2008 Health Care Staffing Services Certification Quality Report User Guide

Transcription

1 2008 Health Care Staffing Services Certification Quality Report User Guide A Guide to Using The Joint Commission Certification Quality Report

2 Welcome to The Joint Commission s Quality Report! We know how important reliable information is when making health care decisions. Since 1951, The Joint Commission has been the national leader in setting standards for health care organizations. When a health care staffing firm seeks certification, it demonstrates a strong commitment to providing safe, high quality health care and to continually work to improve that care. Your comments are important to us. The content and format of the Quality Report will be updated from time to time based on changes in the health care industry and your suggestions. Please call Customer Service at or the Joint Commission at [email protected] with your comments and suggestions. Mark R. Chassin, M.D. President of The Joint Commission 2

3 Table of Contents What is Health Care Staffing Services Certification?...2 Facts About Certification Decisions...4 Benefits of Joint Commission Certification...5 About the Summary of Certification Quality...6 About the Locations...7 About the Organization Commentary...8

4 What is Health Care Staffing Services Certification? The Joint Commission s Health Care Staffing Services Certification Program provides a comprehensive evaluation of a health care staffing agency s key processes such as verifying the credentials and competencies of health care staff. Standards address: Leadership Human Resources Management Performance Measurement and Improvement Information Management In developing the standards and processes, we enlisted the use of two external groups to help develop the certification program: Advisory Council composed of representatives from health care staffing firms and associations. Standards Task Force composed of industry recipients, providers and other stakeholders Certification results will be publicly disclosed to provide certified staffing firms with a marketing advantage and providers with meaningful, comparative information. A Certificate of Distinction will be awarded to health care staffing firms that meet the requirements for certification. Eligible Organizations The Joint Commission s Health Care Staffing Services (HCSS) Certification Program provides an independent, comprehensive evaluation of a staffing firm s ability to provide qualified and competent staffing services. Health care staffing firms are eligible for Joint Commission certification if they: Place clinical staff in other organizations that oversee or provide direct patient care. Place clinical staff under the direct supervision of another organization s personnel. Have placed at least 10 clinical staff at the time of review. 2

5 What is Disease-Specific Care Certification? (cont d) What is Health Care Staffing Services Certification? Certification Process HCSS firms undergo an announced initial review. Re-certification reviews are unannounced and are conducted via an on-site review every other year. The review focuses on a firm s ability to provide competent staffing services and evaluates performance, continuing education and training, placement criteria, and other areas. The standards, contained in the Health Care Staffing Services Certification Manual, are divided into four sections: Leadership Human resources management Performance measurement and improvement Information management Performance measurement The Joint Commission has identified a set of standardized performance measures for the HCSS program. Effective January 1, 2008, all certified staffing firms are expected to collect monthly data points on three standardized performance measures. These data are reported to The Joint Commission at regular intervals. A Certificate of Distinction will be awarded to health care staffing firms meeting the requirements for certification. Public Information Organizations with Certified programs are highlighted on and have a Certification Quality Report. If an organization has achieved both Joint Commission certification and accreditation, their Accreditation Quality Report will contain both certification and accreditation information. These organizations will also have a separate Certification Quality Report. 3

6 Facts About Certification Decisions Certification is awarded after a review to a health care program or service that is in compliance with all standards, uses clinical practice guidelines (applicable to Disease-Specific Care Certification programs only), and meets performance measurement requirements and certification participation requirements at the time of the on-site review; or, if it has not been place in Conditional or Preliminary Denial of Certification status, has successfully addressed all requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 days following the review. If the program or service does not meet these requirements for certification, it will receive one of the following decisions. Provisional Certification results when a health care program or service fails to do one or more of the following: 1) Successfully address all requirements for improvement in an ESC within 45 days following the review or in a Measures of Success submission. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 31 days of the due date(s).* Conditional Certification results when a health care program or service fails to do one or both of the following: 1) Be in substantial compliance with the standards, usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The program or service must remedy identified problem areas through preparation and submission of ESC or Measures of Success and a conditional follow-up review. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 61 days of the due date(s).* Preliminary Denial of Certification results when there is justification to deny certification to the health care program or service as usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The decision is subject to appeal prior to the determination to deny certification; the appeal process may also result in a decision other than Denial of Certification. Denial of Certification results when the organization chooses not to appeal or the appeal of a Preliminary Denial of Certification decision is rejected; or a health care program or service does not permit the performance of any review by The Joint Commission; or the program or service fails to do one or more of the following: 1) Meet requirements for the timely submission of data and information to The Joint Commission within 91 days of the due date(s).* 2) Resolve a Conditional Certification status prior to withdrawing from the certification process. 3) Submit payment for review fees or annual fees. * Data and information that is expected to be submitted on a timely basis to The Joint Commission include but are not limited to the certification contract, annual updates to the health care program or service s application for certification, and annual intra-cycle evaluation. 4

7 Benefits of Joint Commission Certification Strengthens community confidence in the quality and safety of care, treatment and services Achieving certification makes a strong statement to the community about an organization s efforts to provide the highest quality services. Provides a framework for program structure and management Certification involves not only preparing for a review, but maintaining a high-level of quality and compliance with the latest standards. Joint Commission certification provides guidance to a program s quality improvement efforts. Validates compliance with nationally recognized standards by the preeminent health care evaluator Meeting Joint Commission standards is an accomplishment recognized with the awarding of The Joint Commission s Gold Seal of Approval. Certified organizations proudly display the Gold Seal to advertise their commitment to health care quality. Improves risk management and risk reduction Joint Commission standards focus on state-of-the-art performance improvement strategies that help organizations continuously improve the safety and quality of care, thereby reducing risk. Provides education on good practices to improve business operations Joint Commission Resources, The Joint Commission s not-for-profit affiliate, provides continuing support and education to certified organizations, including good practices and other enhancements. Provides professional advice and counsel thereby enhancing staff education Joint Commission reviewers are experienced health care professionals trained to provide expert advice and education during the on-site review. Can be a tool to attract and retain quality personnel Joint Commission certification can attract qualified personnel who prefer to serve in certified organizations. Certified organizations also provide additional opportunities for staff to develop their skills and knowledge. 5

8 About the Summary of Certification Quality The Summary of Quality Information provides an overview of all of the following quality of care components included in the Certification Quality Report: Advanced Certification Programs: Identifies the program(s) that received advanced certification by The Joint Commission. Certified Programs: Identifies the program(s) that are certified by The Joint Commission. Certification Decision: The program s Joint Commission certification decision. Effective Date: The date the certification decision was awarded. Last Full Review Date: Last Full Review Date represents the end date of the on-site review that began the listed program's current certification cycle Last On-Site Review Date: Last On-Site Review Date represents the end date of the most recent on-site review. 6

9 A Disease-Specific Care Facility 1199 Sun Valley Road, Houston, Texas About the Locations Q. What are locations and services? The Certification Quality Report contains a listing of the site and service information collected as part of the certification process. The primary location of a health care staffing firm is the main location where it provides services Q. Why are services displayed on the Certification Quality Report? Consumer health care research and focus groups have pointed out that one way health care consumers want to identify potential locations of health care is by the services provided. The Joint Commission has taken steps to support this option as a benefit to our certified organizations. Q. How are the services determined for an organization? The services listed on the Certification Quality Report come from the data an organization provided on the Application for Certification. The Joint Commission then categorizes all of the potential services into user-friendly groups to display on the Certification Quality Report. 7

10 Sample Disease-Specific Care Certification Quality Report About the Organization Commentary The Joint Commission provides certification information consistent with its public information policy. Each health care organization is invited to submit a brief commentary on its Certification Quality Report. The intent of the commentary is to offer a certified organization the opportunity to provide its perspective on its Certification Quality Report and to convey important messages to the public about its performance and the services it provides. Submitted commentaries must meet the following criteria: The commentary may not be longer than two pages in length and is to be prepared on a standard form. Reviewers may not be mentioned by name in the commentary. Defamatory or libelous language may not be used. The organization may provide only one two-page commentary. The decision to prepare and submit a commentary is up to the health care organization and is not required. The commentary will be sent with the Certification Quality Report each time a request for a Report is made. When an organization submits a commentary, the commentary is included as the last page of both the online and hard copy versions of the Certification Quality Report. Commentaries accessed in Quality Check may be read using Adobe Reader, a program which is free and easy to download. 8