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Joint Commission puts antimicrobial stewardship standard up for field review

The Joint Commission seeks comments from healthcare facilities about a proposed standard that would require organizations to establish antimicrobial stewardship programs. The purpose of the new standard is to decrease the use of antimicrobials whenever possible to prevent the creation of drug-resistant strains of disease.

The deadline to provide feedback via comments or completing a survey is December 30.

Read the proposed standard and submit your comments here.

Readmissions plummet for elderly joint replacement patients

A recent AARP report revealed a significant drop in elderly patients being readmitted within 30 days of a hip or knee replacement surgery. Between 2009-2013, unplanned readmissions for knee replacement patients aged 65-84 dropped by 36%. Readmissions for hip replacement patients dropped by 38% in the same time frame.

The report attributes this success in part to the Medicare Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excessive readmission rates for certain conditions.

Lowered readmissions become increasingly important as the number of hip and knee replacements rise. According to the American Association of Orthopedic Surgeons (AAOS), the number of total hip replacements have doubled since 1993 and knee replacements have tripled.

Read the full AARP report here.

December webcast to highlight survey hot spots for 2016

What are the CMS and Joint Commission hot spots for 2016? Join Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, on Wednesday, December 16 at 1 p.m. ET as they examine current survey focuses and point out where CMS and The Joint Commission will concentrate their efforts during your next survey.

In just 90 minutes, find out how to prepare for your next accreditation survey and comply with the most troublesome CMS and Joint Commission requirements. Pate and Eddy will provide strategies for preparing your staff for survey and give you valuable tips about what surveyors will expect when they arrive at your facility.

For more information and to register for the webcast, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.

Joint Commission releases list of top performing hospitals

The Joint Commission just released its annual report on improving quality and safety in 3,300 American hospitals. The report recognizes 1,043 hospitals as the best facilities in the “Top Performer on Key Quality Measures” program. Within that group, 23 hospitals collected and reported data on seven or more core measure sets in 2014 and were named top performers in all of those areas.

The Joint Commission shows its results as “composites,” or the sum of all the accountability measures and steps taken to meet certain measure sets. This is the first year the accreditor had data on its new tobacco treatment and substance use measure sets, reporting tobacco measure compliance at 75.8% and substance use at 58.2%. The report found that the most improved area was perinatal care, which jumped from a composite score of 74.1% in 2013 to 96.3% in 2014.

However, only 80.3% of accredited hospitals that received a total composite score greater than 95% this year. This marks a 0.8% decrease from the prior year, which the report claims is due to hospitals adjusting to the new tobacco treatment and substance use measure sets.

Read the full report here.

We need your feedback on accreditation books!

Hi there,

We’re in the process of planning for 2016 and would love your feedback to ensure that we provide you with the information that is most useful for you. What are your biggest accreditation-related challenges and priorities?

Now is your chance to tell us what topics you would like covered in 2016 and beyond.

Click here for the survey. As always, your information will be kept confidential.

Everyone who completes the survey will be registered for chance to win $50 to be used at


AAAHC acquires HFAP

The Accreditation Association for Ambulatory Health Care (AAAHC) acquired the Healthcare Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA), HFAP announced on their website yesterday.

The acquisition has been approved by Centers for Medicare and Medicaid Services (CMS) and is the first time two organizations with deeming authority will transition to single ownership.

The management and operations of HFAP will fall under the direction of Accreditation Association for Hospitals and Health Systems (AAHHS), the accrediting arm of AAAHC.

Read the full release on HFAP’s website.

New name for Briefings on The Joint Commission

Briefings on The Joint Commission has a new name: Briefings on Accreditation and Quality!

For the last few years, in addition to covering the latest Joint Commission happenings, we’ve also included a broad focus on CMS compliance and quality improvement. We think our new name better reflects the quality content we strive to bring you each month. You’ll still be able to access prior issues of Briefings on The Joint Commission on our website.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

We’re excited about this change and hope you will be too. If there are any topics you would like to see covered in upcoming editions of Briefings on Accreditation and Quality, please email me at


New Sentinel Event Alert focuses on patient falls prevention

Sentinel Event Alert (SEA) #55, issued by The Joint Commission today, urges healthcare facilities to take action to prevent falls and fall-related injuries.

Falls are routinely in the top 10 sentinel events reported to The Joint Commission each year. The most common causes of falls or fall-related injuries, include poor patient assessment, lack of communication, failure to follow healthcare facility protocols and safety practices, and the absence of strong leadership, according to the SEA.

The Joint Commission recommends the following actions under the command of a strong leadership:

  • Raise awareness of the need to prevent falls
  • Create an interdisciplinary falls injury prevention team
  • Implement a standardized tool to assess possible fall risks
  • Develop patient-specific plans of care based on possible fall and injury risks
  • Create standardized practices and interventions for healthcare professionals and patients
  • Perform a root cause analysis after a fall

Read the SEA for further information on The Joint Commission’s recommendations to prevent falls and fall-related injuries.

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space.

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

Reduce clinical alarm fatigue with new HCPro webcast

The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission created a new National Patient Safety Goal to address it. With so many device alarms going off, staff may tune them out and miss important warnings that can lead to adverse patient events.

In this webcast scheduled for Wednesday, October 14 at 1 p.m. Eastern, Deborah Whalen and Jim Piepenbrink of Boston Medical Center will explain how their facility successfully reduced alarm fatigue through process management, collaboration, and governance. Register today for “Clinical Alarm Management: Reduce Alarm Fatigue and Meet The Joint Commission’s National Patient Safety Goal” and get the knowledge you need to improve alarm management in your facility.

Visit here for more information.