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Brian Ward

Brian Ward is an Associate Editor at HCPro working on accreditation news.

Joint Commission revamps Quality Check

Originally launched in 1996, The Joint Commission’s Quality Check website gives customers a way to search for accredited and certified organizations. The site can be used to find how many facilities there are in a given area by typing in a state, city, or zip code. Or if one is trying to find out what certifications a specific facility has, they can type its name or Joint Commission ID number.

This month, The Joint Commission announced that it was updating the Quality Check site as part of an ongoing effort to provide “meaningful information about accredited organizations’ performance to the public.” The updated page is easier to navigate and allows customers:

  • To search by services and Doing Business As (DBA) names.
  • Interact with The Joint Commission via its Facebook, Twitter, LinkedIn and Vimeo accounts.
  • View overviews of accreditation and certification components using Shareable Quality Reports®
  • Download accreditation and certification data

Visit the updated Quality Check website here.

Joint Commission to elaborate on texting policy in June

The Joint Commission plans to release additional information on its new texting policy next month. The accreditor says that the new guidance will cover how frequently medical orders can be texted, the requirements for read back/text back confirmation, and the difference between text orders that are digitally or manually entered into the electronic health record.

Click here to read the full Accreditation Insider article on the new texting policies. 

Joint Commission announces Pioneers in Quality panel members

The Joint Commission this week selected 13 technical experts to work on its Pioneers in Quality Advisory Panel. The panel was created to help accredited hospitals transition towards the use of electronic clinical quality measures (eCQM). Along with providing support and education to facilities, the panel will also update The Joint Commission on challenges facilities are facing as well as the best methods of using eCQMs to measure and improve the quality of care.

“The combined expertise of this outstanding group will better inform our efforts and benefit hospitals who need real world solutions,” said David Baker, MD, MPH, FACP, executive vice president of The Joint Commission, in a press release. “We are steadfastly focused on developing viable solutions to the measurement-related issues that hospitals are facing.”

The advisory panel members are:

  • David W. Baker, MD, MPH, FACP, executive vice president, Healthcare Quality Evaluation, The Joint Commission
  • Jennifer Besch, director, Population Health, Cerner Corporation
  • Zahid Butt, MD, FACG, CEO, Medisolv, Inc.
  • Jayne Hart Chambers, MBA, senior vice president Quality, Federation of American Hospitals
  • Paul Conlon, PharmD, JD, senior vice president, Chief Quality and Patient Safety, Trinity Health
  • Nancy Foster, vice president for Quality and Patient-Safety Policy, American Hospital Association
  • Thomas French, MStat, system director of Clinical Analytics, Division of Clinical Effectiveness and Quality, Providence Health & Services
  • Steve Horner, RN, BSN, MBA, vice president, Clinical Analytics, HCA, Inc.
  • Deborah Krauss, MS, BSN, RN, nurse consultant, Division of Electronic and Clinician Quality, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services
  • Kevin Larsen, MD, FACP, medical director, Meaningful Use, Office of the National Coordinator for Health Information Technology; CMS Lean Implementation, Office of the Administrator/Center for Medicare & Medicaid Innovation, U.S. Department of Health and Human Services
  • Lynn Lenker, BSN, MS, RN-BC, ONC, NE-BC, system chief nursing information officer, SSM Healthcare; Nurse Champion-Project Beacon
  • Helen Lindsay Macfie, Pharm D, FABC, chief transformation officer, Certified Lean Leader, MemorialCare Health System
  • John S. Pirolo, MD, senior vice president and chief medical information officer, Ascension
  • Cindy Tourison, MSHI, acting director, Division of Quality Measurement, Quality Measurement and Value-Based Incentives Group, Centers for Medicare & Medicaid Services

For more information on the Pioneers in Quality ™ Program, click here.

Newest Joint Commission Speak Up campaign targets identity verification

The Joint Commission launched its “Speak Up™: Right ID, Right Care” campaign on May 6, focusing on the importance of dual identifiers in healthcare. The accreditor’s press release contains an animated video, podcast, and infographic that are free for download and reuse.

The campaign is aimed at teaching patients why healthcare providers ask them for two forms of identification every time they come in; such as name, birthday, or phone number. The accreditor says that patients can become confused or worried if they don’t know why they are continuously asked to identify themselves. The campaign hopes to teach patients that the verification process is to prevent patient mix-ups and potentially giving the wrong treatment to the wrong patient.

Click here to visit the “Speak Up™: Right ID, Right Care” page.

Advanced heart failure certification requirements updated

The Joint Commission this week released its prepublication standards for advanced certification for heart failure. The updated standards go into effect on January 7, 2017, and are based on the 2013 “American College of Cardiology/American Heart Association Guideline for the Management of Heart Failure.”

Click here to see the advanced certification for heart failure prepublication standards. 

Featured Webcast: How to Establish an Antimicrobial Stewardship Program

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How to Establish an Antimicrobial Stewardship Program Webcast

Antimicrobial overuse is a major problem for hospitals. Overuse of antibiotics can lead to the development of multidrug-resistant organisms, unintended antibiotic toxicity, and Clostridium difficile infections. CMS and The Joint Commission have increased their emphasis on antimicrobial stewardship programs as a way to control this growing issue.

On Wednesday, May 18, from 1-2:30 p.m. Eastern, join expert speaker Jennifer Pisano, MD as she explains why antimicrobial stewardship programs (ASP) are important and how to establish a one for your facility. Utilizing her experience and successful track record, she will show attendees how her center has achieved a 95% acceptance rate by providers for stewardship recommendations.

At the conclusion of this program, participants will be able to:

  • Discuss the importance of antimicrobial stewardship and its relation to overall patient care (inside/outside the acute care setting)
  • Understand how to get an ASP started
  • Discuss ways to measure outcomes of an ASP
  • Outline the aspects of ASPs that are of interest to regulatory bodies

To sign up or learn more, visit the HCPro Marketplace.

Sponsored by:
Patient Safety & Quality Healthcare


Joint Commission rolls out changes to Denial of Accreditation decisions

The Joint Commission has set up a program for healthcare organizations that receive Preliminary Denial of Accreditation (PDA) decision PDA02. The decision is rendered when a facility has serious and widespread noncompliance issues. The accreditor says the new policies are to help organizations with a PDA02 improve themselves and get back up to standard.

The changes include:

  • Organizations must submit an acceptable Evidence of Standards Compliance (ESC) within 30 days and address the Requirements for Improvement (RFI) identified as the drivers of the PDA decision.
  • Upon approval of the ESC, the accreditor will conduct an on-site ESC survey.
  • If Condition-level findings are identified, a Medicare Deficiency Survey must be conducted within 45 days. The organization will have the option of combining this survey with the on-site ESC survey.
  • If the organization has a successful on-site ESC survey, the accreditation decision will change from PDA to Accreditation with Follow-up Survey (AFS).
  • Areas of risk and available Joint Commission resources will be reviewed in a conference call with leadership from The Joint Commission and the organization.
  • The organization’s leadership must participate in the Intracycle Monitoring (ICM) process, which occurs at 12 and 24 months.
  • The organization’s next triennial survey will occur in the earlier segment of the 18-to-33–month window.
  • If the organization’s next triennial survey results in a repeat PDA decision, the organization will receive a recommendation for Denial of Accreditation (DA) with the opportunity of an expedited appeal.

CMS adopts 2012 Life Safety Code®


In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).

CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code. The New Life Safety Code® Field Guide for Healthcare Facilities cover


Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.

The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.

Some of the main changes required under the final rule include:

  • Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years. after the rule’s effective date.
  • Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • The provisions offer long-term care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ASCs, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.

To get up to speed on the 2012 Life Safety Code®  check out the following resources from HCPro Marketplace:

Visit the Federal Register document to read the final rule in full, and view the CMS press release on the LSC here.

Physicians may now text medical orders

In 2011, The Joint Commission ruled that physicians and practitioners were forbidden from using text messaging to send patient care orders. Now the accreditor has reversed its ruling, and effective immediately hospital staff are allowed to send orders for care, treatment, and services via text. The change applies to all Joint Commission-accredited and certified organizations.

The Joint Commission had originally ruled against using text messaging in medicine because:

  1. Worries about private medical information being sent through unencrypted texting services
  2. A lack of a way to verify who was actually sending the text

However, technology has finally reached a point where the twin issues of verification and encryption for texts are no longer a problem. That said, organizations are still expected to comply with Medication Management standard MM.04.01.01 and there are restrictions on the type of texting program that can be used. The Joint Commission says that for a messaging service to be used, it must have:

  • A secure sign-on process
  • Encrypted messaging
  • Delivery and read receipts
  • Date and time stamp
  • Customized message retention time frames
  • Specified contact list for individuals authorized to receive and record order

Click here to read the full Accreditation Insider article on the new texting policies. 

Joint Commission updates look of Leading Practice Library

In mid-April, The Joint Commission updated its Leading Practice Library (LPL) to a more user-friendly interface. The LPL is full of real-life solutions to healthcare problems, all of which have been reviewed and approved by The Joint Commission. Users can browse the LPL by specific topics and all the documents are cross-referenced with Joint Commission manuals.

The changes include:

  • More refined search options including program, chapter, location, and organization size.
  • The ability to create your own personal library of “favorited” practices and documents.
  • A faster, simpler, and less technical submission process.
  • New help guides in both written and video formats.

The LPL is available to Joint Commission accredited or certified organizations for free on their secure extranet.