Joint Commission Compliance Assistance

by dawnconrey
Joint Commission Compliance Assistance

Joint Commission Compliance Assistance

Patton Healthcare Consulting offers a full range of pre-survey and post-survey consulting services to healthcare organizations seeking to obtain or maintain Joint Commission accreditation. The four principals with the firm have a combined total of 50 years working directly for the Joint Commission and an additional 30 years of hospital and other healthcare consulting and leadership experience. In addition to our principal partners, we have a strong team of associates with industry expertise in all areas of accreditation and patient safety.

PHC Services Include:

  • Mock surveys to identify GAPs and suggestions for compliance
  • Help with adverse decisions, post survey corrections and preparation for follow up surveys
  • Education and Training; onsite or remotely via the web
  • Proprietary tools for survey preparation

The PHC team conducts mock surveys tailored to your organization’s unique services and size and are designed to mirror your anticipated Joint Commission agenda and survey.

  • Assess your compliance with Joint Commission standards and elements of performance using the “tracer” methodology;
  • The written report uses a color coded safety risk matrix to help you identify and prioritize non-compliance findings;
  • Advice and examples on necessary changes to come into compliance;
  • Real time feedback and education of staff on how to effectively showcase compliance to the Joint Commission survey team;
  • Daily Agenda, Closing Conference, Action Plan/Report
    Prior to our arrival we will propose and work with you to agree on a daily agenda of mock survey activities based on the Joint Commission’s template. The consultants will hold a final conference on our final day with leadership to summarize findings and discuss any significant gaps identified in the organization’s readiness for survey and discuss significant milestones required to correct what was observed. A final report of recommendations and action plans for survey preparation will be provided one week following the on-site visit. The final report is provided in an excel document and is formatted as a work plan using a color coded safety risk matrix. Many of our clients use the final report to assign corrective action to staff and use the document to track completion and ongoing compliance. Clients find that our report format helps them achieve and maintain compliance.
  • Onsite Education
    As a routine part of the mock survey, ad hoc education will be provided during tracers. In addition, we would encourage you to permit time during the onsite visit to be allocated to formal education of your staff. Many organizations find that an educational program conducted on the final day of the engagement allows their staff to learn more about the frequently scored standards, new standards, success strategies staff can implement. The education will focus on what was noted during the visit as well as practical implementation suggestions.
  • Webinars
    To encourage broader participation and timely learning we provide custom education to your staff remotely via live web based education programs with time for question and answers.

The PHC Continued Accreditation Service (CAS) Program is designed to provide you with ongoing assessment, preparation, industry updates and a long-term strategy for a successful survey outcome.

This program differs significantly from competitors in its depth and duration.

  • Site Visits
    The chief component of the CAS program is the proposed ongoing, on-site visits where our PHC consultants will be probing, evaluating compliance, teaching, explaining fine-points of compliance, and helping you to refine practices to enable greater standards compliance. At each on-site visit, a PHC consultant will evaluate readiness according to a planned, contract period calendar of priority focus areas while providing ongoing “train-the- trainer” education.
  • Newsletters
    Each month we review Perspectives, Environment of Care News, Sentinel Event Alert, the publicly posted FAQ’s, and any new CMS postings that require a hospital to take action. A summary of the actions needed, appropriately referencing the source, will be prepared in a newsletter format and sent to the CAS leader at the hospital for distribution to department heads or chapter leaders that have responsibility to make the changes.
  • Ask Our Experts
    As the Joint Commission makes its changes, or your staff identifies an ambiguous existing standard, you may pose questions to our consultants and request their expert advice. PHC consultants will respond to all electronic inquiries within 2 business days and the response will be tailored using the knowledge that our consultants have about your hospital. The CAS program offers this service for up to 25 inquiries per month as part of the base, contract period subscription.
  • Tools and Resource Library
    You will be provided a login and password to our secure client page on our website. Located there are dozens of valuable survey preparation tools and power point slide sets you can use or customize for your hospital’s ongoing readiness efforts.
  • Clarification Help
    The PHC team offers expert assistance assessing and drafting appropriate clarifications following a Joint Commission survey.
  • ESC Assistance
    We work with your implementation teams to help you prepare your post survey Evidence of Standards Compliance (ESC).
  • AFS & Follow-Up Survey Support
    Follow up surveys need to be a smooth successful demonstration of your compliance with those items found out of compliance; our consultants are experts in preparing your staff for a successful outcome in a follow up survey, such as such as Accreditation with Follow-up Survey (AFS) and Condition Level Follow-up Survey (CON).
  • PDA & ITL Guidance
    For the healthcare organization that has been informed that they are recommended for Preliminary Denial of Accreditation (PDA) decision, time is limited and the work needed to successfully navigate through this and prepare for Review Hearing Panel (RHP) requires the expertise of consultants who have successfully helped numerous organization emerge successfully from this outcome. Call us to discuss.

Behavioral Healthcare Expertise

Patton Healthcare behavioral healthcare specialists provide Survey Preparation and Continuous Accreditation Support to the Behavioral Healthcare field. Our consultants assist you so that you are ready for survey. Areas of specialization include accreditation preparation, regulatory compliance, and accreditation program development. In addition to our consulting activities, we provide customized training and education on accreditation standards, survey processes and quality for the behavioral healthcare field led by the former Executive Director of the Behavioral Healthcare program at the Joint Commission and other behavioral health experts and former surveyors.