Using the ICM Profile Review Form

Transcription

1 Using the ICM Profile Review Form The ICM Profile Review form is provided as a WORD document to facilitate modification to your organization s specific needs. ou are not required to use this form. The form is designed to extract summary data points from the ICM Profile - - it can usually be completed within 15 minutes. The form was originally developed as a support tool for new hires entering The Joint Commission s surveyor corps. The form is available to surveyors, Standards Interpretation Group reviewers who conduct ICM conference calls, and organization accreditation staff. Organization staff may find the basic form useful when conducting an annual selfassessment of the organization s accreditation status and level of standards compliance. An example of a completed form is located at the end of this document.

2 Section 1 Key Contacts Role Identified ame / Title Primary ICM Mary Anderson / Associate Director, Accreditation and Compliance 1 Key Contacts Primary Accreditation Louise Mahoney / Director, Accreditation and Compliance CEO Arthur Goodfellow / President & CEO CMO CO Are the organization s key contacts listed in the extranet s contact/security access page? Use the link in the lower right tile of the ICM Profile to access and review the Contact Type tab of the extranet user list. Keeping the list of key contacts current facilitates communications. In our example organization, this quick check revealed that two key roles had not yet been populated - - Chief Medical Officer and Chief ursing Officer. Section 2 ICM ICM submission history? ICM does not exist prior to 2013 es o Option Type Date Completion Date Full o Call 5/13/2013 Same 2 ICM If FSA data was included in the most recent submission, list the number of identified RFIs. (List count by chapter) HAP: PC (2); MM (1); EC (1) OME: IC (2) Were there any organization-identified Topics for Discussion or Risk Areas in the most recent submission? Is there any ICM submission history (orange Go To button)? If no, check the Focused Standards Assessment (FSA) history within the ICM Profile to review the historical submission options selected for the former Periodic Performance Review (PPR) tool. What was the last submission type? When was it submitted? Our example organization displays a Full o Call submission. The inclusion of FSA data in the submission ( identified ot Compliant standards) resulted in a review by a TJC reviewer. Go to the historical FSA submission to explore the submitted Plans of Action. Previously, if a reviewer decided the submitted plans were acceptable, no response comments would be returned to the organization. Beginning in 2014, responses comments will be displayed for all FSA data submission that identify not compliant standards, regardless of whether a conference call is requested or not. Conference calls are highly recommended, however, as they provide an opportunity for a live interchange regarding specific organization circumstances. Did the organization request conference call interaction regarding any issue via the Topics for Discussion text box? This is an especially useful technique for organizations to gain knowledge about standards compliance without necessarily disclosing their specific level of compliance. Listing these topics on the Review form will aid your subsequent information synthesis. Page 2 of 5

3 Section 3 Survey Multiple accreditation programs? HAP, OME 3 Survey Any pending survey follow-up? Current accreditation cycle Intracycle survey events? ICM Profile Accreditation Status tab - - is the organization accredited for multiple general accreditation programs? If es, list them. Are there any pending survey follow-up events? An ESC or MOS submission due soon? List the standards related to the pending submission. Are intracycle survey events listed in the last two accreditation cycles - - extension surveys, for cause/complaint surveys, random unannounced surveys? If es, list any standards identified as ot Compliant. Section 4 Quality Report 4 Quality Report Special Quality Awards Sites of care # 4 on-compliant PSGs egative Quality Improvement Goals Commentary Current? Quality Check and Quality Report display accreditation information to the general public about your organization. Review each for accuracy. Print a copy of each to attach to the Review form. Are all Special Quality Awards applicable to your organization properly listed? Are all the sites of care from your submitted Eapp displayed correctly? Are there any ational Patient Safety Goals displayed as non-compliant? PSG goals are reported in the Quality Report from the most recent on-site survey event for which a decision has been rendered. Are any of the Quality Improvement Goals displaying a red minus sign? If es, which ones? Is there a posted Organization Commentary (if a Commentary has been submitted for attachment to a Quality Report, a link for Organization Commentary is visible in the left navigation column)? If es, is it current? Organization Commentaries remain displayed until the organization removes it from the Quality Report - - the annual ICM check provides you with a reminder to review it! Page 3 of 5

4 Section 5 ICM Risk Areas Current cycle RFIs # 8 HAP (); OME (2) 5 ICM Risk Areas Direct Impact RFIs (List count by chapter) Multiple programs, duplicated RFIs # 3 HAP: PC (2); EC (1) Multiple events, repeating RFIs ICM Profile Accreditation Risk Area tab - - Survey RFI section How many current cycle RFIs are displayed? How many are Direct Impact standards? Listing the chapter areas will help you synthesize historical information from the Profile review process. If your organization is accredited for more than one accreditation program, are any of the RFIs reported for one program also reported for another? If es, which standard(s)? If your organization has experienced multiple survey events in the current accreditation cycle (for example, a Full survey followed later by an Extension Survey for a ew Program), has the same standard been reported in the multiple events? If es, which standard? Section - - FSA FSA Compliance with APR For FULL or OPTIO 1 historical submissions, frequency of requested conference calls with SIG Always / Usually / Sometimes (ot since 2008) ever Has your organization been compliant with the annual submission requirement for ICM, and the previous PPR? If the submissions have been for either a Full or Option 1 submission, did your organization request a conference call with a Standards Interpretation Group (SIG) reviewer? ICM conference calls are part of your annual subscription service fees - - is your organization taking advantage of the opportunity for this educational support? Section 7 - Information synthesis, identification of at least two key risk areas facing the organization 7 Based upon the synthesis of the data and information presented in the ICM Profile, the E- app, and/or the esoc, list two key risk areas appropriate for initial tracer activity. Requesting an on-site Option 2 or 3 survey? Preparing for a Full survey? Discuss your Profile review with the survey team during the opening conference; help them focus on your specific areas of risk in order to gain the most educational support from the on-site event. Page 4 of 5

5 General ICM Profile Review - EXAMPLE Role Identified ame / Title Key Contacts ICM Survey Quality Report ICM Risk Areas FSA Primary ICM Mary Anderson / Associate Director, Accreditation and Compliance Primary Accreditation Louise Mahoney / Director, Accreditation and Compliance CEO Arthur Goodfellow / President & CEO CMO CO ICM submission history? ICM does not exist prior to 2013 If FSA data was included in the most recent submission, list the number of identified RFIs. (List count by chapter) Were there any organization-identified Topics for Discussion or Risk Areas in the most recent submission? Multiple accreditation programs? HAP, OME Any pending survey follow-up? Current accreditation cycle Intracycle survey events? Special Quality Awards Sites of care # 4 on-compliant PSGs egative Quality Improvement Goals Commentary Current? Current cycle RFIs # 8 HAP (); OME (2) Direct Impact RFIs (List count by chapter) Multiple programs, duplicated RFIs Multiple events, repeating RFIs Compliance with APR For FULL or OPTIO 1 historical submissions, frequency of requested conference calls with SIG es o Option Type Date Completion Date Full o Call 5/13/2013 Same # 3 HAP: PC (2); EC (1) HAP: PC (2); MM (1); EC (1) OME: IC (2) Always / Usually / Sometimes (ot since 2008) ever 7 Based upon the synthesis of the data and information presented in the ICM Profile, the E- app, and/or the esoc, list two key risk areas appropriate for initial tracer activity. List additional notes on the reverse or next page Page 5 of 5