Tuesday, June 29, 2010

Priority Focus Area: Managing Communication and Informaton

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Priority Focus Areas

The Priority Focus Process is a data-driven methodology that consistently uses pre-survey information about

healthcare organizations to create priorities for reviewing standards compliance, thus lending consistency to the Survey process.

Pre-survey information is gleaned from data in your organization’s application for accreditation, your organization's past survey findings, our Quality Monitoring System database of complaints and non-self reported sentinel events, any ORYX core measure data, and certain external data, if available.

External data consists of publicly available data that are applicable to the accreditation program(s) being surveyed, such as HCAHPS for Hospitals, Nursing Home Compare, Home Health Compare, and failed laboratory proficiency testing data from CMS.

Priority Focus Process Summary Report

This summary report contains results for your organization. For a User’s Manual on the Priority Focus

Process, and a Definitions Guide on the Priority Focus Areas and Clinical/Service Groups, please refer to the

Joint Commission Connect Extranet site. These documents are located under the Priority Focus Process

link, by clicking on the link for Reference Documents.

Priority Focus Process Reports are updated quarterly and pull in data up to 3 years back from the date the

tool is run, except for laboratories which pull in data up 2 years back.

The Priority Focus Process brings consistency to the survey process for organizations having similar pre-survey data for the early part of their surveys as surveyors use the Priority Focus Areas and Clinical/Service Groups depicted in this report.

However, based on initial findings, surveyors will broaden or change focus appropriately. Organizations performing their own standards compliance assessment for their Periodic Performance Review and/or other quality improvement activities can use this information to enhance their evaluations, as well.

2 Staffing

2 Rights & Ethics

2 Patient Safety

1 Infection Control

1 Assessment and Care/Services

2 Information Management

2 Communication

2 HH- Home Personal Care/Support Services

1 HH- Home Health Services

Priority Focus Areas Clinical Service Groups

Assessment and Care/Services

Assessment and Care/Services for patients/clients/residents comprise the execution of a series of processes including, as relevant: assessment; planning care, treatment, and/or services; provision of care; ongoing reassessment of care; and discharge planning, referral for continuing care, or discontinuation of services.

Assessment and Care/Services are fluid in nature to accommodate a patient’s/client's/resident's needs while in a care setting.

While some elements of Assessment and Care/Services may occur only once, other aspects may be repeated or revisited as the patient’s/client's/resident's needs or care delivery priorities change.

Successful implementation of improvements in Assessment and Care/Services rely on the full support of leadership.

Sub-processes of Assessment and Care/Services include:

• Assessment

• Reassessment

• Planning care, treatment and/or services

• Provision of care, treatment and services

• Discharge planning or discontinuation of services

Infection Control

Infection Control includes the surveillance/identification, prevention, and control of infections among patients/clients/residents, employees, physicians, and other licensed independent practitioners, contract service workers, volunteers, students, and visitors.

This is a system-wide, integrated process that is applied to all programs, services, and settings.

Sub-processes of Infection Control include:

• Surveillance/identification

• Prevention and control

• Reporting

• Measurement

Priority Focus Areas

Priority Focus Areas (PFAs) are defined as processes, systems or structures in a health care organization that

significantly impact the quality and safety of care. They can be used to guide assessmet of standards compliance in

relation to the patient/resident/client experience.

Home Care Accreditation Program Home Care Accreditation Program

Home Care Accreditation Program


Communication is the process by which information is exchanged between individuals, departments, or organizations. Effective Communication successfully permeates every aspect of a health care organization, from the provision of care to performance

Improvement, resulting in a marked improvement in the quality of care delivery

and functioning.

Sub-processes of Communication include:

• Provider and/or staff-patient/client/resident communication

• Patient/client/resident and family education

• Staff communication and collaboration

• Information dissemination

• Multidisciplinary teamwork

Information Management

Information Management is the interdisciplinary field concerning the timely and accurate creation, collection, storage, retrieval, transmission, analysis, control, dissemination, and use of data or information, both within an organization and externally, as allowed by law and regulation. In addition to written and verbal information, supporting information technology and information services are also included in Information Management.

Sub-processes of Information Management include:

• Planning

• Procurement

• Implementation

• Collection

• Recording

• Protection

• Aggregation

• Interpretation

• Storage and retrieval

• Data integrity

• Information dissemination

Human Resource Management: Staffing

Effective Staffing entails providing the optimal number of competent personnel with the appropriate skill mix to meet the needs of a health care organization's patients/clients/residents based on that organization's mission, values, and vision.

As such, it involves defining competencies and expectations for all staff (the competency of licensed independent practitioners and medical staff are addressed in the Credentialed Practitioners priority focus area for all accreditation programs);

Staffing includes assessing those defined competencies and allocating human resources necessary for patient/client/resident safety and improved patient/client/resident outcomes.

Sub-processes of Staffing include:

• Competency

• Skill mix

• Number of staff

Rights & Ethics

Rights & Ethics include patient/client/resident rights and organizational ethics as they pertain to patient/client/resident care.

Rights & Ethics addresses issues such as patient/client/resident privacy, confidentiality and protection of health information, advance directives (as appropriate), organ procurement, use of restraints, informed consent for various procedures, and the right to participate in care decisions.

Sub-processes of Rights & Ethics include:

• Patient/client/resident rights

• Organizational ethics pertaining to patient/client/resident care

• Organizational responsibility

• Consideration of patient/client/resident

• Care sensitivity

• Informing patients/clients/residents and/or family

Patient Safety

Effective Patient Safety entails proactively identifying the potential and actual risks to safety, identifying the Underlying cause(s) of the potential, and making the necessary improvements so risk is reduced.

It also entails Establishing processes to respond to sentinel events, identifying cause through root cause analysis, and making necessary improvements.

This involves a systems-based approach that examines all activities within an organization that contribute to the maintenance and improvement of patient/client/resident safety, such as performance improvement and risk management to ensure the activities work together, not independently, to improve care and safety.

The systems-based approach is driven by organization leadership, anchored in the organization's mission, vision, and strategic plan, endorsed and actively supported by medical staff and nursing leadership, implemented by directors, integrated and coordinated throughout the organization's staff, and continuously re-engineered using proven, proactive performance improvement modalities.

In addition, effective reduction of errors and other factors that contribute to unintended adverse outcomes in an organization requires an environment in which patients/clients/residents, their families, and organization staff and leaders can identify and manage actual and potential risks to safety.

Sub-processes of Patient Safety include:

• Planning and designing services

• Directing services

• Integrating and coordinating services

• Error reduction and prevention

• The use of Sentinel Event Alerts

• The Joint Commission's National Patient Safety Goals

• Clinical practice guidelines

• Active patient/client/resident involvement in their care


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