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Joint Commission changes for March 2018

Deleted: RI.01.01.01, EP 8

Effective immediately, The Joint Commission (TJC) has deleted element of performance (EP) 8 from Rights and Responsibilities of the Individual (RI) standard 01.01.01. While it’ll take some time to come out of the manual, surveyors can no longer survey for it. The EP said that a hospital must respect the patient’s right to pain management. The accreditor said that after reviewing its comprehensive pain assessment and management requirements, the EP was found to be irrelevant.

Revised: EC.02.03.05, EP 25

The point of this revision is to provide extra clarity on non-rated doors. TJC made the revision to make the Environment of Care (EC) chapter align with the Life Safety Code (LSC). This revision applies to ambulatory care, behavioral healthcare, critical access hospitals, home care, and hospitals. You can read the program-specific EPs here.

Revised: EC.02.05.01, EP 27

The purpose of this revision is to address environmental features of areas administering inhaled anesthetics. TJC made the revision to make the EC chapter align with the LSC. This revision applies to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices. You can read the program-specific EPs here.

Joint Commission plans to make new suicide prevention standards

This December, The Joint Commission (TJC) convened the fourth meeting of a suicide prevention expert panel. The accreditor announced in the March edition of Perspectives that the recommendations they came up with went beyond what’s in the standards. So they intend to convert some of them into new Elements of Performance in National Patient Safety Goal 15.01.01. When they are finished updating the NPSG, it will be sent out for national field review, just like it normally would.

The first and second panels were published in November and centered on inpatient psychiatric units, general acute inpatient settings, and emergency departments. The third panel discussed other behavioral healthcare settings and had its recommendations published in January.

Involving patients and representatives in care decisions

Involving patients in their care isn’t just polite, it’s a CMS requirement. Condition of Participation (CoP) §482.13(b)(2) says that patients have the right to make informed choices about their care and be involved in crafting their care plan. And CoP §482.13(a)(1) requires hospitals to take reasonable steps to decide who the patient’s designated surrogate is when the patient is unable to make the decision.

According to CMS, patients have the right to make informed choices about their care and be involved in crafting their care plan. Diana Topjian, a patient safety coach with Studer Group, says that when talking to patients about their care plan, it must be clear that they understand the risks and benefits of agreeing or declining to the treatment regimen.

“It’s incumbent upon us as providers to ensure we present the plan of care in such a way that the patient (and/or family) understand and clearly can follow the information we used in reaching those decisions,” Topjian says.

“I believe that this is a two-part process,” adds Erin Shipley, RN, MSN, a patient safety coach with Studer Group. “Not only continuing to involve the patient and family as much as possible in the planning around their plan of care and any preferences that they have, but also assessing for any changes to these wishes, and deliberate teach-back with the patient, to ensure that the knowledge and information taught and shared has been retained.  This also helps improve the engagement of the patient to understand any perceived or actual barriers the patient and family has with following the plan developed.”

Editor’s note: you can read more about this in Briefings on Accreditation and Quality. 

Like CMS, you should pay attention to sexual harassment

With all the recent focus on sexual harassment in the workplace, healthcare organizations shouldn’t expect to avoid scrutiny. Especially not from CMS or the press. Sexual harassment always has been an issue in healthcare, and it’s not hard to find examples. Like the California surgeon who slapped a nurse’s rear every morning while saying “I’m horny.” That behavior and the facility’s inaction led to a $168 million lawsuit, plus months of bad publicity.

“I suspect we’re going to see much more attention to this in healthcare, because it’s in the headlines,” says Kate Fenner, PhD, RN, managing director of Compass Clinical Consulting. “We know that we have some healthcare incidents that have gotten national attention. We know that CMS takes this seriously, Joint Commission takes this seriously. So healthcare organizations need to review their vows about how they provide a safe working environment for employees.”

The Joint Commission requires that its accredited facilities meet all applicable laws (Civil Rights Act of 1964, Title IX, for example, the recognition of sexual harassment as an infringement on civil rights for employees), and CMS is stringent about protecting patient rights (CMS Tag A-0145), including the right to receive care without harassment.

“Regulators and surveyors (CMS and The Joint Commission) pay careful attention to the news and trends in public interest,” Fenner says. “Allegations of improper conduct such as that recently lodged against a physician then practicing at a highly regarded medical center pique regulator interest and focus attention.”

Editor’s Note: You can learn more about sexual harassment in the April editions of Patient Safety Monitor Journal and Briefings on Accreditation and Quality. 

Joint Commission updates LS, EC chapters

Three revisions to The Joint Commission’s Life Safety and Environment of Care chapters will go into effect on March 11. The respective changes add more clarity to requirements regarding non-rated doors, environmental features of anesthetics areas, corridor door latch. However, not all changes apply to all the same programs, so you should check to see which ones impact you. The changes are intended to improve alignment with CMS regulations. You can find the prepublication standards below:

•    Ambulatory Health Care
•    Behavioral Health Care
•    Critical Access Hospital
•    Hospital
•    Nursing Care Center
•    Office-Based Surgery
•    Home Care

Tell us what you’re looking for in Accreditation Books

Hi there!

I’m working on the newest batch of Accreditation books out and I need your help!

This year we’re planning on writing books on:

  • Mock Tracers
  • CMS Compliance Crosswalks
  • Suicide Prevention
  • Survey Readiness

These book will come with with the newest updates to CMS and other Accrediting Orgs. Plus tools, checklists, and quizzes, and more! But before we can get started, we need to get your feedback.

Please answer this 3 minute survey so we can write the best books we can!


Brian Ward, Associate Editor

Public comments open for NFPA active-shooter standards

Preparing to respond to an active-shooter event, whether that involves a surge of patients to your facility because of an incident off-campus or a hostile intruder inside your building, has become a major concern to most hospital officials.

For only the second time in its history, the National Fire Protection Association (NFPA) is fast-tracking development of a standard to help first responders, healthcare providers, facility managers and others to prepare for an active shooter incident, and they are looking for public input.

NFPA 3000, Standard for Preparedness and Response to Active Shooter and/or Hostile Events, could be ready as early as April, so public comments must be submitted by Feb. 23.

A draft copy is available online but you may be required to register with the NFPA first. To comment on draft of NFPA 3000 go to . And to read the NFPA 3000 fact sheet  go to

Tell us what you think about PSMJ and BOAQ

Dear BOAQ & PSMJ Subscribers,

We’re making much needed overhauls to BOAQ and PSMJ’s website this year. But before that happens, we want to hear your thoughts on how we can improve in 2018. Please share your feedback by taking this quick survey:

BOAQ Survey:

PSMJ Survey:

Your responses are invaluable to us and if you have ideas or suggestions for us, send them our way!

Brian Ward, Associate Editor

CMS Inpatient-Only List: Preparing for Critical Changes in 2018

Each year CMS revises its inpatient-only list of approximately 1,700 procedures. The most notable changes to the list that went into effect January 1, 2018 include the addition of coronary revascularization during an acute myocardial infarction and the removal of total knee arthroplasty. Knee replacements, according to CMS, now may be performed on either an inpatient or an outpatient basis.

These list revisions are vital for hospitals to track and take into account. For example, “removing knee replacement surgery from the inpatient-only list is going to cause major changes for hospitals and physicians who do these procedures,” says Kurt Hopfensperger, MD, JD, vice president of compliance and physician education at Optum Executive Health Resources. Moving forward, they will have to apply utilization review processes more rigorously.

Keeping pace with change

Hospitals that closely follow and interpret the CMS inpatient-only list benefit in several ways. The list follows evidence-based medicine and looks at the average length of stay, as well as typical risks and comorbidities, for each procedure. Thus, correctly placing a patient in inpatient status is a clinically good decision, and it helps organizations stay in compliance with Medicare rules.

Hospitals also protect revenue by making sure every patient undergoing a procedure on the inpatient-only list has a correct status determination, says Hopfensperger. As procedures drop off of the list, hospitals must do the same to avoid potential revenue integrity issues. “You want to make sure you are appropriately compensated for those patients who are high risk or who require a longer stay in the hospital,” he notes.

Continued at Health Leaders Media

Surgeon sued for double booking surgery

There’s a reason why the American College of Surgeons (ACS) recommends asking patients if they’re okay with a concurrent surgery before operating. A Manhattan doctor found that out the hard way, after two former patients sued him last month for $14 million, according to the Boston Globe.

The patients claim that David B. Samadi, MD, chief of urology at Lenox Hill Hospital, allowed doctors-in-training to perform their prostate surgeries, and was only present for 25 minutes for one of the surgeries. Further, they claimed they were put kept under general anesthesia longer than necessary to hide Samadi’s absence, and that the operations were botched.

Last year, a review of more than 2,000 neurosurgical cases published in the Journal of the American Medical Association found no greater risk of postoperative complications for patients operated on by surgeons conducting overlapping surgeries. That said, the ACS guidelines are clear that patients need to know about and consent to an concurrent surgery before a provider does one.

Bradley T. Truax, MD, principal consultant of the Truax Group, says that patients should absolutely be informed if you plan to do their surgery concurrently.

“It is one thing for the surgeon to discuss with the patient that other personnel (residents, fellows, surgical assistants, etc.) will be participating in their surgery,” he says. “But the surgeon needs to make it clear what their roles will be and that the attending surgeon him/herself may not be present for the entire procedure.”