Case Study
Quality affirmation and unforeseen benefits: WellMed's journey to The Joint Commission's ambulatory care accreditation
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By Laura Huete, MD, MBA, FACMQ, CMQ, senior medical director, WellMed Medical Group; Lisa Schmidt, MSA, MSS, RN, vice president of clinic operations, WellMed Medical Management; Cynthia Henderson, RN, CCM, senior director, clinical programs, WellMed Medical Management; and Denise Sewell, MSM, RN, director, clinical health and safety, WellMed Medical Management, San Antonio, Texas
The Joint Commission is well known to those who work in a hospital setting, as there are more than 4,000 hospitals in good standing with the nation’s oldest and largest healthcare accrediting and standards-setting body. It’s less well known, however, in the outpatient primary care medical community, where the nuts and bolts of healthcare are delivered daily to millions of Americans.
When leaders at WellMed Medical Management Inc., San Antonio, Texas, examined the primary goals of The Joint Commission, they found that their goals aligned: Promote patient safety, quality of care and efficiency of care — all priorities for improving the way WellMed has delivered care to patients for nearly three decades.
To reach its goals, the company would have to achieve what only an exclusive number of medical groups have accomplished in the United States. The Joint Commission, a non-governmental, not-for-profit organization, offers a Primary Care Medical Home Certification (PCMH) as an added recognition to clinics that earn its Accreditation for Ambulatory Health Care. Fewer than 250 U.S. medical groups hold both distinctions (accreditation and medical home certification).
In 2016, WellMed began its journey to demonstrate that its 89 primary care and specialty clinics met The Joint Commission’s rigorous, nationally accepted healthcare standards. WellMed leaders set out to obtain The Joint Commission Gold Seal of Approval® for Ambulatory Health Care and Primary Care Medical Home Certification.
Founded by Chairman and CEO George M. Rapier III, MD, in 1990 with two clinics in San Antonio, Texas, WellMed’s goal was to redirect the focus from acute, emergent care prevalent in the primary care community toward a WellMed model that:
This led to the creation of the Clinic Operations 360 (CO360) initiative to provide a comprehensive view of the clinics and to implement process improvements and changes.
CO360 has three clearly defined drivers:
For example, The Joint Commission considers the management of both stock and sample medications, including identifying high-alert or look-alike, sound-alike medications. CO360 developed a stock and sample medication formulary to provide standardization across the enterprise. However, WellMed needed a dedicated process to approve or deny medications to be added and maintained on the formulary. With the governance structure, the Ancillary Support Sub-Committee was chartered under the Clinical Health and Safety Committee to include medical directors, a pharmacist and market leadership to carry out the required oversight.
These committees delegate and supervise activities conducted by a series of subcommittees with representation from WellMed geographic markets (Texas and Florida) to ensure they have input into any new initiatives or decisions affecting their regions. This also creates a critical communications stream to the markets to keep them informed about outcomes. A collaborative multidisciplinary team makes decisions that help support patient-centered care across multiple states/regions.
Subcommittees review and make recommendations for improvement in several areas, including recognition and compensation, well-being, healthcare access, standardizing medical equipment and supplies, medication management and credentialing.
The clinical safety subcommittee focused on patient falls, which remains the most-reported patient safety incident at the clinics. Falls are particularly devastating to the older patient population, as they are the leading cause of fatal and non-fatal injuries for older Americans.
This led to the creation of a “Falls Workgroup,” which recommended ways to reduce falls in WellMed’s clinics:
To ensure success, chapter champions — experienced physician and nurse leaders or healthcare administrators and executives — were identified and given oversight of an assigned chapter and coordinated with appropriate executive leadership and departments.
Additionally, a Joint Commission core team composed of a senior medical director, a vice president of clinic operations, a vice president of clinic administration, two clinical directors and a project manager offered another layer of guidance and oversight of the champions. The core team met weekly to review progress, discuss issues and develop strategies to ensure the survey was successful.
While the primary focus of pursuing The Joint Commission Accreditation and PCMH Certification was to provide patients with an excellent experience, there were specific processes that needed to be validated, implemented and/or documented to ensure compliance with The Joint Commission standards. To meet these requirements, the project manager met monthly with each chapter champion to monitor progress and ensure the project plan for each chapter was on track. The project manager assisted in problem-solving to overcome issues and delays and brought members of several chapter teams together to work on shared goals. The project manager also led monthly status meetings for the entire chapter team. Each chapter champion reported progress from the past month, chapter status, key issues or risks and planned activities for the upcoming month.
Additionally, WellMed contracted with consultants to conduct on-site assessments and identify opportunities for improvement in preparation for the accreditation survey.
Consultants visited clinics in several Texas and Florida markets as well as corporate headquarters in spring 2016. A gap analysis provided a road map for each chapter champion to prioritize the work needed to prepare for the survey. One consultant returned in November 2016 to conduct a second round of mock surveys to determine the progress made toward survey readiness.
The following organizational strengths were identified:
On Aug. 14, WellMed received notification that it had been granted Ambulatory Health Care Accreditation and Primary Care Medical Home Certification.
The rigorous preparation validated WellMed’s compliance with federal (CMS, OSHA, etc.), state and local regulatory policies and procedures, as well as safety policies set by its affiliated healthcare companies, Optum and UnitedHealth Group.
WellMed’s average score on the Optum annual Patient Health and Safety Assessment (PHSA) increased from 79% in 2015 to 97% in 2017, even with more rigorous standards added by Optum each year. WellMed leaders largely credit this improvement to the reflective process of working to meet The Joint Commission’s complementary standards.
Another benefit is the improved collaboration and communication between departments, such as credentialing and education and training. This accomplishment also provides increased confidence in WellMed providers regarding patient safety processes outside the exam room, including improved medication and lab management such as monitoring refrigerator temperatures for safely storing vaccines, medications and lab controls/reagents. It also validates clinical competencies of staff, including medication administration and lab testing and quality controls.
WellMed leaders believe the staff’s hard work to achieve the Gold Seal of Approval from The Joint Commission will continue to have a greater impact beyond the goodwill and marketing benefits received from this achievement. It has helped clarify the way WellMed delivers healthcare for the benefit of its patients.
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The Joint Commission is well known to those who work in a hospital setting, as there are more than 4,000 hospitals in good standing with the nation’s oldest and largest healthcare accrediting and standards-setting body. It’s less well known, however, in the outpatient primary care medical community, where the nuts and bolts of healthcare are delivered daily to millions of Americans.
When leaders at WellMed Medical Management Inc., San Antonio, Texas, examined the primary goals of The Joint Commission, they found that their goals aligned: Promote patient safety, quality of care and efficiency of care — all priorities for improving the way WellMed has delivered care to patients for nearly three decades.
To reach its goals, the company would have to achieve what only an exclusive number of medical groups have accomplished in the United States. The Joint Commission, a non-governmental, not-for-profit organization, offers a Primary Care Medical Home Certification (PCMH) as an added recognition to clinics that earn its Accreditation for Ambulatory Health Care. Fewer than 250 U.S. medical groups hold both distinctions (accreditation and medical home certification).
In 2016, WellMed began its journey to demonstrate that its 89 primary care and specialty clinics met The Joint Commission’s rigorous, nationally accepted healthcare standards. WellMed leaders set out to obtain The Joint Commission Gold Seal of Approval® for Ambulatory Health Care and Primary Care Medical Home Certification.
The WellMed care model
WellMed is a physician-led and patient-centric organization specializing in coordinated and preventive care for older patients with Medicare coverage. WellMed operates in Texas and Florida, and closed 2017 with a patient roster of 325,000.Founded by Chairman and CEO George M. Rapier III, MD, in 1990 with two clinics in San Antonio, Texas, WellMed’s goal was to redirect the focus from acute, emergent care prevalent in the primary care community toward a WellMed model that:
- Promotes coordinated and preventive care to help patients live longer, healthier lives, and better manage their chronic disease states
- Supports physicians with robust data-driven analytics, a compensation structure rewarding positive patient outcomes, a strong clinical support team and more.
Improving the process through Clinic Operations 360
One of the challenges of maintaining its care model was sustaining the WellMed culture with the rapid growth of clinic acquisitions across two states and three time zones. Clinics had fragmented policies and operated independently. Processes and equipment were not standardized. Communication across departments was decentralized.This led to the creation of the Clinic Operations 360 (CO360) initiative to provide a comprehensive view of the clinics and to implement process improvements and changes.
CO360 has three clearly defined drivers:
- Deliver an exceptional patient experience: Everything from ensuring patient safety, meeting clinical practice guidelines and transportation to and from medical appointments for patients.
- Exceed patient expectations for access: Access is very important to WellMed’s patients (and integral to the medical home model). This includes answering patient calls in a timely manner, providing them with 24-hour access to the clinic and scheduling appointments when needed.
- Create a healthier organization: A well-supported workforce – physicians, advanced practice clinicians, nurses and ancillary staff – is essential when providing the best possible care. Striving for this goal helped ensure appropriate staffing, training, development and recognition for all employees.
Establishing CO360
To meet the above goals and to make them sustainable during a time of explosive growth in patient volume, it was imperative to establish an effective governance structure to provide oversight and support. Governance was divided into four main committees:- Excellence in Service
- Process/Performance Improvement
- Clinical Health and Safety
- Creating a Healthier Organization
For example, The Joint Commission considers the management of both stock and sample medications, including identifying high-alert or look-alike, sound-alike medications. CO360 developed a stock and sample medication formulary to provide standardization across the enterprise. However, WellMed needed a dedicated process to approve or deny medications to be added and maintained on the formulary. With the governance structure, the Ancillary Support Sub-Committee was chartered under the Clinical Health and Safety Committee to include medical directors, a pharmacist and market leadership to carry out the required oversight.
These committees delegate and supervise activities conducted by a series of subcommittees with representation from WellMed geographic markets (Texas and Florida) to ensure they have input into any new initiatives or decisions affecting their regions. This also creates a critical communications stream to the markets to keep them informed about outcomes. A collaborative multidisciplinary team makes decisions that help support patient-centered care across multiple states/regions.
Subcommittees review and make recommendations for improvement in several areas, including recognition and compensation, well-being, healthcare access, standardizing medical equipment and supplies, medication management and credentialing.
The clinical safety subcommittee focused on patient falls, which remains the most-reported patient safety incident at the clinics. Falls are particularly devastating to the older patient population, as they are the leading cause of fatal and non-fatal injuries for older Americans.
This led to the creation of a “Falls Workgroup,” which recommended ways to reduce falls in WellMed’s clinics:
- Perform an annual fall risk assessment on patients over 65 years old
- Educate staff on identifying at-risk patients for falls
- Develop protocols for helping patients and caregivers to better understand the risk and to take evidence-based preventive measures
Accreditation preparation
Senior leadership at WellMed began preparing clinics and corporate teams for The Joint Commission accreditation and certification efforts nearly 18 months prior to the accreditation survey.To ensure success, chapter champions — experienced physician and nurse leaders or healthcare administrators and executives — were identified and given oversight of an assigned chapter and coordinated with appropriate executive leadership and departments.
Additionally, a Joint Commission core team composed of a senior medical director, a vice president of clinic operations, a vice president of clinic administration, two clinical directors and a project manager offered another layer of guidance and oversight of the champions. The core team met weekly to review progress, discuss issues and develop strategies to ensure the survey was successful.
While the primary focus of pursuing The Joint Commission Accreditation and PCMH Certification was to provide patients with an excellent experience, there were specific processes that needed to be validated, implemented and/or documented to ensure compliance with The Joint Commission standards. To meet these requirements, the project manager met monthly with each chapter champion to monitor progress and ensure the project plan for each chapter was on track. The project manager assisted in problem-solving to overcome issues and delays and brought members of several chapter teams together to work on shared goals. The project manager also led monthly status meetings for the entire chapter team. Each chapter champion reported progress from the past month, chapter status, key issues or risks and planned activities for the upcoming month.
Additionally, WellMed contracted with consultants to conduct on-site assessments and identify opportunities for improvement in preparation for the accreditation survey.
Consultants visited clinics in several Texas and Florida markets as well as corporate headquarters in spring 2016. A gap analysis provided a road map for each chapter champion to prioritize the work needed to prepare for the survey. One consultant returned in November 2016 to conduct a second round of mock surveys to determine the progress made toward survey readiness.
The following organizational strengths were identified:
- Implementation of infection prevention/disinfection processes
- Management of stock and sample medications
- Stock medication formulary (reduced from 1,000 medications to 256)
- Implementation of anticoagulation protocols
- Clinic-specific orientation tool and competencies
- Environment of care plans
- Credentialing and clinical privileges
- Organizational chart
- Provider and staff engagement
- Scope of practice
- Consistent documentation of training for staff and providers
- Governance Committee
- Health literacy
- Communication plan for community-wide disaster
Improving access to care
WellMed took several steps to improve patient access to care. First, leaders set up a standard phone tree for all clinics to track call volumes, abandon rates, average speed of answer and calls diverted to the answering service during regular business hours. Next, the team standardized appointment types and templates to enhance EHR reporting to gauge access metrics across the enterprise.
In November 2017, the company launched a Patient Service Center (PSC) on a trial basis at one of its San Antonio clinics to provide patients 24-hour access to care. The PSC handles many patient requests, including scheduling appointments and transportation, medication refills and nurse triage. The PSC also connects patients with clinic staff or patients’ providers, if needed.
WellMed also created a new position, market nurse leader, to serve as a clinical advisor to market leadership and a clinical liaison to the corporate CO360 team. These experienced nurses help with clinical support and training in the clinics in six markets. They conduct routine audits and oversee remediation of any findings, identify opportunities for standardization across the enterprise, assist with policy priorities/reviews/development and mentor junior nurses. They also played a key role in the development of the standardized stock and sample medication formularies.
Accreditation survey
The accreditation survey was conducted May 15-18, 2017, across several markets. End-of-day conferences were held daily during which the team-lead surveyors reported findings from the day and announced survey sites for the next day. One of the team-lead surveyors returned June 15 to provide a preliminary summary report of findings with the Final Joint Commission official accreditation report received June 23. Any findings had to be remediated within 60 days. The chapter champions successfully addressed the findings and submitted an evidence of survey compliance plan on July 28.On Aug. 14, WellMed received notification that it had been granted Ambulatory Health Care Accreditation and Primary Care Medical Home Certification.
Benefits of the journey
By working to obtain The Joint Commission accreditation, WellMed has improved its healthcare delivery system and achieved some unforeseen benefits.The rigorous preparation validated WellMed’s compliance with federal (CMS, OSHA, etc.), state and local regulatory policies and procedures, as well as safety policies set by its affiliated healthcare companies, Optum and UnitedHealth Group.
WellMed’s average score on the Optum annual Patient Health and Safety Assessment (PHSA) increased from 79% in 2015 to 97% in 2017, even with more rigorous standards added by Optum each year. WellMed leaders largely credit this improvement to the reflective process of working to meet The Joint Commission’s complementary standards.
Another benefit is the improved collaboration and communication between departments, such as credentialing and education and training. This accomplishment also provides increased confidence in WellMed providers regarding patient safety processes outside the exam room, including improved medication and lab management such as monitoring refrigerator temperatures for safely storing vaccines, medications and lab controls/reagents. It also validates clinical competencies of staff, including medication administration and lab testing and quality controls.
WellMed leaders believe the staff’s hard work to achieve the Gold Seal of Approval from The Joint Commission will continue to have a greater impact beyond the goodwill and marketing benefits received from this achievement. It has helped clarify the way WellMed delivers healthcare for the benefit of its patients.
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