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The Joint Commission Opens Advanced Certification Program

The first of its kind for ASCs BY SAHELY MUKERJI


he Joint Commission launched its Total Hip and Knee Replace-

ment Advanced Certification Pro- gram and began to accept applications from interested facilities on Decem- ber 17, 2015. On-site reviews started on March 14, says Wendi Roberts, executive director of certification at The Joint Commission. “We are get- ting applications every week and cur- rently have approximately 15 applica- tions, including one from an ASC [as of April 15, 2016],” she says. “The Total Hip and Knee Replace-

ment Advanced Certification Pro- gram is a disease-specific certifica- tion program offered to hospitals and ASCs,” says Michael Kulczycki, exec- utive director of the Ambulatory Care Accreditation Program at The Joint Commission. “We have 11 advanced programs offered to hospitals. This


Visit The Joint Commission’s booth at ASCA 2016, number 305, for more information on the Total Hip and Knee Replacement Advanced Certification Program.

is the first advanced certification pro- gram applicable to ASCs as well.” More than 800 hospitals and ASCs are already enrolled in The Joint Commission’s core orthopedic disease certification programs. The review process that ASCs will need to undergo to qualify for this advanced certification will take two days, Roberts says. “This program is unique in comparison to other certi- fication programs because the ASC

will have to have a patient available to have a surgical procedure done for the reviewer to observe,” she says. “The surgery could happen on day 1 after- noon or day 2.” The reviewer will go into the surgical suite to observe the surgery, look for certain measures before the procedure—such as educa- tion of the patient and pre-surgical his- tory—and follow the patient as he or she is handed off from nurse to nurse, from pre-surgery to surgery to post- surgery. “The reviewer will follow each one of those processes to make sure that there is no gap,” she says. The reviewer also will talk to ASCs about their interdisciplinary processes and look at staff competencies to see if they have appropriate education, licenses and credentials. “We will also look at other patients in different stages of surgery, pre- and postop,” Roberts says. “Depending on how many patients an ASC has, we will go back and look at the whole process and might ask ASCs to pull old records.” The reviewer will work with ASCs in partnership and focus on best practices. “This is not meant to be a punitive process,” she says. “It is about going in and help- ing the ASCs succeed. This is how we do our regular accreditation surveys; we track the ASC processes through a patient from registration to postop.” The Joint Commission currently has a core hip and knee certification program for both hospitals and ASCs. The Total Hip and Knee Replacement Advanced Certification Program came about in recognition of the increased requirements being placed on these procedures by the orthopedic com- munity nationally, Roberts says. “We felt that our program needed to mir- ror those increased requirements,” she says. “We wanted to look at the higher level process functioning. The expert panel providing input to the program included ASC representation.” The desire to be able to recognize ASCs as expert in this field was ini-

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