Joint Commission Accreditation

Standards Compliance 201:

Strategies for Complying with Challenging Standards

Presented by:Margherita C. Labson BSN, MSHSA, CCM, CPHQ

Certified Green Belt

Executive Director, Business Development

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Joint Commission Accreditation

Standards Compliance 201:

Strategies for Complying with Challenging Standards

Presented by:Margherita C. Labson BSN, MSHSA, CCM, CPHQ

Certified Green Belt

Executive Director, Business Development

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Objectives

• An overview of the methods organizations can use to uncover process failures

• Strategies to address process failures

• Tools and resources to prevent process failures

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Top Standards Out of Compliance That May Trigger an On-Site Follow-up Survey

Standard Percentage of Surveys with RFI

PC.02.01.03 74.4%

PC.01.03.01 72.1%

RC.02.01.01 65.1%

HR.01.06.01 55.8%

IC.02.01.01 41.9%

PC.01.02.01 41.9%

HR.01.02.05 39.5%

IC.01.03.01 37.2%

NPSG.15.02.01 34.9%

IC.01.04.01 30.2%

IC.02.04.01 30.2%

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This much appears to be true:

Involves one or more processes

Root cause likely one of 3 things:

– Communication

– Human Factors

– Leadership

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Uncovering Process failures

• PC.02.01.03: Care and service is provided in accordance with orders

• PC.01.02.01: The organization assesses and reassesses its patients.

• RC.02.01.01: The patient record reflects the patient’s care, treatment, or services.

• HR.01.02.05: The organization verifies staff qualifications.

• IC.02.01.01: The organization implements the infection control plan.

• NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires.

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What When and Who

Defining What, Where, When, and Who

• Purpose Driven

• Goal Oriented

• Focused

• Actionable

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Medication orders

Notes of clinicians who administer

meds

Medication profiles

Med error reports

Plan of Care

Consent Forms

Home health aide notes

Therapy and SW notes

Assessment forms

On-call reports

Lab results

Example of results 5/6 errors involved intermediate acting insulin

4/6 were administered by patient or caregiver and 2 by nurses

Retrospective review of last 50 insulin dependent diabetics indicated 8%

error ratio (wrong dose/total number of insulin orders). Occurred with all

three of the largest endocrinology practices.

Approaching process failures

• Work back from the end

• What is wrong

• Follow the individual who uses the process

• Listen, watch and stay in the moment

• Seek to understand, humble inquiry

• Patient respectful observation

• No judgements

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Gemba walk- The real place where the process occurs

Value Stream Map- Best used when you are trying to

make a process more efficient and eliminate waste

Process Mapping- High level overview of a process

Other useful tool to map a process

• Process Map

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• Value Stream Map

Getting to the root of the problem

Appreciation-So What

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Cause and Effect Diagram

5 Whys

Once defined, focus your efforts to get the greatest return on your investment

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58%

23%

7% 6% 6%

PM CLINIC SENDS BATCH

UPDATES

CAN'T FIND NEEDED

INFORMATION

STAFF OMITS CHECKING FOR

UPDATE

PATIENT DISPUTES CHANGE

COMPUTER DIDN'T SYNC

UPDATE

Causes why insulin orders are incorrect

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Using Failure Mode Effects Analysis

Design Failure Modes and Effects Analysis (DFMEA)

Item or Process ..enter info here Process Responsibility ..enter info here Prepared by: …enter information here.

Unit of Improvement ..enter info here Key Date ..enter info here DFMEA Dates: (Originated) 00/00/00 (Latest Revision Date) 00/00/00

Core team ..enter info here Action Results

Solution Potential Failure Mode Potential Effect(s) of Failure

Se

ve

rity

Cla

ss Potential Cause(s)/Mechanisms of

Failure

Oc

cu

rre

nc

e

Current Process

Controls PreventionCurrent Process Controls Detection

De

tec

tio

n

RPNRecommended

Actions(s)

Responsible

Person

Target

Completion

DateActions Taken

S

E

V

O

C

C

D

E

T

R

P

N

10 10 1 100

Check

Check

Check

Check

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Staying in control with a Statistical

Process Control Chart (SPC)

Time for Your Questions!

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• Please continue to submit your

text questions and comments

using the Questions Panel

Note: Today’s presentation is being

recorded and will be posted on the

Joint Commission website.

Attendee Participation

Submitting Your Questions

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Home Care Team Contacts

Account Executive

Standards Interpretation Help Desk: 630-792-5900, option 3

Joint Commission Resources: 877-223-6866 or www.jcrinc.com

Brenda Lamberti, BS

Senior Business Development

Specialist

630-792-5252 or

blamberti@jointcommission.org

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

Monnette Geronimo

Business Development Specialist

630-792-5251 or

mgeronimo@jointcommission.org

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Standards Compliance 301: What to Expect on Survey

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