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


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


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


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


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


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


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