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TJC Surveys Resume —Know What to Expect Webinar
June 30, 2020
Welcome
Robyn ThomasonDirector Education Program DevelopmentCalifornia Hospital Association
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Questions
Online questions only
Type your question in the Q & A box, press enter.
Continuing Education
Continuing education credits will be offered for this program for nursing. (Note: Approval still pending for compliance CEs.)
Full attendance and completion of the online evaluation and attestation of attendance are required to receive CEs for this webinar.
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Overview
Kiyomi BurchillVice President, PolicyCalifornia Hospital Association
Faculty
Gail Weinberger is the Director, Stakeholder Relations at TJC. With over 30 years there, Ms. Weinberger currently is responsible for relationship management with key TJC stakeholders including various advisory groups and state hospital associations. Previously, as the Director, Accreditation & Certification Policy & Administration, she was very involved with monitoring the changing healthcare landscape and its effect on TJC accreditation/certification process.
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Faculty
Chad Larson is the Executive Director of the Hospital Accreditation at TJC. In this role, he builds new client and partner relationships and leads strategic initiatives intended to provide value-added services within the hospital accreditation program.
Prior to his current role, he served as Director of Business Operations where he led the administration and management of operational, financial, and planning activities for the organization.
CHA Staff/Facilitator
Lois Richardson has a multifaceted job at CHA. She is responsible for evaluating the legal impact of proposed legislation/regulations on California hospitals and providing legal advice to CHA’s advocacy staff. In addition, she is the author of numerous CHA publications, including among other things, the Consent Manual, California Health Information Privacy Manual and California Hospital Survey Manual, and Cal/OSHA Safe Patient Handling Regulation Guidebook.
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Review of the Joint Commission’s Planfor the Resumption of Surveys/Reviews
Gail E. Weinberger, MA Chad Larson, MBADirector, Stakeholder Relations Executive Director, Hospital ProgramThe Joint Commission The Joint Commission
10© 2020 The Joint Commission. All Rights Reserved.
Agenda
Feedback from you on …
1. The Joint Commission’s decision process for for the resumption of surveys/reviews
2. Components of the survey process that may need to change
3. Additional considerations and support needs going forward
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11© 2020 The Joint Commission. All Rights Reserved.
In planning to resume surveys/reviews,
the key determinant is safety!
Safety for the organization!
Safety for the survey team!
12© 2020 The Joint Commission. All Rights Reserved.
Our plan is gradual and flexibleas states lift stay-at-home orders
and coronavirus cases decline!
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13© 2020 The Joint Commission. All Rights Reserved.
Decision Process for Determining Low-Risk Areas
14© 2020 The Joint Commission. All Rights Reserved.
https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
NY Times Data
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15© 2020 The Joint Commission. All Rights Reserved.
Two Data Points in Determining a “Low Risk” County
1. Current two weeks/Previous two weeks = < 1
2. Number of cases per 1,000 people = < 0.5
THEN
The County is identified as “low risk” or a GO county.
Note: A county may change from a GO/No Go if there is a downward trend.
AND
16© 2020 The Joint Commission. All Rights Reserved.
Go to TJC home page. Click Resources and the click Research from the drop‐down
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17© 2020 The Joint Commission. All Rights Reserved.
Select Operations Support Research home page. Once on the OSR home page then scroll down to
the dashboard
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19© 2020 The Joint Commission. All Rights Reserved.
20© 2020 The Joint Commission. All Rights Reserved.
JC OnlineArticleAnnouncingResumptionof Survey/ReviewActivity
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Account Executives Calls to Hospitals
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If conditions at theorganization changesafter the call
The organization’s survey may not occur!
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23© 2020 The Joint Commission. All Rights Reserved.
California Counties Identified as “Low Risk”
June 3rd June 23rd
Contra Costa Contra Costa
Sacramento El Dorado
San Joaquin Mendocino
San Luis Obispo Sacramento
Shasta San Francisco
Stanislaus San Joaquin
San Luis Obispo
Santa Cruz
Shasta
Stanislaus
24© 2020 The Joint Commission. All Rights Reserved.
If there are any unique, additional factors that can/may influence the safety of the
survey, please share this information with yourAccount Executive!
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Modifications to theOn-Site Survey
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Focus
− Will be on the organization’s current practices of providing safe, high quality care
− Will consist of a thorough assessment
− But, will not include a retroactive review of compliance between March 1, 2020 through the end of the emergency declaration
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27© 2020 The Joint Commission. All Rights Reserved.
− Limiting the number of people in group meetings
− Conducting tracers on patient units
− Avoiding areas with aerosolized procedures
− Driving in separate cars to off-site locations
Physical Distancing
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Personal Protection Equipment (PPE)
− Surveyors will be required to wear masks and any other PPE required by the organization
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29© 2020 The Joint Commission. All Rights Reserved.
Use of Technology
− Record review
− Interviews with staff
− More staff are working remotely
− Simulation of high risk areas
30© 2020 The Joint Commission. All Rights Reserved.
High Risk Procedures by Program
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31© 2020 The Joint Commission. All Rights Reserved.
High Risk Procedures by Program (cont.)
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32© 2020 The Joint Commission. All Rights Reserved.
Standards Programs Implementation Date
Perinatal Safety HAP 1/1/2021Hospital Redeeming HAP 7/1/2020
Suicide NPSG 15 application to CAH CAH 7/1/2020NPSG Phase 1 Editorial Revisions & Moves to Standards
AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME
7/1/2020
Introduction to Standard LD.04.03.09 change for "off‐site"
AHC, BHC, CAH, HAP, NCC 7/1/2020
Burden Reduction Changes not implemented at March 2020 release (b/c waiting on CMS approval)
CAH, HAP 9/13/2020
Implementation Date for New/Revised Hospital Standards
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33© 2020 The Joint Commission. All Rights Reserved.
CMS Related Issues
− Virtual Surveys
− CoPs/Waivers
− Extensions of Anniversary Dates
− Lifting of Public Health Emergency
− Survey of Hospital-Based Outpatient Services
34© 2020 The Joint Commission. All Rights Reserved.
Areas in Hospital-Based Outpatient Services Requiring Review
− Life Safety Code Drawings
− Means of Egress
− Locked/blocked exits
− Exit access
− Exit discharge Illumination
− Battery back-up
− Corridor widths
− Corridor obstructions
− Visible exit signs
− Above Ceiling
− Electrical Outlets
− Electrical Panel
− Safety Data Sheets (SDS)
− Security/Access
− Smoke\Fire Barriers
− Fire Extinguishers Inspection
− Mounting and Visibility of Extinguishers
− MRI locations
− Biohazardous and Pharmaceutical Waste
− Alcohol-based hand rub (ABHR) Dispensers
− Eye Wash Stations
− Storage Rooms
− Medical Equipment
− High-level disinfection
− Compounding
− Cylinder Storage
− Sprinkler Heads/System
− Fire Drills
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Potential for Virtual Surveys or a Hybrid Virtual/Onsite Survey
− More care is provided by telemedicine/telehealth
− More organization staff are working remotely
− Need capability to survey high-risk areas
− Review documents prior to arriving on-site
36© 2020 The Joint Commission. All Rights Reserved.
Status of Virtual Surveys
− Involves both a virtual component & a
subsequent, limited survey
− Have been conducted in Nursing Care Centers,
hospital initials and Home Care
− Interest in DSC, LAB, ASC and the VA
− Proposals into CMS
− No follow-up survey for AFSs & MEDDEFs− Currently, addressing expansion, security concerns,
what areas/document can be reviewed virtually and cost
structure
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37© 2020 The Joint Commission. All Rights Reserved.
Checklist of Documents Required During a Hospital Virtual Survey
Examples of Required Documents
− Hospital license
− CLIA Certificates
− An organization chart
− List of all contracted services
− Agreement with outside blood supplier
− Performance improvement data from the past 12 months
− Analysis from a high risk process
− Infection Control Plan
− Medical Staff Bylaws and Rules and Regulations
38© 2019 The Joint Commission. All Rights Reserved.
Resources Available at www.jointcommission.org/COVID
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39© 2019 The Joint Commission. All Rights Reserved.
Example of a Recent Resource Posted on Website
40© 2019 The Joint Commission. All Rights Reserved.
1. What do you think of the Joint Commission’s decision process for the resumption of surveys/reviews?
2. What do you think of the proposed changes to the survey process?
3. What would you like the Joint Commission to do to help support you going forward?
Questions
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Contact Information
Chad Larson, MBAExecutive Director, Hospital Accreditation ProgramAccreditation and Certification OperationsThe Joint CommissionCLarson@jointcommission.org
Gail Weinberger, MADirector, Stakeholder RelationsAccreditation and Certification OperationsThe Joint CommissionGWeinberger@jointcommission.org
Kiyomi BurchillVice President, PolicyCalifornia Hospital Associationkburchill@calhospital.org
Closing
Any Questions?
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Thank You and Evaluation
Thank you for participating in today’s webinar. An online evaluation will be sent to you shortly.
For education questions, contact:
CHA Education at (916) 552-7637 or education@calhospital.org
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