Intracycle Monitoring Process and
Focused Standards Assessment
Patton Healthcare Consulting
Joint Commission -101
• The Joint Commission
– Non-Profit
– Accredits 80% of Hospitals in
the Nation ~ 90%+ of the beds
– Deemed Status Provider for
Medicare Certification by CMS
– Composed of Representatives of
Professional Organizations
Standards & Requirements
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APR
Environment of Care
Emergency Management
Human Resources
Infection Control
Information Management
Leadership
Life Safety
Medication Management
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Medical Staff
NPSG
Nursing
Provision of Care
Performance Improvement
Record of Care
Rights
Transplant Safety
Waived Testing
Annual Internal “Self Assessment”
Former Process known as Periodic Performance Review (PPR)
• Required annually – though not due in year of survey
• Due date established by TJC
• Measures of Success (MOS) required for non-compliant EPs
– Audit data to demonstrate your compliance once fixed
– If requested had to be shown to surveyors during
triennial survey
– Results were used to help “guide” surveyors
The New and Improved
Intracycle Monitoring Process
• PPR Process Retired as of Nov. 2012
• New Intracycle Monitoring (ICM) Jan 2013
– You will now submit a Focused Standards
Assessment (FSA)
– You still have same submission options
– You can request a TJC call
– You can submit specific questions/online chat
– Surveyors will not ask for FSA MOS data
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FSA Replaces the PPR
• The new FSA is an abbreviated set of
standards/EPs deemed to be high risk*
• Will include high risk EPs – designated in
manual with an “R” icon – most of direct
impact and some indirect impact
• About 500 EPs are “R” or high risk
• NPSG are all “R”s
• You will also have to score previous findings
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High Risk*
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Proximity to the patient
Probability of harm
Severity of harm
Number of patients at risk
ICM Profile
• An online workspace on your extranet site
• Includes the FSA tool and quick links to
FAQs, Leading Practice Library™, TST™, etc.
• The FSA is required at approximately 12 and
24 months from last survey date
• Not required at the 36 month anniversary
• Full FSA submission, or options 1, 2, and 3
Full FSA or one of the 3 Options
• According to TJC, historically
– 75% of hospitals submitted the full PPR
– 15% did Option 1 (attest that you did PPR)
– 10% did either Option 2 or 3 (surveyor
comes on site, Option 2 provided a
written report, Option 3 = no report)
– TJC would like to steer those who choose
Option 1 to Full or Options 2 or 3
– Option 2 or 3 survey limited to just FSA
The FSA Tool
• The AMP tool is designed to be “pulled
in” from the ICM Profile extranet page
• It is auto-loaded with the risk-selected
FSA standards/EPs/ NPSGs
• Along with the standards/EPs found
non-compliant in your last survey
• Capability for on-the-fly free-text/chat
questions to Standards Interpretation
Sharing Options with ICM Profile
• Onsite survey teams have access to
– Previous survey findings and follow up reports
– Accreditation application data
– ORYX Reports, Quality Check Reports
• You may “opt-in” to allow the onsite team
to see the full ICM profile with or without
your FSA (self-assessment)
ICM/FSA Goals
• You are scoring as if you were the
Surveyor to determine compliance!
• Rigorously complete the FSA tool
– Score yourself at each applicable EP
– Identify where evidence that you are
compliant can be found (annotate)
– Identify areas of weakness/vulnerability
– Identify data that demonstrates compliance
Scoring Basics:
What You Score Yourself On
• You must be compliant with:
– The applicable standards/EPs including the
situational decision rules
– The FAQs published by the Joint
Commission
– Anything in Perspectives
– Your own internal policies
• The surveyor will hold you to the most
stringent where differences exist!
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Read the Book
3/10/2016
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READ THIS NEWSLETTER
Get it Distributed
And Look on the Website, Print All FAQ’s
http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards
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Standards
• Consist of Three Parts:
– Standard Statement
– Rationale and/or Notes (not in the
excel file)
– Elements of Performance (EP)
• These are the score-able elements
FSA Scoring Sample
The CAMH
Scoring of Standards
• Standards are NOT scored per se
• You score only the Elements of
Performance (EP) under the standard
• If one EP is non compliant or partial, the
standard is considered non compliant by
The Joint Commission.
How EP’s are Scored
• Category A
– Relate to structural and process
requirements, such as policy
– Scored as either exist or not. Either
compliant or not. All or nothing.
How EP’s are Scored
• Category C
– Based on the number of times you do NOT meet a EP
– Scored by the surveyors as:
• 0 = Insufficient Compliance = 3 or > instances of noncompliance
• 1 = Partial Compliance = 2 instances of non-compliance
• 2 = Satisfactory Compliance = 0 – 1 instance of noncompliance
– In other words …. Two observations is NON-COMPLIANT
How EP’s are Scored
• “D” for Documentation Requirement
• Conceptually a great idea – identify those issues where
you just have to do it vs. those where you have to do it,
and document that you did it.
• Many D’s appear to be missing; when the body of the EP
says document
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Example: NPSG.08.02.01, EP 1 – Communicate the medication
reconciliation list and the communication among providers is
documented.
• Many C elements with MOS, but no D – how would you
measure these?
How EP’s are Scored:
– Measure of Success
• Some EP’s have a “Measure of Success” (MOS)
associated with them.
• Requires an Audit - a quantifiable measurement if
found out of compliance during FSA or on-site
survey.
• Remember this important change! The on-site
surveyor may no longer request to see your
historical MOS data on any EP you found out of
compliance on a previous PPR or FSA. (Though
you may opt-in to let them view your FSA results)
MOS – Sample Size
• Sample Size Requirements for Category C
Standards
– Recommended for use in FSA
• Population size up to 100 = 30 cases or 100% if < 30
• Population size 101 – 500 = 50 cases
• Population size > 500 = 70 cases
SEVERITY LEVELS FOR EP’S
Immediate Threat
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3
“Situational”
CONT / PDA
Decision Rules
Direct Impact – 45 days
Indirect Impact - 60 days
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Situational Decision Rules
Short Cut to Trouble
Immediate
Threat
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“Situational”
Decision Rules
Direct Impact
• Severity “2”
• Very bad news, may result in
Preliminary Denial (PDA) decision
• Examples include:
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Unlicensed practice
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“Busted plan”
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Failed ILSM or Failure to
Assess for ILSM
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Use of surveyors as
consultants
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Falsification
Indirect Impact
Situational Decision Rules cont.
Immediate
Threat
2
“Situational”
Decision Rules
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Direct Impact
Indirect Impact
New Decision Rules
CONT02 – Failure to resolve all prior
findings that resulted in Accreditation
with Follow Up (AFU)
• CONT03 – Credible evidence indicates
possible fraud has occurred.
New Survey Type:
• Accreditation with Follow Up (AFU08)
an onsite follow up survey w/in 45
days in Medicare certified hospitals for
a condition level deficiency(s)
• (AFU01-02) Systemic pattern of repeat
findings of direct or indirect standard
• AFU03 Failure to address all RFI in an
ESC/MOS
For Each Standard/EP
• Ask yourself, ask your staff:
– Do we do this?
– Where is it written we do this?
– How well, or how often do we do this?
– Show me the evidence that we do this
– Validate the “doing” with high risk and high
priority standards
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FSA Scoring – How To:
Complete the sections for:
• Annotate Supporting Evidence
– (Policy # and/or Data)
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Observations
Compliant? Yes/No
Action Items
Responsible Person
In summary: Why Do the FSA?
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It’s required!
Get staff ready for the survey
Find it before the survey team does
Allows you to fix it or find another way
Focus on
– Actual performance
– Execution, not your potential to do it right
• Assemble evidence that you are at least 90% compliant
for those things that are frequently scored. You are
huge. Measure internal compliance
• Opportunity to request resources, if needed.
FSA Focuses on the Priority Issues
• The 2013 standards have 1900 EPs that can
be scored
• The Joint Commission does >90% of its
scoring on about 25 standards/NPSGs
– Focus on the top scored direct and indirect EPs
– Focus on all NPSGs
– Focus on any NEW standards or FAQs
– Focus on previously scored issues
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The FSA is Complete, Now What?
Bullet Proof Weak Areas
• Internal FSA tracers/data will highlight
these
• Formalize decisions in writing, do risk
analysis, communicate decisions
• Communicate top hot spots
– In pocket guides, in games, in annual
education, screen savers, table tent cards
– Engineer to sustain compliance
• Make the right thing to do the easiest thing to do
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Questions?
• Kurt Patton
– Kurt@PattonHC.com
• Jennifer Cowel
– JenCowel@PattonHC.com
• John Rosing
– JohnRosing@PattonHC.com
• Mary Cesare Murphy
– MCM@PattonHC.com