AGENDA
TJC Survey Process (hospitals)TJC Chapter RequirementsPeriodic Performance Review (PPR)Survey ReadinessInfection Control & Prevention Chapter
ResourcesDiscussion & Questions
OBJECTIVES
Provide an overview of TJC Survey Process (hospitals)
Review the TJC Chapter Requirements & Infection Control & Prevention Chapter
Discuss Periodic Performance Review (PPR) & Survey Readiness
Share TJC Survey Related Resources
TJC SURVEY PROCESS
Unannounced Survey Process Posted on TJC secure extranet site by 7:30 a.m.
Survey window – 18 to 39 months after previous full survey
Strategic Surveillance System (S3- past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data.
TJC Survey Team Composition (based on size & complexity of your organization) -> Lead Surveyor, Administrator, Nurse, Generalist, Specialist (e.g. lab), Life Safety Code Specialist
TJC SURVEY PROCESS
Opening Session (Leadership)– survey overview & orientation to organization
Document Review – Policies, Plans, Meeting Minutes, CensusIndividual Tracer Activity– Isolation Patient, Surgical PatientSystem Tracers – depends on the size/complexity of your
organization Infection Control & Prevention Medication Management Data Use
Program Specific Tracers – suicide prevention, patient flow, lab integration
Competency & Medical Staff Credentialing & Privileging
TJC SURVEY PROCESS
Infection Control & Prevention System Tracer Composition of Team (IC members -> Employee Health,
Pharmacy, Lab, EVS, Facilities Management, Nursing, Procedure Areas)
Scheduled after Document Review & Individual Tracers Discussion - review of accomplishments and opportunities
Exit Briefing & Exit Summary - “Summary of Survey Findings Report” Direct Impact Standards Condition of Participation Deficiencies -> Central Office
Review Indirect Impact Standards
Infection Control & Prevention System Tracer
IP Program Assessment & PlanPopulation Demographics Annual PlanMDROs -> Lab (culture result tracking), Pharmacy,
Dietary, EVS, NPSG, trackingSSIs -> Health Optimization Prior to Elective Surgery,
types of procedures monitored, Joint, Cardiac and Bariatric Surgery
Device Related Infections -> CLABSI, VAP, CAUTIReview of a patient in isolation as a table top tracer
Type of isolation Education of staff, patient, visitors Tracking & Notification
TJC SURVEY PROCESS
Potential Accreditation Decision – “Accreditation Survey Findings Report” posted on secure extranet site includes the potential accreditation decision (within 2 days usually)
Central Office Review – COP, Immediate Threat, Situational Decision Rules
Final Accreditation Decision – Evidence Standards Compliance (ESC) Immediate Threat to Health or Safety Situational Decision Rules Direct Impact Standards (45 days) Indirect Impact Standards (65 days) MOS – 4 months
Continuum of survey activity outcomes
Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or a report with a CMS Condition level or APR deficiency will be reviewed by TJC Central Office. Reminder: CMS conducting validation surveys
TJC CHAPTER REQUIREMENTS
Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TSStandard (Requirement) – statements that define
the performance expectations and/or structures or processes
Rational – background, justification, additional information
Element of Performance (EP) – identify performance expectations
References – help to identify related standards/EPs
Icons
TJC CHAPTER REQUIREMENTS
Numbering Requirements Standard six digit number broken down into three
sets of two numbers each For Example, IC.02.04.01
First two letters are the chapter acronym First two digits refer to the Roman numeral in the outline Second two digits refer to the letter under the Roman
numeral in the outline Last two digits refer to the standard number
Chapter Roman Numeral
Letter in Outline
Standard Number
IC 02 04 01
Infection Prevention and Control
II (section – Implementation)
D 01
TJC CHAPTER OUTLINE - IC
I. Planning A. Responsibility (IC.01.01.01) B. Resources (IC. 01.02.01) C. Risks (IC.01.03.01) D. Goals (IC. 01.04.01) E. Activities (IC. 01.05.01) F. Influx (IC. 01.06.01)
II. Implementation A. Activities (IC.02.01.01) B. Medical Equipment, Devices, and Supplies (IC.02.02.01) C. Transmission of Infection (IC. 02.04.01)
III. Evaluation and Implementation (IC. 03.01.01)
TJC Glossary of Terms
EP
Element of Performance
M Measure of Success required
DWritten Documentation required
2/3EP Criticality Tag: 2=Situational Decisional Rule; 3=Direct Impact
A/CScoring Category: A=Y/N; C=3 strikes out
EP Scoring Scale
0 Insufficient Compliance
1 Partial Compliance
2 Satisfactory Compliance
High
Low
What is the immediacy of risk to the patient?
What is the time line for resolution of non-compliant findings?
Short
Long
TJC Periodic Performance Review
Tool for self-assessing compliance with standards and requirements between on-site surveys
Process to identify potential areas of concern, and opportunities to make ongoing adjustments.
PERIODIC PERFORMANCE REVIEW
Organization’s self assessment with chapters, standards and EPs
Noncompliant Standard – Plan of Action(POA); Measure of Success (MOS)
Completed annually one year after survey
Several Options for submission Full PPR and 3 other options
TJC Survey Readiness
PPR – self assessment & POAs/MOSMock Individual/Patient, Progam Tracers – IP
and TeamInfection Prevention & Control related examples
Isolation Patient Tracers – MDRO’s, Precautions Surgical Patient Instrument handling and reprocessing Biohazard Waste Food and Nutrition Services Environment of Care
Practice Infection Control System Tracer
Infection Control & Prevention Chapter Summary - Planning
IC.01.01.01 – Identifies individual(s) responsible for program
IC.01.02.01 – Leaders allocate needed resources for program
IC.01.03.01 – Hospital identifies risks for acquiring and transmitting infections
IC. 01.04.01 – Based upon risks hospital sets goals to minimize possibility of transmitting infection
IC. 01.05.01 – Hospital has an IP and Control PlanIC. 01.06.01 – Hospital prepares to respond to an
influx of potentially infectious patients
Infection Control & Prevention Chapter Summary - Implementation
IC.02.01.01 – Hospital implements its IP and Control program
IC.02.02.01 – Hospital reduces the risk of infections associated with medical equipment, devices, and supplies
IC.02.03.01 – Hospital works to prevent transmission among patients, LIPs and staff
IC. 02.04.01 – Hospital offers vaccination against influenza to LIPs and staff
Infection Control & Prevention Chapter Summary – Evaluation &
Improvement
IC.03.01.01 – Hospital evaluates the effectiveness of its IP and Control Plan
National Patient Safety Goals
Goal 7 – Reduce the risk of health-care associated infectionsMeeting Hand Hygiene GuidelinesPreventing MDRO’sPreventing CLABSIPreventing SSI2012 – VAPs and CAUTI
Sentinel Events – separate chapter
2010 Challenging Standards - IC
Identify risks for acquiring/transmitting infection. IC.01.02.01/EP#1&2 (Identify & prioritize risks based on location, community, and services provided)
Reduce the risk of infections associated with medical equipment, devices, supplies. • IC.02.02.01/EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}
Resources Available
JCR & TJC Publications – Perspectives
Infection Prevention & Control Publications
TJC Hospital E-dition 2011 (updated July and before January)
TJC website (www.jointcommission.org/Standards/FAQs) BoosterPak R3 Report TJC Leading Practice Library
Joint Commission Center for Transforming Healthcare (www.centerfortransforminghealthcare.org/)
IP Networking