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[Music] you [Music] the work that we're doing that goes beyond being just an accreditation organization really how we hope to inspire hospitals out there in the United States and really internationally so at the onset of this presentation some of the objectives which I hope to the audience will gain from this conversation today will be to get a deeper understanding of how the Joint Commission goes beyond being an accreditation organization we're going to review some of the emerging survey trends for hospitals in the United States today we're also going to help you identify some available educational resources and information that the Joint Commission offers that could help organizations address some common issues that they may be experiencing in their hospitals and finally I hope to help you all understand how Joint Commission's working with organizations to inspire them to deliver high quality safe and effective patient care so a little bit of background about the Joint Commission if you're not familiar we were founded in 1951 we are a nonprofit organization governed by a 21 member Board of Commissioners we are the nation's oldest and largest standard setting an accrediting body in the United States and we have more than 22,000 healthcare organizations who are accredited and certified today in the United States we have over 4,000 United US hospitals who are accredited by the Joint Commission so who are we really today the Joint Commission prides itself on and being an improvement organization or focused on health care for the public our mission and the two words I really like to focus on is that we like to evaluate and inspire health care organizations to excel in providing safe and effective care of the highest quality and value we partner with organizations across the entire continuum of care with our the only a creditor to accredit and certify across the entire continuum of care and we go beyond accreditation as an improvement organization creating and delivering solutions that would help organizations in advancing quality and safety improvements in their organization we're going to talk a little bit today about some of those tools that the Joint Commission offers complimentary to accredited organizations we do write and maintain our own standards which are all evidence-based and we are continuously using Lean Six Sigma and change management methodologies within our own organization to see how we can continuously improve our own business and the work we're doing and finally the Joint Commission has been on a initiative and leading the way to zero harm so creating that vision for high reliability in healthcare today and providing a roadmap for organizations to get there and why start a little bit about and share a little bit with how the Joint Commission's advancing their efforts and advocacy the Joint Commission does work on a daily basis on Capitol Hill in working in regular healthcare topics we do work with and regularly interface with many governmental agencies on that go beyond just CMS we've also done a number of advancements in ways that we can inspire organizations to improve quality and safety we have our own advisory groups that we work with on a daily weekly monthly initiative to to advance healthcare as well and again voiced the customer and feedback from organizations there are a number of professional associations that the Joint Commission works with and we've also developed and maintained some exclusive payer relationships with some quality incentive programs of our disease-specific care certification programs and one thing we really like recently as we do more advanced work with State Hospital Association so how we can work with your state hospitals to provide education and resources that they would see to be most beneficial to the hospitals whether accredited or not accredited by the Joint Commission within their respective states so a little bit of background about the Joint Commission's survey process in 20 2016 the Joint Commission changed their survey process in using what we call a safer matrix so the grids the right-hand side of the screen displays our safer matrix this is how we give a visual representation of survey findings after the close of an on-site survey event so we've had a complete shift in how our survey is focused it's completely looking at a risk assessment risk identification within organizations the safer matrix is really developed to communicate an organization's biggest risk points helps an organization to prioritize their improvement efforts within their system and then it can be used as an in to internal comparison tool for your health system as well so there's a lot of information and data that the Joint Commission provides in these areas we're going to dive a little deeper into that as we further the discussion but it's not just how Joint Commission is providing that data to organizations but also how your organization can use it across your entire system is a comparison tool our on-site survey evaluation also in in discussions with how our surveyors differentiate our surveyors are all they have very extensive background in education and they have numerous ongoing continuous education initiatives they're all trained in some form of Lean Six Sigma the process improvement initiatives the approach what we've really sort of prided ourselves on recently is being very data-driven in the on-site survey process it's very specific to your organization and also patient centric our surveyors are also selected based on the background of your organization our surveyors do also have they're selected based on their educational background and their expertise so some of those areas could be in the pediatric the oncology world as well as we do employ on psychiatrists as well for psychiatric hospitals and another point to really speak about here is how the on-site survey process is also engaging organisations on their own journey in high reliability so really having the surveyor speak with your leadership and staff about your own efforts internally on advancing quality and patient safety as well I'm going to talk about some of the most common areas of risk that hospitals are facing today this is data that we've actually collected through our on-site survey process so this is data that was collected through from January 1st to 2019 through June 30th of 2019 and these were first strictly Hospital surveys from the Joint Commission so that our safer matrix really depicts risk in organizations as well as the likelihood to harm a patient so sort of how this grid works is your lower left-hand corner the yellow box would speak to what percentage of findings occur in what we call a low limited category so the scope of it impacting a hospital would be in a limited capacity maybe it's contained to a unit or department within your hospital and it's not in a widespread fashion and the the likelihood to potentially harm a patient or staff would be the other side of your access of your grid here so if you move up into the upper right hand box of this of the sort of the nine box grid here you can kind of get an idea of where placement of findings occur in hospitals at least for the first six months of the year in 2019 so if we dig a little deeper into our most frequently cited standards and elements of performance this is sort of our top ten list of frequently cited standards within the hospital program today and really the way to read this is looking top down what the most frequently cited standard is and what the most common issues are that organizations face today I've put a little box here on the right hand side that would within a few key words give you an idea of what these areas are that organizations find most challenging today and the way to read it would be in terms of likelihood to harm or where they fall within that nine box grid that's how the color scheme advances as you move left to right and the total number of surveys where you would have a likelihood to harm versus a limited sort of finding this is something Joint Commission provides very regularly today I would say that the Joint Commission has advanced their efforts in the use of analytics and data so how we're using this data to proactively share with organizations all accredited organizations do regularly receive this sort of update we provide this as a way for organizations to stay ready for their surveys and just to show them what are some of the common trends that are occurring in US hospitals today I did want to provide just an example a few examples in our presentation today of what we consider to be a sample survey observation so we see one of the most frequently cited standards in an infection control area and the bullet points of what you could see a sample observation being in these areas so one of our most common commonly cited standards and elements performance or in the areas high level disinfection and sterilization and the following bullet points would provide us a few examples of some of those observations that are found in hospitals today and we won't go over every one of these in details will be in your slides for you to review and I've also provided a little bit of background in your materials and the appendix of the materials that do talk a little bit about our safer matrix and go a little bit in a more detail about the definitions but hot behind scope and likelihood to harm patients so you can kind of get an idea of what those operational definitions are within our safer matrix these are some of the most frequently cited high likelihood to harm standards and elements performance and this is just a way to show organizations some of the most common themes that are going on in hospitals today and where they're most likely to harm patients so the idea would be providing organizations this information proactively in order to prevent further harm or an opportunity to harm a patient in your organization and again we've provided on the right-hand side of each of these ten commonly cited high likelihood harm a few key words so you can have an idea of what these standards entail and again a few examples of what some these frequently cited sample observations are so you can take a look at these and I've separated some of the most commonly cited standards and elements performance from a clinical standpoint to an environment of care and life safety code standpoint so the found the slides that preceded these were strictly clinical standards and elements performance now we're looking at the environment of care and life safety components within your hospital setting so what are some of the issues that you're facing from a building standpoint the Joint Commission does employ and send life safety code specialists and engineers to all of our Hospital surveys and they look specifically at those two chapters standard so you can have an idea of what the top ten frequently cited standards and elements of performance are in the environment of care world and some similar to previous slides some examples of what those observations are today and like the previous slides we have some frequently cited high likelihood to harm standards and elements performance from the life safety and environment of care areas as well it's a safe environment being number one on that list and everything on the left-hand side is a reference to the particular standard for Joint Commission I've provided some definitions at the bottom here but like I said the appendix will provide some operational definitions of high likelihood to harm and prata scope as well and you can see some sample observations in here as well so now we've shown some of the data behind some of the surveys this year what are some quality and safety improvement tools that the Joint Commission is offered to they're accredited customers that could help in resources to to assist organisations in preventing these from occurring so one powerful tool that the Joint Commission is launched for the last 10 years or so has been in the targeted solutions tool area we do have currently for quality improvement tools in our targeted solutions area and these are really sort of aimed at the four areas that are very critical within your hospital and in terms of compliance as well and those are hand hygiene safe surgery handoff communications and preventing Falls we also have a fifth module that is currently under development that should be launched in the first quarter of 2020 on sepsis all of these targeted solutions tools are evident provide are intended to provide your organization with evidence-based solutions that are unique to your organization so this is an online tool that your organization can use that they can access you can assign users within your own organization that can use this tool to enter root causes they can enter issues that are going on in their facility that are preventing them at achieving high compliance rates in these areas and they will get unique solutions to their organization to help implement and fix those issues today so what I did was took one of the tools those targeted solutions tools this was the preventing Falls tool and a little bit of data that went behind this that when the Joint Commission was developing these tools we did use Lean Six Sigma and change management methodologies to develop these tools to provide to organizations so this gives you a little bit of a background on that tool today and when we were piloting the project and looking at how these tools could be utilized we use we used a pilot of hospitals and look at different causes for why Falls occurred in those facilities and then results of our pilot was that these organizations and using our targeted solutions tool reduced to their fall rate overall by 73% and of those they result the the results concluded that they've reduced Falls with injuries by 84% so using this tool here was the data that was provided to you that shows that these tools actually do work and within the preventing Falls targeted solutions tool here's some implications of a typical hospital today and if you're successful in using a tool that's provided such as this here are some of these the outcomes of that may be able to occur if unsuccessfully used and implemented so this gives you a little bit of a breakdown between two completely different organizations by bed size and expectation of if the fall rate occurred at the rate that it has been what the how you could reduce the number of Falls and what that cost avoidance could be within your organization so here are all the targeted solutions tools that I spoke about and from these projects the results of each of these tools through pilots with organizations are provided in the right-hand column our hand hygiene targeted solutions tool resulted in an increase in compliance by 71% hand off communication failures decreased by 50 percent 56 percent you can see how this these tools have positively impacted organizations today some other red educational resources that we provide organizations there are number of resource portal that are out there for organizations today these are actually available to the general public through our websites if you follow the topics page of our website you'll find these portals today so particularly one I like to highlight is a new suicide prevention portal that the Joint Commission launched in the first quarter of 2019 very important to take a look at that there's a resource compendium that the Joint Commission has put together that is there for organizations to use as an additional resource the Joint Commission also provides a number of newsletters and communications to organization organizations today and it's really geared at some of the most important quality and safety issues in organizations our quick safety and Sentinel event alerts are two very common communication methods the Joint Commission uses today on to help your organization's stay up to date on work that Joint Commission's doing in those areas as well as hoping bigger organizations raising awareness aboard in organizations as well these are some of the resources that Joint Commission offers today in some of the most common hospital-acquired conditions so the left-hand column would provide you with some of the most common hospital-acquired conditions followed by a middle column which are the actual resources Joint Commission offers to combat or prevent these these issues from occurring in your organization and then the cost of occurrence from AHRQ data from 2017 which provides you a little bit of a background about what the cost could be for one occurrence in your organization and just the number of tools that the Joint Commission can provide to prevent these areas I also want to touch base today on talking about how the Joint Commission has advanced efforts in making the healthcare world more highly reliable industries so our president and CEO dr. Matt mark Chason had an article in the Milbank quarterly in 2013 that you can find called high reliability health care getting there from here there's a little bit of a reference here in the slides and I encourage everybody to take a look if you have not seen this article before so what does transforming healthcare into a high reliability industry look like well the Joint Commission is leading the way to zero campaign has really aimed at helping organizations get to zero Falls or complications of care or really any lost opportunities to provide exemplary care within organizations today and also looking at ways to reduce or eliminate harm to staff and visitors of your hospital as well the Joint Commission's higher reliability model is sort of made up of three pillars one of those is your leadership skom it meant to the goal of zero harm another would be your organization's safe adoption of a safety culture and finally some form of process robust process improvements Lean Six Sigma tools change management tools something to help your organization vamps in those areas today so this is sort of the model that the Joint Commission has employed and highly ripe high reliability this is what organizations and engaging organizations on their Kappa high reliability what surveyors would discuss with organizations as well so one tool that the organ that the Joint Commission provides organizations is a high reliability assessment tool this is a self-assessment tool that hospital leadership can use complimentary to accredited organizations today this self-assessment tool is really intended to gauge an organization on their level of maturity towards their advancement of high reliability in their organizations so there's really four maturity levels that the Joint Commission provides through this tool the idea is you're providing this organization assessment at your individual level of leadership c-suite leadership and then coming together convening as a group and discussing the outcome of those self assessments and working as an organization to take that assessment as well now part of this tool the high reliability tool that we call oro 2.0 is that it also provides a resource library that has resources and by educational topic to help organizations on this high reliability journey as well these are the components of that assessment tool so of the three sort of pillars of leadership safety culture and robust process improvement these are sort of the areas of my topic that the assessment tool will take you three through so the assessment tools made up is somewhere around 50 questions and these would be some of the areas that the tool would speak to now getting into the appendix there's a number of resources I have also put in here a few that would like to just point out so I did give an overview of the Joint Commission as an enterprise the enterprise today is sort of made up as three organizations you have the Joint Commission Joint Commission Resources which provides our publications new product continuous compliance sort of tools and then our Center for transforming healthcare which develops high reliability tools such as the Toro 2.0 higher or high reliability assessment our targeted solutions tools all of these complementary resources that we provide organizations to advance quality and patient safety efforts in their organization today as an enterprise we we all share one vision within the organization so you can see sort of how the enterprise is made up now we touch across the entire continuum of care I spoke about that earlier but there are a number of certifications that reside within each of our accreditation programs to these certification programs are specifically targeted to a program in our disease specific care program they will just they're there to work within a specific disease condition or a procedure so it's really specific to your organization or within that program and here with the operational definitions from are safer matrix I just wanted to point those out as well they're in here for you to review and here is an example of the suicide prevention portal and the resource compendium that I also spoke to as well here's an example of our one of our Sentinel event alerts developing a reporting culture talking about safety culture within your organization and I did provide a video that you may watch at your leisure on Xero patient harm this is our leading away to zero initiative our president dr. chasm speaks to in the video I will not play it for time purposes today but I encourage everybody to take a look at that if you've not already seen that and this is just a slide to provide you an overview of Joint Commission's impact and quality and patient safety a lot of things of what we hear with organizations is you know the Joint Commission does very well in providing meaningful assessments across the entire continuum of care so something we hear back regularly from our customers is in that area we're and ways of finding risk within their facilities as well this just gives you a little bit of an provides you a little bit of how we are how organizations who our Joint Commission accredited are sort of viewed to the public as well so with that I will pause here for any questions and happy to take any questions about the presentation or any general questions that we might have providing my contact information here as well so that we can always continue any dialogue outside of here thank you chat so much that was a very very informative webinar really appreciate that we do have a few questions here so one question we have here is about survey eligibility and requirements and how to apply can you describe the application process and the follow-up process for us yes absolutely so I'm I would be the key contest for your organization through the application process or just understanding eligibility for your organization we do provide some general eligibility on our website but it's very important to also understand from each individual organizations sort of what services they provide and where they are in meeting criteria so I encourage organizations to reach out to me to see if they are eligible for our Hospital accreditation or critical access Hospital accreditation as well we do have specific patient eligibility criteria to undergo a survey in terms of the application process it's really we we work with organizations on their own timeline for for the application process so it's really just providing an application through an electronic format that an organization can complete on their own time and also in that electronic format with of the application is where we house some of those quality improvement tools educational resources that I told you that we provide complimentary to organizations so there's a number of tools that are out there that we also provide organizations in helping them prepare for surveys so in addition to conversations with me and my staff it would also be pointing in to some of these resources that can help your organization in preparation for a survey as well okay actually that was the next question that we had it was how can I prepare for a Joint Commission survey so if you could and yeah yeah absolutely well there's a number of resources we do provider organizations today you know we do have a manual that's very important in preparation for survey depending on the type of organization that you are as well there are a number of resources we offer also provides so things in our site for psychiatric hospitals for instance ways to prepare organizations with survey data such as what I showed here today those would be excellent preparation tools in helping our organization prepare for an initial Hospital critical access Hospital survey okay all right are those manuals for for sale are they for download or what yeah there's a we actually yes so we can so they are available for sale all organizations that are undergoing the application process it is a the manual is actually complimentary and if you ever have questions if an organization wanted to see the standards we can also work with organizations I'd be happy to speak with you and how we could get you some access to some of these tools as well okay perfect okay we have another question here when oh okay it's about it's a question of timing when will I have my accreditation decision yes good question so lightest is really built on an organization and their readiness for survey so I like to work with organizations on their own timeline and we sort of work backwards from when they would like their accreditation decision to be in place so you know we we really work on in organizations sort of timing for survey I typically tell organizations to build a couple of months into the post survey process so that's the work that is done after the surveys taken place to fix any corrective actions that are required in order to attain your accreditation I typically will guide organizations to provide you know to give two or three months in that timing as well so we really work backwards from when the accreditation decision when they would like the accreditation decision and we can sort of build a time frame of when the application can be submitted and all the follow-up work and the preparation going into the survey as well okay okay here's another one our successful surveys achievable for organizations with no knowledge of or who have not worked with the Joint Commission in a very long time I would say yes absolutely the preparation is what key and what's important and oftentimes what I when speaking to organizations that have no knowledge or have limited knowledge or have not worked with Joint Commission for for a certain period of time I think there's sometimes a little bit of concern over the readiness of their organization and I can assure you that we'd love to work with organizations in this process and help them understand it that's what we're here for guiding them in any questions that they have we also have a standard interpretation group we post a number of frequently asked questions on our website those are really great resources that organizations can use today in preparation for a survey if they have questions about their own compliance in a particular standard as well it's very achievable mm-hmm okay yeah what is I would say it's very achievable with a lot of preparation and working working directly with you and your organization okay here's a good question the average cost for accreditation yes yes so cost is really dependent on the type of organization in the size its it would be hard to pinpoint with every organization that might be listening today cost could be completely different depending on house how large an organization is fees are typically built into really two components the Joint Commission has an on-site survey fee that is billed at the completion of an on-site survey so organizations hospitals that go through a survey would be billed for that on-site survey once every three years and there's a separate fee for Joint Commission that we call an annual subscription fee that annual fee is determined on the size of your organization as well and there are a number of things that are part of that annual fee but the complimentary resources and tools that are provided to your organization would be considered part of the annual subscription fee I should also make note that the Joint Commission offers a dedicated account executive for each of their organizations thus individual works as a liaison to your organization so they're available to you at any time to kind of guide you to any questions that you have as well those are considered part of your annual fee wonderful great well I'd be happy no I would just say in terms of price if you ever have any questions about per unique to your own organization I'd be happy to take those questions as well wonderful great well thank you do you have other any other words advice or any any other thoughts that you might have thought of here that you wanted to leave us with or advice I would just like to reiterate the Joint Commission's really efforts to advance safety within hospitals today you know I think what the Joint Commission is doing with the worst the work that they're doing with the analytics and the survey findings and how we've advanced the survey and identifying true risk points I think have really become of value to organizations today we hear quite often how the survey process has transformed over the years and organizations really find value today in the safer matrix and it helps organizations really understand what their survey outcome has looked like it helps them better prepare for future surveys and also the way that we've provided this data the transparency that we provide organizations now in preparation for survey only helps organizations along the way as well okay I truly truly appreciate you coming here today Chad from the Joint Commission it's been a real honor to have you here and to come and speak with our audience so I really appreciate it thank you so much thank you you're very welcome and thank you for having me yes well and thank you attendees for coming and listening as well please use the contact information on the screen for any additional questions that you might have