The Joint Commission Accreditation Experience Anne Arundel County Providers Presentation July 14, 2015 Peggy Lavin, LCSW, ACSW, DCSW Senior Associate Director

The Joint Commission

Accreditation Experience

Anne Arundel County Providers Presentation

July 14, 2015

Peggy Lavin, LCSW, ACSW, DCSW Senior Associate Director

Behavioral Health Care Accreditation

© Copyright, The Joint Commission

Mission & Vision Reputation & Recognition What It Is & What It Will Do Accreditation Requirements The Surveyor Cadre & The Survey Process Assistance & Resources The Accreditation Process


Today’s Agenda

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Mission and Vision

Our MissionTo continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel, in providing safe and effective care of the highest quality and value.

Our Vision“All people experience the safest, highest quality, best-value health care across all settings”

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REPUTATION&

RECOGNITION

Reputation - Across the Healthcare Continuum

Over 20,000 Health Care Organizations Accredited

Ambulatory Physical Health Care

Behavioral Health Care

Critical Access Hospital

Home Physical Health Care

Hospital

Laboratory Services

Nursing Care Centers

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Reputation

Accrediting Behavioral Health Care organizations since 1969

Experienced in accrediting a broad range of settings/services

2190 Accredited Organizations• Over 8,017 sites• 54% not-for-profit• 27% for profit• 18% governmental agencies/facilities

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Accredited Behavioral Health Care Providers by State

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2 4

24

3168

56

186

4

13

511439

100

34

347

42

17

27

613586

35

37

133

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4

14

15

11

16

4

11

16

20

101

4

12

926

2025

5

16

98

10

7

DC 6

31

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Recognition

Excellent recognition by the physical and behavioral health care community for referrals and care coordination

Excellent recognition by 3rd party payers (Medicare/Medicaid/Commercial Insurance)

Valued by liability insurance carriers: http://www.jointcommission.org/liability_insurers

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Recognition

National Level Recognition:Federally deemed by SAMHSA as an approved provider of opioid treatment program accreditation

• There are 1,250 federally certified opioid treatment programs in the United States. The Joint Commission accredits 1/3 of these organizations.

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Recognition

State Level Recognition: Approved accreditor for state requirements or regulatory relief by 196 distinct administrative agencies within 49 states and the District of Columbia

16 states with Medicaid Health Home SPAS; 8 in process

4 states require Behavioral Health Home Certification

www.jointcommission.org/BHCS

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http://www.jointcommission.org/BHCS

http://www.jointcommission.org/state_recognition/state_recognition.aspx?ps=100&b=41



WHAT IT IS&

WHAT IT WILL DO

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.

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What Will Accreditation Do For You?

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.

Supports board members in meeting fiduciary responsibilities.

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QUESTIONS?

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Accreditation Requirements

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Guidance for Good Practices

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 NovakDirector of Quality ImprovementAdult and Child Community Mental Health Center, Indianapolis

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Joint Commission Accreditation Requirements

Requirements found in Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) online via manual called “E-dition”

Based on Recovery/Resilience and Trauma-Informed concepts

Applicability of standards determined by setting(s), service(s)/program(s), and specific population(s)

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The Joint Commission Behavioral Health Care Accreditation Requirements

Care, Treatment, Services

Emergency Management

Environment of Care

Human Resources Management

Infection Control

Information Management

Leadership

Life Safety

Medication Management

National Safety Goals

Performance Improvement

Record of Care, Treatment, & Services

Rights of the Individual

Waived Testing

Sentinel Event Policy

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Outcome Measurement:

Performance Improvement Chapter

Outcomes of care, treatment or services

• Individual’s progress

• Populations outcome(s)

The Joint Commission Behavioral Health Care Accreditation Requirements

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LD.04.01.01: The organization complies with law and regulation

— EP 1: The organization is licensed, certified, or has a permit, in accordance with law and regulation to provide the care, treatment or services for which the organization is seeking accreditation from The Joint Commission.

— EP 2: The organization provides care, treatment or services in accordance with licensure requirements, laws and regulations.

— EP 3: Leaders act on or comply with reports or recommendations from external authorized agencies, such as accreditation, certification, or regulatory bodies.

BHC Standards Sampler

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CTS 02.01.01: The organization has a screening procedure for the early detection of risk of imminent harm to self or others.

─ EP. 1: The screening procedure determines the need for immediate intervention to protect the individual served or others.

─ EP. 2: The organization has a process for responding when an immediate risk of harm is identified.

─ EP. 3: The organization responds when it determines the individual served poses an immediate risk of harm to self or others.


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PI.01.01.01: The organization collects data to monitor its performance.

─ EP. 1: The leaders set priorities for data collection.

─ EP. 2: The organization identifies the frequency for data collection.

─ EP. 16: The organization collects data on whether individual served was asked -

─ about treatment goals and needs

─ if her treatment goals and needs were met

─ view of the individual regarding how the organization can improve the safety of treatment provided.


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CTS.02.03.07: For organization providing treatment to individuals with addictions: The assessment includes the individual's history of addictive behaviors.

─ EP. 1: For organization providing treatment to individuals with addictions: The history includes age of onset, duration, patterns of use.

─ EP. 2: For organization providing treatment to individuals with addictions: The organization obtains the individual's history of mental, emotional, behavioral, legal and social consequences of dependence or addition.

─ EP. 4: For organization providing treatment to individuals with addictions: The organization obtains the individual's history of physical problems associated with substance abuse, dependence, and other addictive behaviors.


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CTS.01.01.01: The organization accepts into treatment only those individuals whose identified treatment needs it can meet.

─ EP. 1: “ icon" The organization has a written process for determining eligibility of individuals.


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D

D

QUESTIONS?

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SURVEYOR CADRE&

THE SURVEY PROCESS


The Joint Commission Surveyor Cadre

“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

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Experienced behavioral health care professionals

Licensed clinicians

Trained, mentored, and monitored to deliver consistently valuable surveys

Trained to be culturally sensitive to diversity

Diverse cadre

• Experience

• Cultures/Ethnicity(Several Spanish speaking)

• Geography

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Each surveyor surveys 12-15 times per year

Average length of service is 11 years

Surveying is a skill set that needs to be exercised

Surveyors share good practices

Surveyors help organizations in their commitment to provide safe and high quality care, treatment and services

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The On-Site Survey Process

Shortest survey is onesurveyor for two days

Surveys can be multiplesurveyors for multiple days

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The Initial On-Site Survey

At least 30 days notice is provided prior to the Actual on-site survey date once it is scheduled

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Evaluator EducatorConsultant

and

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In sync with an organization’s normal operational systems

Customized to setting(s), service(s) and population(s) served

Focus is on actual delivery of care, treatment, and services–not just paperwork

• The “tracer method” follows a person’s experience in your treatment setting using interviews and observation to determine compliance with accreditation requirements

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Opening Session– Orientation to the Organization:

A discussion that provides an opportunity for the surveyor(s) to learn from you about your organization

• What you do• Who you serve• Your staff• Your philosophy and values• How you are organized

Ensures a meaningful on-site survey experience

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Individual “Tracers” Traces the continuum of care, treatment or services provided

Usually at least 60% of the on-site survey

Directly involves staff who provide care, treatment or services

Follows care, treatment or services provided throughout the organization

Individual served/family is involved as appropriate

Samples from all programs/services operated by organization

Surveyors attempt to minimize disruptions to the organization

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Safety First!

Buildings/Offices

Grounds

Transportation

Review of the Environment:

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Data Session: Discussion of how the

organization uses data

Identification of data to be collected

Aggregation and analysis (turn data into information)

Use of the information to drive performance improvement

Outcomes

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Competence of staff session: Job Descriptions Staff selection Verification of education

and licensure Orientation and training

Determination of staffing Patterns

Competence assessment (initial and ongoing)

Performance evaluation

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Other Systems Tracers as Applicable: Medication Management

• Reviews the medication processes from prescribing to administrating

• Only reviews those aspects relevant to the organization

Infection Control• Reviews processes for preventing and responding

to infections

• Varies based on settings(e.g. facility-based vs. community-based)

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Daily Briefing: Start of each day after the first day

Review of the previous day’s activities

Identification of any areas of potential non-compliance with accreditation requirements

Opportunity for organization to clarify misunderstandings

Surveyor(s) offer suggestions for achieving full compliance

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Leadership Session:

Discussion with organization leadership

Last day of survey

Based on observations during the survey

An opportunity for the leaders and surveyor to discuss how the leaders can use the surveyors’ observations to move the organization forward

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Achieve Maximum Consultation: Educate Your Staff About the Survey Process:

Compliance & Education

Encourage organizational staff to be Open to Learn, Share, and Seek to Understand

If An Organization is Eager to Learn, Grow, and Improve, more consultation is likely

How will the organization measure the success of the survey?

Hint: It should not be the number of findings

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Closing Session and Report: Meeting with CEO, if desired, to review report

Meeting with staff chosen by organization

Report

• Organization receives written preliminary report of any compliance areas during the closing session

• Official report is provided on organization's extranet site within 10 days after survey

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The Survey Process After Accreditation: Triennial: 18–36 months after last full survey

Unannounced, except for 7-day notice for:

• Correction Settings

• “Small” Settings (Average daily census < 100)*

• Outpatient and Day Programs*

• 24 Hour Service Settings*

* No exception if program is operated as a component of a hospital

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“We talked to several accredited behavioral health care organizations that were not Joint Commission accredited. Interestingly, those organizations felt that

their review was only procedural, and it did not help improve the quality of care. We were only interested in accreditation if it would help us improve. After talking with those organizations, I knew The Joint Commission was the right choice.”

Jeff Shearer, ACSW, LCSW, CAP - Founder Tykes & Teens

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QUESTIONS?

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ASSISTANCE&

RESOURCES

Assistance and Resources

Behavioral Health Care team — Monthly Email Tips ([email protected])

Online tools to aid in the accreditation process www.jointcommission.org/BHCS

Online resources for accreditation activities

— Secure extranet site, eDition (online standards)

Publications and educational opportunities — available through Joint Commission

Resources www.jcrinc.com

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http://www.jointcommission.org/BHCS

http://www.jcrinc.com/


Joint Commission

Behavioral Health Care

Annual ConferenceOctober 15-16, 2015

Rosemont, IL

An opportunity for a deep dive into the accreditation experience with our experts

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Note: Register for webinars or view already conducted webinars at www.jointcommission.org/BHCS

2015 Complimentary Webinars

Jan 14 Basics of Accreditation: Myth-buster Edition

Feb 18 Roadmap to Accreditation: Your Path to Success

Mar 11 Strategies for a Successful Survey

May 13 Integrated Care: Considerations for Quality

Jun 10 Improving Reimbursement in Behavioral Health

Jul 8 Orientation to the Accreditation Requirements

Aug 12 Peer Services and Accreditation: Improving Outcomes

Sept 9 Roadmap to Accreditation: Your Path to Success

Nov 4 Strategies for a Successful Survey

Dec 2 New Standards and Best Practices in Medication-Assisted Opioid Treatment

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Accreditation Workshop

When: August 12 Where: Doubletree by Hilton Philadelphia Valley Forge

301 West DeKalb PikeKing of Prussia, PA 19406

Time: 9:00 am – 1:30 pm (continental breakfast)

To Register or for more info:www.jointcommission.org/accreditation_workshop_0812/

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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

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Standards Interpretation Group (SIG) Joint Commission engineer, clinical social worker,

behavioral health care advanced nurse practitioner Experts on accreditation requirements

• Interpretation of accreditation requirements• Compliance issues• Applicability of standards and elements of performance

Provide examples from similar agencies/organizations

Call 630-792-5900 or submit online

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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 FettermanQuality Improvement/Compliance ManagerNew Vitae Mental Health Center, Quakertown PA

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“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 DunnStandards and Compliance ManagerHazelton, Center City MN

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Strategies for a Successful Accreditation Experience

Appoint an Accreditation Champion— Communicate value and benefits of accreditation

— Provide leadership support

— Inspire staff

— Establish expertise and credibility

— Embed accreditation into daily operations and culture of organization

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Request access to online application for accreditation and manual of accreditation requirements

Ask for an orientation to the manual• Conduct a high level review of accreditation

requirements

• Complete application with a "ready" date

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Strategies for a Successful AccreditationExperience

Submit application and non-refundable deposit

Mine for your gold (current compliance level)

Use the Standards Interpretation Group (SIG)

Implement action plan to "fill the gaps“

Access Survey Activity Guide

Organize policies and procedures (Required Written Document)

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Conduct "mock" survey

Conduct "mock" tracer activities

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"To consult or not to consult. That is the question"Bill Shakespeare

Do It Yourself vs Hiring a Consultant• Time Frames• Cost• Human Resources

Other Resources to Utilize:• Peer Organizations• State or National Associations

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QUESTIONS?

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The Joint Commission’s Gold Seal of ApprovalTM means your organization has reached for and achieved the highest level of performance recognition available in the behavioral health field.


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Behavioral Health Care Accreditation Team

Tracy Griffin Collander, LCSWExecutive Director

[email protected] 630/792-5790

Peggy Lavin, LCSWSenior Associate Director

[email protected]/792-5411

Megan Marx, MPAAssociate Director

[email protected]/792-5131

Darrell Anderson, BASenior Business [email protected]

630/792-5866

Peter Vance, LPCC, CPHQField Director

[email protected]

630/792-578868

mailto:[email protected]







Behavioral Health Care Accreditation Team

For Accreditation/Certification Requirements Questions:

Merlin Wessels, LCSW

Associate Director

[email protected]

630/792-5900 Option # 6

(If your question concerns the Life Safety Chapter,

please call 630/792-5900 and ask for a Joint Commission engineer

or email [email protected])

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Documents

The Joint Commission Accreditation Experience Anne Arundel County Providers Presentation July 14, 2015 Peggy Lavin, LCSW, ACSW, DCSW Senior Associate Director