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Caroline Isbey. RN, MSN, CDEAssociate Director

Disease-Specific Care CertificationMarch 11, 2016

Preparing for

Advanced Heart Failure

Certification

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Presenter Disclosure Information

Caroline Isbey, RN, MSN, CDE

Preparing for Advanced Heart Failure Certification

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FINANCIAL DISCLOSURE:

Employment: The Joint Commission

Speakers Bureau: The Joint Commission

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Advanced DSC Certification for

Heart Failure

What three important points to leave

with today?

1. Certification raises the bar

2. Certification is attainable

3. Certification is a shared & continuous

process

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The Joint Commission Mission and

Vision Statements

�Mission: To 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.

�Vision: All people always experience the safest, highest quality, best-value health care across all settings.

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Certification vs. Accreditation

�Certification Reviews

– Product or service-specific evaluation of care and outcomes

�Accreditation Surveys

– Organization-wide evaluation of care processes and functions

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What’s Different about Certification?

�Reviews are service-based, focused on quality, safety, and outcomes of improving clinical care

�Eligibility criteria�Voluntary—not an add-on to accreditation

– Accreditation, in accreditation eligible organizations, is a pre-requisite to certification

– Separate and distinct decision and award

�2-year cycle�Required 12-month intracycle event

�Separate cadre of reviewers

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Disease-Specific Care Certification

� 3300+ DSC certifications since 2002 in– 1375+ organizations

– 50 states plus DC and PR

� Core DSC Program – Can fit any disease or condition– More than 100 different types of programs certified

� Specialty (Advanced) Certification programs– Acute Stroke Ready Hospital – 4 programs

– Chronic Kidney Disease – 2 programs– COPD – 11 programs– Comprehensive Stroke Center – 101 programs

– Heart Failure – 56 programs– Inpatient Diabetes – 87 programs

– Palliative Care – 87 programs– Primary Stroke Center – 1087 programs

� CMS National Decision Coverage– VAD for DT – 139 programs

– Lung Volume Reduction Surgery – 5 programs

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Disease-Specific Care Certified Programs

1 - 20 21 - 50 101 - 199 200 +51 - 100

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Journey to Quality Care

Tools1. CPGs2. Cert Info

3. PM & PI Plans

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Who is eligible for Advanced Certification in

Heart Failure?

�Accredited hospitals with an established inpatient heart failure clinical treatment program

�Provide ambulatory care services through a

hospital-based and hospital-owned heart failure clinic OR a collaborative relationship with one or more cardiology practices

�At least a Bronze performance award from Get

With The Guidelines - HF

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Advanced Certification in Heart Failure

�Organizations must demonstrate compliance with all DSC program requirements

�Measure set has been expanded to included six (6) new inpatient measures and seven (7) optional outpatient measures.

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Disease Specific Care Certification

Quality & Safety of Care for Patients with Heart Failure

ProcessCPGs

StructureDSC Standards

Outcomes PM & PI Process

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Process: Clinical Practice Guidelines

�Care based on guidelines / evidence-based

practice

�Review validates:

– Implementation of CPGs

– Rationale for selection / modification

– Monitoring & improving adherence

�Online resource: National Guidelines

Clearinghouse at www.guidelines.gov

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Structure:

Disease-Specific Care Standards

Program Management

7 standards

Delivering or Facilitating

Clinical Care

6 standards

Supporting Self-Management

3 standards

Clinical Information

Management

5 standards

Performance Improvement and

Measurement

6 standards

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Program Management:Advanced Heart Failure Highlights

�Program scope includes inpatient and outpatient, transitions and care coordination

�Care coordination is provided across inpatient and outpatient settings

�Care Coordinator(s) is/are identified

�Patients re-evaluated within 72 hours after discharge (via phone call, home visit or scheduled office visit)

�Prior to discharge, a follow up appt. is scheduled to occur within 7 days

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Delivering or Facilitating Clinical Care: Advanced Heart Failure Highlights

�Program follows ACC/AHA heart failure guidelines

�Functional capacity is assessed

�Comprehensive plan of care developed

�Heart Failure team implements interventions (addressing assistance with self-management activities, fluid management, symptom management, nutrition, medications,

exercise, stress and risk reduction, coping, immunizations,

palliative care)

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Supporting Self Management: Advanced Heart Failure Highlights

�Program promotes life style changes (nutrition,

fluid management, activity and exercise, weight management,

symptom-aggravating behaviors)

�Program provides education on risks (excessive

alcohol consumption, tobacco use, illicit drug use)

�Patient understanding evaluated prior to discharge (medications, recognizing symptoms needing

attention, diet & weight monitoring, activity level, plan of care’s impact on ADLs)

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Clinical Information Management: Advanced Heart Failure Highlights

�Care coordinator responsible for– communicating medication info at all transitions of care to

all relevant practitioners

– communicating info necessary to continue treatment to

relevant practitioners within 72-hours after discharge

�Medical record includes diagnostic test

results and therapeutic interventions and procedures

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Performance Measurement: Advanced Heart Failure Highlights

�PI approach is organized, well-designed and planned and the scope includes inpatient, outpatient and care transitions

�Data collection includes:

– functional capacity improvement

– symptom stability

– 30-day readmissions for heart failure symptoms

�Patient Satisfaction and perception of care

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Attentive to the Detail

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Heart Failure Performance Measure Sets

Mandatory as of January 1, 2015 Encouraged but not Required

ACHF Measures ACHFOP Measures

ACHF–01: Beta-Blocker Therapy Prescribed at Discharge

ACHFOP–01: Hospital Outpatient Beta-Blocker Therapy Prescribed for LVSD

ACHF–02: Post-Discharge Appointment for Heart Failure Patients

ACHFOP–02: Hospital Outpatient ACEI or ARB Prescribed for LVSD

ACHF–03: Care Transition Record Transmitted

ACHFOP–03: Hospital Outpatient Aldosterone Receptor Antagonist for LVSD

ACHF–04: Discussion of Advance Directives/Advanced Care Planning

ACHFOP–04: Hospital Outpatient NYHA Classification Assessment

ACHF–05: Advance Directive Executed ACHFOP-05: Hospital Outpatient Activity Recommendations

ACHF–06: Post Discharge Evaluation for Heart Failure Patients

ACHF-06: Discussion of Advance Directives/Advanced Care Planning

ACHFOP-07: Advance Directive Executed

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Measure Specifications Manuals

http://www.jointcommission.org/certification/heart_failure.aspx

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Journey to Quality Care

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Challenges of Certification

�Consistent implementation of Clinical

Practice Guidelines

�Evaluating patient perception of care

quality

�Performance Measurement:

– Data collection

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Keep working on the Challenges

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Persistence pays off

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Preparation Tips

1. Obtain from Joint Commission Resources:

a. Disease-Specific Care Certification Manual, 2016 (hard copy or e-dition)

b. Contact information (877) 223-6866 or www.jcrinc.com.

2. Assess compliance with standards (Gap analysis)

– Identify opportunities for improvement and implement action plans

– Register for email news and alerts on The Joint Commission public home webpage.

3. Review treatment protocols based on Clinical Practice Guidelines (Gap Analysis)

4. Develop and implement Gap closure plans for standards and Clinical Practice Guidelines

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Preparation Tips (cont’d)

5. Develop process for performance measure data collection- Identify opportunities for improvement

in performance measurement process

- Implement action plans / PI plans

6. Submit application

7. Maintain continuous compliance with Joint Commission requirements

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Timeline in Months

- 6 - 5 - 4 - 3 - 2 - 1 0

Review Scheduled

Onsite

Review

Org. receives notice of review date (for initial

review of program)

Submit E - Application

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The On-Site Evaluation

�Activities:– Program overview

– Patient tracers

– System tracer on data use

– Competency assessment and credentialing

�Engaging practitioners and patients

�Educative

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Getting Ready for Onsite Review

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Resources through The Joint Commission

� Website:– http://www.jointcommission.org/certification/dsc_home.aspx

– Two webinar replays on this webpage – Part 1: Quick Steps to Certification

– Part 2; DSC Certification Most Cited Standards

– Home webpage for Advanced HF under “Cardiovascular”

� Quality Check: finding certified Organizations:– http://www.qualitycheck.org/help_certified_orgs.aspx

– http://www.qualitycheck.org/consumer/searchQCR.aspx (Used to search for the organization once identified)

� Publications:– Disease-Specific Care Certification Manual 2016 edition –

electronic version and hard copy– Contact:

– www.jcrinc.com – 877-223-6866

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Benefits of Certification

Provides an objective assessment of clinical excellence

Creates a loyal, cohesive clinical team

Improves the quality of patient care

Requires a systematic approach to clinical care

Promotes a culture of excellence across the organization

Facilitates Marketing

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Advertise Your Achievement

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Questions?

Caroline Isbey RN, MSN, CDE

Associate Director

Disease-Specific Care Certification

The Joint Commission

cisbey@jointcommission.org

630-792-5279

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The Joint Commission

Disclaimer

� These slides are current as of 03/03/16. The Joint Commission

reserves the right to change the content of the information, as appropriate.

� These slides are only meant to be cue points, which were

expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards

interpretation or represent all the content of the presentation.

Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

� These slides are copyrighted and may not be further used,

shared or distributed without permission of the original presenter

or The Joint Commission.