Joint Commission Accreditation for a Private Practice: Worth the Pain?


Dr. Michelle Koury began her session by explaining the goals of her session: to help attendees learn to organize leadership to pursue and achieve accreditation, apply strategies and tools to assist in accreditation success, and understand the organizational, financial, regulatory, and political advantages of accreditation.

Michelle Koury, MD, chief operating officer, Crystal Run Healthcare LLP, Middletown, NY, and Betty Jessup, director of quality and patient safety, Crystal Run Healthcare

The challenges of Joint Commission Accreditation can seem daunting. In this interactive session, you will gain insight into the challenges and advantages of Joint Commission Accreditation. You will clarify strategies and tips for creating your path to successful accreditation, as well as key success factors, including how to identify critical resources.

Dr. Koury began her session by explaining the goals of her session: to help attendees learn to organize leadership to pursue and achieve accreditation, apply strategies and tools to assist in accreditation success, and understand the organizational, financial, regulatory, and political advantages of accreditation. She said her key take-away point was the ability for attendees to see the value of accreditation in being an operational tool for patient safety and for engaging staff.

Why get accreditation, she asked. Because doing so can help provide a framework to improve patient care and optimize patient safety, allowing for higher quality and the application of modern management practices. Accreditation also allows a practice to distinguish itself from peers and competitors, because of an improved reputation as a place that provides excellent care. Lastly, becoming accredited helps a practice distinguish itself to its payors because of the improved quality of care.

To explain the value of Joint Commission accreditation, Koury quoted Hal Teitelbaum, MD, MBA, Managing Partner, Crystal Run Healthcare, who in June 2008 said “Ambulatory care accreditation by the Joint Commission afforded not only external validation of our multispecialty group effort, but even more importantly, the accreditation process provided a disciplined framework for improvement of patient care and safety. My partners and staff rank accreditation by the Joint Commission as one of the most important and meaningful undertakings in the history of our practice.”

Leadership, Koury continued, is key to getting the job done. At Crystal Run Healthcare, they looked to their leadership and performed an internal assessment of staff knowledge and experience with regulatory agencies and survey processes, reviewed their organizational structure (or lack thereof), mobilized the executive team leadership, and made a point to respect the practice “style” of individual physicians. “Physicians need to be engaged in the process,” she explained. “Get their input. They’re reluctant to change, and they can’t be thrown off their game.” Part of the introspection process was to see what staff they lacked (eg, pharmacist, oncologist) and identify those physicians who would champion the move toward accreditation. Koury noted that Crystal Run was at an advantage because they had already adopted an EHR system (in 1999) and had an IT infrastructure well established.

Betty Jessup continued the session, first reviewing the strategies and tools of importance in gaining accreditation. A consultant, she said, is essential for success and will help form a bridge to the knowledge gap for priority focus areas. The consultant will also help perform a mock survey to aid in addressing compliance with accreditation.

A structure of committee is also key for obtaining and maintaining accreditation, Jessup stated. First, a quality and patient safety committee is needed, a team the Crystal Run set up 5 months before applying for accreditation. This committee oversees performance improvement activities, and performs patient satisfaction surveys, critical test result reporting, turnaround time reporting, and benchmark reports.

The infection control committee at Crystal Run is very active in training for their infection control plan, hand hygiene compliance, how to avoid and handle medical device-related infections, red bag waste and sharp compliance, how to avoid and handle infections associated with IV infusion therapy, and reportable infectious disease.

The medication management committee develops policies and procedures related to procurement, storage, dispensing, and administration of medication; error reports; formulary selection and approval; par levels; and vaccine management.

The environment of care committee provides training for safety measures for physical environment and workplace areas, fires and other emergency situations, hazardous material handling, and security.

The physician quality committee is lead by Crystal Run’s chief physician officer. The committee develops standards of care and performance initiatives, and oversees the patient-centered medical home.

Training and education never stops explained Jessup. Crystal Run’s training and education includes a leadership team that runs provider retreats and new-hire and annual training, oversees the committees, and offers “in-the-trenches” coaching. The key is get physician buy-in, she stated.

Crystal Run uses a proactive risk assessment called Failure Modes Effects Analysis (FMEA) that is used to review current literature, develop the risk assessment, develop an action plan, and help implement changes. The very intense process, Jessup explained, takes about a year.

Jessup moved on to explain that tracer methodology is the heart of the accreditation survey. Patients are traced from check in to check out. It serves as a way to measure compliance. Crystal Run performs both internal and external surveys.

A patient safety team is also helpful in creating and promoting a culture of safety initiatives, increasing awareness of occurrence reporting, improving analysis, assessing risk proactively, closing the feedback loop between staff and executives, improving medication safety, improving cross-department efforts, and involving the patient in their own care.

With an already established EHR system and intranet, Crystal run only needed to development a small number of templates and simply improved existing ones. They developed an electronic policy and procedure manual and a Joint Commission information intranet that provides ongoing updates. Also helpful is Tuesday Tips program that helps keep staff informed on processes.

Koury closed the session with a review of the advantages of accreditation, explaining that accreditation is a barometer or quality that’s recognized by the community, regulators, and politicians. Business advantages include better negotiation abilities with payers, the opportunity to market the practice’s success, and improved recruitment ability of both staff and physicians, who Koury explained are well aware of that accreditation means. Staff pride and expectations are also a huge advantage, as is patient pride in accredited providers.

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