law and licensing requirements Company is operational and providing care Traditional accreditation and DMEPOS recognition Must have served 10 clients/patients, minimum of 2 active at time of survey Home health deemed status Must have served 10 skilled patients, minimum of 7 active at time of survey Hospice deemed status Must have served 5 patients, minimum of 3 active at the time of survey 8
Additional Requirements for Deemed Status Applicants ONLY Approved CMS Form 855a State notified that agency will use The Joint Commission for deemed status Successful test transmission of OASIS data (Home Health only) 9
Applying for Accreditation is Easy You determine when you are ready to apply Create a reverse road map Be realistic with your goals and expectations Reviewing the standards Register online for the Free 60-day access to help determine a realistic target date Access to the application Register online for access to your extranet Access to supportive team members Business Development Standards Help Desk Account Executive 10
Request an Application Visit http://www.jointcommission.org/accreditation/home_care.aspx Call the Home Care line at 630-792-5070 11
Access to Joint Commission Connect 12
Completing the Application Who has access to the extranet? Submit accurate organizational information Names, addresses, titles Services provided Hours of operation Submitting payment Scheduling the survey What is the Ready Date 13
Getting Ready for Survey Make the E-dition your online handbook Compare performance to standards Make compliance everyday work National Patient Safety Goals Take advantage of the resources available to help you 14
Standards E-dition 15
As You Begin Survey Preparation Understand and identify laws/regulations for your state Use the Standards Manual as a Reference Guide Review Written Documents Required Review National Patient Safety Goals Risk Areas/Clinical Service Emergency Preparedness Infection Control Human Resources Leadership Performance Improvement 16
Accreditation Survey Prep 17
Considerations for Deemed Status Survey Prep Home Health Conditions of Participation Professional Advisory Group Home Health CoPs: http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf Hospice Conditions of Participation Planning for scope of service Hospice CoPs: http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf 18
The Onsite Survey Patient/Client-centric & educational Observation of patient/client care with permission Individual and system tracers guide the time Determining Compliance Observations shared as they are made Leaders/managers encouraged to participate Preliminary, printed findings provided on site Minimal interruption of care activities; flexible Survey agenda accommodates operational systems and schedules 19
Joint Commission Surveyors Home Care Professionals Professional Experience in Home Care Clinicians and administrators Collaborative Open communication Rigorous hands-on initial education Ongoing professional education 20
Typical Onsite Survey Agenda Announced vs. Unannounced Posted on extranet at 7:30 a.m. Surveyor bio and picture Survey agenda Opening Conference - orientation to the organization Surveyor Planning Staff interviews Individual tracer activities, patient/client record review Systems tracers Daily Briefings Leadership session Exit Conference 21
Other Survey Prep Tips Check your Extranet site daily Keep manuals, contracts, personnel files and documentation ready and accessible Once the surveyor arrives, have plan ready to notify the field Have a daily list of scheduled visits ready to go every morning Have your supervisor available or access to them The more you engage with your surveyor, the more meaningful your survey experience 22
After the Survey On-site survey report will be posted on your extranet site within 10 days If your organization has a standard out of compliance providers must submit evidence of standards compliance within a 45 60 day window Initial surveys, your accreditation decision is effective from the day The Joint Commission approves your FINAL evidence of standards compliance. For Joint Commission to recommend Medicare Certification to CMS: Standard-level deficiencies must be corrected Condition-level deficiencies for first time surveys require a repeat survey CMS is notified of our recommendations; they make the final certification notification 23
Home Care Fees Based on services provided and individuals served Annual and on-site survey fees based on average daily patient/client volumes On-site survey fee Inclusive of all surveyor travel and expenses Non-deemed surveys typically 1-2 days Deemed status surveys typically at least 3 days Accreditation awarded for three-year cycle 24
Sustaining Quality Sharing Success Industry perspective National voice Quality check Practical tools for performance excellence 25
For Accredited Organizations Joint Commission Perspectives newsletter - published monthly Access to the customer-only Leading Practices Library Home Care Bulletin, a complimentary newsletter Online Media Kit with ideas to help publicize your achievement Marketing support through a listing on Quality Check Center for Transforming Healthcare 26
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Achieving Accreditation: A Customer s Perspective Wendy Daigle RN, Quality Manager for LHC Group, Inc. 29
Next Steps! Go to: http://www.jointcommission.org/accreditation/home_ care.aspx Register for the Free 60-day access to the electronic standards (E-dition) Review accreditation information Assess your readiness Request the application Questions? Contact the Home Care Team Phone: 630.792.5070 Email: homecare@jointcommission.org 30
Supportive Resources If you have a question about... Please contact... GETTING STARTED: How to get started The overall accreditation process The cost of accreditation How to get a free trial of the standards How to request an application THE BUSINESS DEVELOPMENT TEAM: Call: 630-792-5070 Email: homecare@jointcommission.org Website: www.jointcommission.org MANAGING THE ACCREDITATION PROCESS: Completing the application Scheduling a survey date Specific issues related to ongoing accreditation AN ACCOUNT EXECUTIVE: Call: 630-792-3007 OUR STANDARDS: Complying with specific standards THE STANDARDS HELP DESK: Call: 630-792-5900, Option 6 Website: www.jointcommission.org/standards MANUALS, EDUCATION AND TRAINING: Obtaining standards manual Registering for a Joint Commission education program Staff training resources JOINT COMMISSION RESOURCES (JCR): Call: 877-223-6866 Email: jcrcustomerservice@pbd.com Website: www.jcrinc.com 31
Time for Your Questions! 32
Home Care Team Contacts Joint Commission Home Care Program Help Desk: 630-792-5070 or homecare@jointcommission.org www.jointcommission.org/accreditation/home_care.aspx Margherita Labson BSN, MSHSA, CPHQ, CCM, CGB Executive Director 630-792-5284 or mlabson@jointcommission.org Julia Finken BSN, MBA, CPHQ, CSSBB Associate Director 630-792-5283 or jfinken@jointcommission.org Brenda Lamberti, BS Business Development Specialist 630-792-5252 or blamberti@jointcommission.org Standards Interpretation Help Desk: 630-792-5900 Joint Commission Resources: 877-223-6866 or www.jcrinc.com