Practical Advice for 2009

Surviving the Joint Commission and CMS Survey Process

May 4, 2009

Overview

Once again, The Joint Commission has changed a significant number of its requirements for 2009. Although some standards contain minimal changes, others create new expectations and documentation requirements. The last-minute additions in January will require further resources to address compliance. The new survey philosophy (“searching for flaws rather than searching for validation”) also makes it likely that there will be more adverse findings during survey. Because the standards leave much to interpretation, hospitals are vulnerable to misunderstanding during survey, making compliance more difficult. The seminar explains how to prepare for the survey process, focusing on the issues that hold the greatest risk for hospitals in 2009, and provides practical solutions for taking immediate action towards the best possible survey outcomes.

Objectives

Upon completion of the seminar, participants will be able to:

  1. Discuss the elements behind the tougher survey process for 2009.
  2. Discuss the impact that the January CMS-driven standard additions to the Joint Commission manual will have on organizational readiness.
  3. Identify three requirements that must be documented for the survey of the leadership standards by the Joint Commission.
  4. Differentiate between the standards and survey processes of The Joint Commission and CMS.
  5. Identify three areas of compliance that could lead to an RFI in their organization.
Agenda
8:30-9:00 Welcome, Orientation to Materials, and Introduction
9:00-10:00 Surveys for 2009: It’s a Lot Tougher

  • Scoring
  • Criticality approach
  • Standard format changes
  • Decision Rules and their impact
10:00-10:30 The January Update: 46 New Pages to Contemplate
10:30-10:45 Break
10:45-Noon Leadership and the 2009 Requirements

  • Major changes
  • Documentation requirements
  • Practical solution
  • Strategies for dealing with the Board
Noon-1:00 Lunch
1:00-2:30 Immediate Jeopardy: Passing Joint Commission and Flunking CMS

  • Understanding the different processes
  • How to approach dual compliance
  • Top compliance hot spots for CMS
  • Recovering from Immediate Jeopardy
2:30-2:45 Break
2:45-4:00 Top Compliance Nightmares

  • National Patient Safety Goals
  • Documentation: From verbal order authentication to H&Ps
  • Revised standards to watch out for
4:00-4:30 Questions and Answers
Faculty

This program will be presented by Ruth Elzer, RN, MS, Compass Group’s Practice Leader for Accreditation and Compliance Services. Click here to learn more about Ruth.

Location

Swedish Medical Center- First Hill
747 Broadway Avenue
Seattle, WA 98122
206.386.6000

Click here for directions to the Medical Center campus.

Parking for this event will be in the Broadway Garage on Broadway Avenue. The rate for parking is $12 for 5-6 hours of $15 for 6-24 hours. Valet parking is also available.

Registration

The registration fee for this program is $175 for individual registrants and $150 for two or more registrants from the same organization. This fee covers all handout materials, beverage breaks, and lunch. You may register by mail or fax. Click here to download the registration form. Participants registering by fax must pay via purchase order.

Cancellations

Registration fees will be refunded to registrants notifying Compass Group of cancellation seven (7) business days prior to the date of the program. No refunds will be made after this date. A $25 processing fee will be charged against each refund. Substitutions are accepted. No-shows will be charged the full registration fee.