A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process
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1 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process
2 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process Page 1 0f 10 INFORMATION MANAGEMENT STANDARDS Standard PCIM.1 Privacy and Security of Health Information (8 elements) PCIM.2 Complete and Accurate Medical Records (5 elements) PCIM.3 Continuity of Information (4 elements) PALLIATIVE CARE STANDARDS PCPC.1 Access & Use of the Palliative Care Program s care/services 1. Process to identify for whom services are indicated and communicate this to organization staff and interdisciplinary team members. 2. Informs patients how to access care/services during business hours 3. Informs patients how to contact staff for emergencies after hours 4. Informs patients about their rights & responsibilities 5. Assists patients to access and use community resources needed to meet health care needs. 6. Informs patients of their responsibility to provide information that is important to care/treatment/services. 7. Informs patients of right to refuse care/treatment/services. Pocket card with referral criteria. Pager information for new consultations. Program brochure. Program brochure; program website. Psycho/social/spiritual (PSS) assessment; community resources patient education materials.
3 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process Page 2 0f 10 PCPC.2 Program communicates with and involves patients in decision making 1. Discusses with patients how they wish to recieve information. 2. Patient wishes regarding how they want to recieve information is communicated to staff across care continuum. 3. The program respects patients right to, and need for, communication that meets their need to stay informed. 4. Patients receive information about the staff responsible for their care. 5. Program educates patients on disease processes and prognosis. 6. Program informs patients about benefits and burdens of care/ treatments. 7. Program involves patients in decisions about their care. 8. Patients and staff agree upon goals of care. 9. Program promotes advance care planning and provides education. 10. Advance Directive is placed in medical record. 11. Documents surrogate decision maker and contact information. PCPC.3 Tailored to meet patient needs/values 1. Palliative care staff demonstrates compassionate presence with patients. 2. Care plan is developed based on patient s needs/goals. 3. Plan of Care (POC) is based on understanding patient s values. 4. Program delivers care according to individual patient POC. Initial patient assessment. Interdisciplinary team rounds. Palliative care initial and daily assessment. Palliative care brochure/business cards. Palliative care daily rounds; family meetings. Palliative care daily rounds; family meetings. Palliative care daily rounds; family meetings. Palliative care daily rounds; family meetings. Palliative care daily rounds; family meetings; psycho/social/spiritual (PSS) assessment/plan. Initial palliative care assessment; PSS assessment/plan. Initial palliative care assessment; PSS assessment. Palliative care daily rounds. Initial palliative care assessment; interdisciplinary team rounds Initial palliative care assessment; family meeting. Palliative care daily rounds. Palliative Care Standards continue on the next page...
4 2. Care plan is developed based on patient s needs/goals. Initial palliative care assessment; interdisciplinary team rounds 3. Plan of Care (POC) is based on understanding patient s values. Initial palliative care assessment; family meeting. A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process 4. Program delivers care according to individual patient POC. Palliative care daily rounds. Page 3 0f Program provides care that meets patient s communicaton needs. 6. Tries to accommodate patient s cultural preferences. 7. Program communicates POC to staff involved in patient care. Palliative care initial assessment. Initial palliative care assessment; psycho/social/ spiritual (PSS) assessment. Medical record documentation; daily rounds. 8. Program informs patient about treatment outcomes including sentinel events.. 9. Evaluates, revises POC based on changes in patient s needs; documents changes. Palliative care daily rounds; interdisciplinary team rounds. PCPC.4 Interdisciplinary team assesses and Reassesses the patient s needs 1. Interdisciplinary team (IDT) completes initial assessment; documents assessment. 2. IDT obtains cultural/spiritual/relicious information. 3. IDT assessment of pain, other physical symptoms and uses standardized scales. 4. IDT does/documents functional assessment. 5. Program monitors effects of medications. 6. Spiritual care available from organization s pastoral care department and/or clergy. 7. Provides grief/bereavement (G/B) referral. 8. IDT completes assessments within defined timeframes. 9. IDT reassesses the patient with change in condition or patient preference; reassessment is documented. 10. Documents patient wishes about care across settings, including site of death. Initial palliative care assessment; IDT rounds records. Initial assessment; PSS assessment. Initial assessment template. Initial assessment template. Daily rounds template. PSS assessment/plan. PSS assessment/plan. Service standards; hospital standards. Daily rounds/progress notes. regarding consultant policies Palliative Care Standards continue on the next page...
5 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process Page 4 0f IDT recognizes transition to iminent death. PCPC.5 Program Provides care, Treatment or services according to the plan of care (POC) 1. Program has process to provide/refer for emergency/urgent care. 2. Patient s comfort and dignity are priorities. 3. Physical symptoms are managed according to POC. 4. Psychological symptoms are managed according to POC. 5. Monitor effects of medications. 6. Spiritual care made available. 7. Referrals made for grief/bereavement if indicated. 8. Process to identify patients at high risk for complicated grief/ bereavement and provide referrals. 9. Provides education/support regarding patient s need for safe/ suitable care. 10. Informs patient/family regarding iminent death. 11. Educates family regarding signs/symptoms of imminent death. 12. Treats body with respect after death. Initial assessment; daily rounds. Daily rounds; medical record documentation. Daily rounds; medical record documentation. Daily rounds; medical record documentation. Psycho/social/spiritual (PSS) assessment/plan. PSS assessment/plan. PSS assessment/plan. PSS assessment/plan; family meeting. Initial assessment; daily rounds. Initial assessment; daily rounds family meeting; education brochures. PCPC.6 THe patient s care is coordinated 1. Patient health information is available for decision making. 2. Medical information is available for internal/external sharing to coordinate care. Check hospital policy. Check hospital policy. Palliative Care Standards continue on the next page...
6 1. Patient health information is available for decision making. A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process 2. Medical information is available for internal/external sharing to coordinate care. 3. Program asssts staff in obtaining knowledge-based information for patient care and self management and patient/ staff ability to make decisions. Fast Facts placed on chart; patient/family educational material Page 5 0f Co-occurring conditions are managed. 5. Interdisciplinary Team (IDT) holds regular team meetings to discuss goals of care, prognosis, advanced care planning. Progress notes. Program Service Standards 6. Ethics consults are available. Check hospital policy. 7. Program assists patients in collecting health information. 8. Process exists to address patients need for continuing care after discharge. 9. Upon transfer to new care setting; patient goals, preferences/ values are communicated. Psycho/social/spiritual (PSS) assessments/plans PSS assessment/plans PSS assessment/plans; medical record documentation PERFORMANCE IMPROVEMENT STANDARDS PCPI 1. Organized approach to performance improvement (PI) 1. Program has written PI plan. 2. Program leader/staff participate in evaluation of provision of care/treatment/services. 3. Patients are involved in evaluation of care provision.. 4. Program sets PI priorities and describes how priorities are adjusted in response to urgent events. 5. PI activities include multiple disciplines and/or settings. 6. Program implements its PI plan. 7. If requested, provides public with information about commitment to PI. Sample PI Plan Patient/Family Satisfaction Data Sample PI plan (PCPI 1.1); strategic plan. Provide PI Plan Data Patient Satisfaction Data Check hospital policy. Performance Improvement Standards continue on the next page...
7 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process Page 6 0f 10 PCP1 2. Collects data 1. Collects data to improve processes/outcomes. 2. Uses consistent data sets, codes and terminology. 3. Data collection is timely, accurate, relevant. 4. Valid, reliable PI measures are selected. 5. Process and outcome measures at the level of the individual patient are collected. 6. Patient satisfaction data is collected. Sample Performance Improvement Plan (PCPI 1.1) CAPC Metrics (NQF When Available) CAPC Metrics Annual PI Report 7. Program monitors the quality of data collected. PCP1 3. Program analyzes & Uses data 1. Program analyzes/uses its data 2. Program uses statistical tool/techniques to analyze data 3. Identifies variables that impact outcomes. 4. Uses patient satisfaction data specific to the care it provides. 5. Uses data analysis to improve and sustain its performance. Annual Performance Improvement Report ; Annual PI Report PCP1 4. Addresses sentinel events 1. Process for reviewing sentinel events. 2. Process for identifying and reporting sentinal events through established channels, internally and externally. Performance Improvement Standards continue on the next page...
8 1. Process for reviewing sentinel events. A Guide to Help 2. Palliative Process for Care identifying Programs and Successfully reporting sentinal Complete events The Joint through Commission (TJC) Certification Process established channels, internally and externally. 3. Process for analyzing sentinel events. 4. Implements a process to conduct analysis of sentinel events. 5. Documents its analysis of sentinel events. 6. Implements changes based on findings of sentinel event analysis. Page 7 0f 10 PERFORMANCE MANAGEMENT STANDARDS PCPM 1.Program learders (PL) Secure Support from the Organization 1. Program leaders describe program philosophy that guides provision of care; philosophy is aligned with organizational mission. 2. PL and organization leaders (OL) work together to formulate program goals. 3. PL are empowered by OL to provide care. 4. PL communicate with OL to obtain recognition/support. 5. PL secure resources from OL to meet the services it provides. 6. PL evaluates care provided via contractual arrangements to ascertain if care is consistently provided. 7. Program makes staff throughout organization aware of program objectives and method for patient referral. 8. PL integrate their care with those of the organization. 9. PL create opportunities for staff to participate in the design of care provided. Program mission statement; business or strategic plan. Business or strategic plan. Strategic plan/annual report. Strategic plan/annual report. Business or strategic plan/annual report. Contractual agency review. Program brochure; marketing tools. Business or strategic plan/annual report. Staff surveys; QI/PI activities that interface with palliative care activities. Performance Management Standards continue on the next page...
9 A Guide to Help Palliative Care Programs Successfully Complete The Joint Commission (TJC) Certification Process Page 8 0f Program performance improvement plan is communicated at least annually to OL. Annual Report PCPM 2. Program Defines its leadership roles 1. Program has dedicated leadership and staff necessary to meet the scope of care it provides. 2. Program defines its leader s accountabilities. 3. Program defines its scope of care/services. 4. Program leaders have opportunities to share best practices with leaders of other similar programs. Job descriptions; operational data report. Job descriptions. Program brochure; Service Standards. Time for attendance at national meetings; audio-conference. 5. Program complies with laws/regulations. PCPM 3. Care provided in accordance with national guidelines or expert consensus 1. Program has policies/procedues that support its clinical practices. 2. Program reviews its clinical practices in response to changes in evidence-based guidelines/consensus or performanceimprovement activities. PCPM 4. Identifies and Minimizes Patient Risk (8 elements) PCPM 5. Program has Process to Address Concerns/Complaints from Patients (4 elements) PCPM 6. Leaders Selecting, Orienting, Educating, Retaining and Providing Incentives for Staff 1. Staff have education and training that is consistent with the program s philosophy and scope of care. 2. Program leaders evaluate qualifications, training individuals considered for membership in the program. Clinical Care Policies (e.g. sq opiod policy) Method of clinical care update review (e.g. monthly business meeting/journal Club). New palliative care staff orientation/training manual. Palliative care credentialing form. Performance Management Standards continue on the next page...
10 1. Process for reviewing sentinel events. A Guide to Help 2. Palliative Process for Care identifying Programs and Successfully reporting sentinal Complete events The Joint through Commission (TJC) Certification Process established channels, internally and externally. 3. Staff maintain a current license/certification in accordance with law and regulation. 4. Program leaders assess staff competence to perform job through observation Page 9 0f Orientation includes information and training necessary to perform their responsibilities. 6. The program leaders identify and respond to team members specific learning needs. 7. Leaders support staff participation in continuing education. 8. Program coaches staff to improve care. 9. Program leaders provide clinical support to promote staff and confidence to provide palliative care. 10. Leaders provide staff with emotional and psychological support. New palliative care staff orientation/training manual. Strategic plan; individual staff annual review. Strategic plan; individual staff annual review. Individual staff annual review. Individual staff annual review. Description of team health activities (e.g. quarterly retreat, team-building workshops). PCPM 7. Program has interdisciplinary team (IDT) with expertise/knowledge about the program s care/services 1. Core IDT has: Licensed Independent Practitioner RN Chaplain SW Note: Program demonstrates effort to have all of the above with palliative care specialty training or BC/RE. IDT also utilizes (in accordance with program services): Child Life Pharmacy Gerontology Nutrition Pediatrics Psychology Rehabilitation Services Job descriptions; annual program report. Business or strategic plan; annual program report; job descriptions; service standards. Performance Management Standards continue on the next page...
11 1. Process for reviewing sentinel events. A Guide to Help 2. Palliative Process for Care identifying Programs and Successfully reporting sentinal Complete events The Joint through Commission (TJC) Certification Process established channels, internally and externally. 3. IDT members responsibilities are in writing. Job descriptions. Page 10 0f 10 PCPM 8. Program Promotes interdependence among program staff involved with patient care 1. Program and organization support a collaborative environment. 2. Program leaders facilitate team communication. 3. Program demonstrates teamwork among interdisciplinary team members and other organization staff who are involved in the patient s care. Service Standards Service Standards
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