Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about recent mid-term release of The Joint Commission’s Survey Activity Guide.
Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”
While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…
The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships.
Continue reading this post at Mac’s Safety Space.
In case you missed it, The Joint Commission added a new frequently asked question (FAQ) and updated 19 existing FAQs last week. The new question tackles the issue of physician texting medical records.
You can read the updates here.
Earlier this week The Joint Commission released the National Patient Safety Goals (NPSGs) for 2012 in an easy-to-read version. Goals for 2012 include identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing mistakes in surgery.
Click on the program links below to view/download the 2012 NPSGs.
- Ambulatory health
- Behavioral health
- Critical access hospitals
- Home care
- Laboratory services
- Long term care
- Office-based surgery
For more information, visit The Joint Commission Website.
The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.
According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.
In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.
The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.
The Joint Commission and the American Society for Histocompatibility and Immunogenetics (ASHI) have entered a cooperative agreement to recognize histocompatibility (HLA) accreditation. Effective July 1, 2011, ASHI will have the authority as a deemed accreditor for transplant testing services in Joint Commission facilities.
The Joint Commission said the agreement will reduce the burdens on health care organizations by eliminating the need for duplicate laboratory surveys for organizations conducting HLA testing, and will also save them money by accepting the ASHI accreditation as evidence of compliance with Joint Commission policies and standards.
Find out more and see what each organization has to say about the agreement by visiting The Joint Commission Website here.
Two former language-expert hospital administrators in conjunction with Language Line Services have released a new report called “The New Joint Commission Standards for Patient-Centered Care,” that finds hospitals are falling short of The Joint Commission’s language access requirements for patients with limited English.
The requirements were announced in 2009, and put in place on January 1 of this year, but won’t have an effect on accreditation during the year-long pilot phase.
According to the report and The Joint Commission, communication breakdowns are the cause for nearly 3,000 deaths every year, and the majority of these breakdowns involve patients with limited English. Studies show that 50 million people speak a language other than English in the home, and according to the report, some hospitals are not making the connection between language services, patient rights, and patient safety.
The report also says that hospitals may think they are being compliant because they have bilingual staff, contract interpreters, and over-the-phone or video interpreters, but the standards require proof of interpreter training and fluency competence for interpreters in spoken languages as well as American Sign Language for deaf and hard-of-hearing patients.
The report says hospitals that aren’t in compliance with the new regulations could do damage to their reputations and accrue untold expenses.
Visit The Joint Commission’s Hospital, Language, and Culture website for more information.
The Joint Commission has updated its website with its latest sentinel event statistics. As of September 30, 2010, the sentinel event database has record of 7,147 sentinel events reviewed by The Joint Commission since its implementation in January 2005. All events were voluntarily reported by Joint Commission accredited organizations, and represent only a small proportion of actual events.
According to the organization’s statistics, the top ten sentinel events submitted to The Joint Commission over the past 15.5 years are:
- Wrong-site surgery: 956
- Suicide: 832
- Operative/post-operative complication: 775
- Delay in treatment: 611
- Medication error: 563
- Patient fall: 461
- Unintended retention of foreign body: 421
- Assault, rape, or homicide: 270
- Perinatal death or loss of function: 229
- Patient death or injury in restraints: 204
A total of 7,288 patients were affected by these events, with 4,844 resulting in patient death.
Click here to view more statistics.
The Joint Commission has launched extensive upgrades to its website in order to improve access to information about healthcare quality and safety. Based on research with healthcare organizations, healthcare professionals, consumers, and the like, the new website features:
- Sign-ups for alerts to upcoming events, newsletters, and field reviews
- A “Daily Update” section with new information from the past 24 hours
- Enhanced search functionality and multi-media functionality for videos, podcasts, and RSS feeds
- Interactive features such as blogs, discussion forums, speaker’s bureau request forms, and options to share information with other people
- Easier navigation and search functionality
- A Joint Commission events and conferences calendar
Visitors to the site will still be able to access Quality Check, The Joint Commission’s search engine for Joint Commission certified healthcare organizations located within the United States and its territories, and a tutorial of the new site is available here.
The Joint Commission’s Target Solutions Tool™ (TST) launched in September has made progress in the area of hand hygiene. Over 700 hand hygiene projects are currently running, over 6,500 hand hygiene observations have been entered into the TST, and more than 2,500 download requests have been received so far for the tools and videos that the TST provides to support these projects.
The TST looks at measurement processes, barriers to success, and methods for implanting solutions, and was designed to smooth the process of solving healthcare’s most stubborn quality and safety issues.
The organization has teamed up with some of the top hospitals in the country to develop these solutions and is still seeking more.
The Joint Commission has announced the field review of its revised medication reconciliation requirement, which it has designated as National Patient Safety Goal (NPSG) 03.07.01.
The field review comes after The Joint Commission announced it would make the existing medication reconciliation goal (NPSG 8) one with which hospitals had to comply, but about which they would not be surveyed. The 2010 NPSGs contain language about medication reconciliation, but the field has widely expected an announcement about what will become of the goal.
The accreditor had previously said it would update the goal because it had received feedback from the field indicating that hospitals felt the goal was too difficult to implement. Last February, The Joint Commission said it would “evaluate and refine the expectations for accredited organizations.” The field review is the result of this refinement.
The revised goal is designed to work in tandem with other medication management requirements. It requires providers to maintain and communicate accurate information regarding a patient’s medications. Specifically, the goal would require hospitals to:
* obtain medication information from patients at admission
* compare that information with the medications ordered for the patient and identify discrepancies
* communicate to the patient at discharge information about the medications he or she should be taking
* impress upon the patient the importance of managing his or her medications outside of the facility.
The Joint Commission is asking for feedback from the field through May 11, although it would prefer feedback by April 30. The standard will be tested in the field prior to implementation. If you’d like to offer your feedback, and to see the full text of the proposed goal, visit The Joint Commission’s page about the field review.
Do you have any initial reaction to this proposed med rec goal? My sense from the field that any change would be a good one, and this seems to really simplify the goal.