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Joint Commission announces four survey focus areas

Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation Program (HFAP), and National Committee for Quality Assurance (NCQA) took the stage at the 2017 NAMSS Educational Conference & Exhibition to share what they have learned from this year’s accreditation surveys and to tell audience members about relevant standards changes

The Joint Commission announced four areas of focus:

1.    The SAFER Matrix: Implemented in January 2017, the SAFER Matrix has nine boxes that measure the likelihood to harm a patient on one axis and scope of occurrence (limited, pattern, widespread) on the other.

2.    Antimicrobial stewardship: The CDC reported that 20% to 50% of antibiotics were prescribed unnecessarily or inappropriately annually. Medical staffs must reduce their antimicrobial use and have a medical staff process to demonstrate an effective use of antibiotics or antimicrobials in their organizations.

3.    Ligature risks for behavioral healthcare units: Due to the increasing rise of inpatient suicides (1,200 to 1,500 each year), 70% of which are by hanging, ligature risks are no longer acceptable in areas specified for the treatment of behavioral healthcare patients with suicide risk.

4.    Culture of safety:Leaders must ensure a culture of safety and identify areas to improve culture of safety. Staff must be comfortable and able to report issues of safety to leadership. This is already a culture of safety standard in the Leadership chapter and the accreditor will unveil a related standard in the Medical Staff chapter in 2018.

According to Louis Goolsby, MD, FACOG, FACHE, the most common citations from the Medical Staff chapter still come from MS.01.01.01, specifically EP3 (specific requirements and associated details are included in the medical staff bylaws) and EP5 (the medical staff complies with the medical staff bylaws). Another common citation is MS.03.01.01 (practitioners only practice within their scope of privileges).

Editor’s note: 
The following article was originally published on the Credentialing Resource Center, October 24, 2017.

West Virginia cities sue Joint Commission over alleged role in opioid crisis

Four West Virginia cities and towns filed a class-action lawsuit against The Joint Commission and Joint Commission Resources on November 2, claiming the accreditor “grossly misrepresented the addictive qualities of opioids” in their pain management standards. The town of Ceredo and cities of Charleston, Huntington, and Kenova claim that those standards forced hospitals to prescribe unsafe amounts of painkillers, fueling addiction and deaths in the state. [Is there any dollar amount named in the lawsuit? What is it asking for?]

“This lawsuit is a critical move toward eliminating the source of opioid addiction and holding one of the most culpable parties responsible,” said Huntington Mayor Steve Williams. “For too long, [The Joint Commission] has operated in concert with opioid producers to establish pain management guidelines that feature the use of opioids virtually without restriction. The [commission’s] standards are based on bad science, if they are based on any science at all.”

West Virginia has the highest drug overdose death rate in the nation, with 41.5 deaths per 100,000 in 2015. Huntington and Cabell County had the highest overdose fatality rate in the state last year.

The lawsuit claims that the pharmaceutical companies like Purdue Pharma (the makers of OxyContin) worked with The Joint Commission to create the pain management standards. These companies stood to gain from the overuse of their drugs, the lawsuit claims.

The Joint Commission accredits at least 10 hospitals and healthcare facilities in Charleston and Huntington, and other cities and towns are expected to join the federal lawsuit.

The Joint Commission updated its pain management standards in June to reduce over prescriptions, which will take effect on January 1. However, the lawsuit says the accreditor waited too long to make those changes.

This isn’t the first time that The Joint Commission has come under fire either. In 2016 more than 60 medical experts and nonprofit organizations signed petitions asking the commission to change its standards. Claiming they “foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families, and communities.”

Joint Commission: screening for violence

In the October edition of Perspectives, The Joint Commission reiterated the need to screen patients for potential risks to themselves or others. This is part of a long-standing and ongoing effort to change the sky-high rates of workplace violence in healthcare.

More than 70% of the 23,000 significant injuries resulting from workplace assault in 2013 happened in healthcare and social service settings, according to the Bureau of Labor Statistics. The settings with the highest rates of workplace violence are emergency departments, behavioral healthcare settings, extended care facilities, and inpatient psychiatric units.

After reviewing 145 sentinel events between 2013 and 2015, The Joint Commission wrote that a common cause of violence was an inadequate behavioral health assessment of patients to identify aggressive tendencies. Sometimes, these assessments weren’t done at all, and the results ranged from assault to rape and even death.

“In order to accurately assess the needs of an individual for care planning, it is important to collect data about the individual’s past emotional and behavioral functioning, to assess his/her current needs and goals, and to analyze the data collected in order to develop a plan of care, treatment, or services that effectively addresses the risk of harm to self or others,” The Joint Commission writes. “These steps are also important to determine if there is a need to collect additional information.”

This includes checking to see if the patient has a history of violent behavior. If so, is there anything in their record that could determine if they’ll repeat their actions?

“If there is a history of aggression, or if the individual is admitted in an agitated state, staff should be alerted and the preliminary plan of care, treatment, or services should address the interventions required to maintain the safety of the individual and others,” “…the Perspectives article continued. “Interventions in the preliminary plan of care would likely include close supervision and monitoring of the individual, individualized de-escalation strategies, and adjustments to the environment of care as needed.”

Here are some other free resources and training on workplace violence prevention:

1.    Workplace Violence Prevention Resources for Health Care Portal (www.jointcommission.org/workplace_violence.aspx)    
2.    OSHA’s Guidelines for Preventing Workplace Violence in Healthcare and Social Services (www.osha.gov/Publications/osha3148.pdf)
3.    OSHA’s Preventing Workplace Violence: A Road Map for Healthcare Facilities (www.osha.gov/Publications/OSHA3827.pdf)
4.    The Center for Health Design’s Safety Risk Assessment Toolkit
(www.goo.gl/eH9IbG)
5.    The CDC’s Workplace Violence Prevention for Nurses course (www.cdc.gov/niosh/topics/violence/training_nurses.html)
6.    The Emergency Nurses Association’s Workplace Violence Toolkit
(www.goo.gl/0GXblW)
7.    ASIS International’s Managing Disruptive Behavior and Workplace Violence in Healthcare
(www.goo.gl/MDGsrf)

Joint Commission updates EM standards to match CMS

In response to CMS’ final emergency preparedness rule issued earlier this month, The Joint Commission announced revisions to its emergency management (EM) standards. CMS is expected to approve the updated standards before they go into effect on November 15.

Accredited organizations can access the proposed drafts on their Joint Commission Connect™ extranet site, with more information on the way.

The Joint Commission’s standards come with new Elements of Performance on the following topics:

•    Continuity of operations and succession plans
•    Documentation of collaboration with local, tribal, regional, state and federal emergency management officials
•    Contact information on volunteers and tribal groups
•    Annual training of all new or existing staff, contractors, and volunteers
•    Integrated healthcare systems
•    Transplant hospitals

Several of the new requirements merely provide more specifics on what The Joint Commission already expects. This includes including documentation for existing practices and annual training for staff.

CMS first announced the emergency preparedness CoPs in September 2016, compelling hospitals to communicate and coordinate their emergency plans with other hospitals and government agencies.

They also require regular emergency preparedness training with staff and disaster contingency planning. CMS published the final version of the new Appendix Z of Medicare’s State Operations Manual online, and state surveyors will use newly created E-tags to score deficiencies and expectations set in it.

 

George Mills is leaving The Joint Commission

The Joint Commission confirmed Thursday afternoon that a key figure in standards interpretation for the healthcare accrediting organization will be departing this fall.

George Mills, MBA, FASHE, CEM, CHFM, CHSP, who has served as director of the organization’s engineering department for the past six years, will leave his post effective October 9. Mills has been with The Joint Commission for 14 years.

“During his tenure he has served as an advocate for healthcare organizations as they strive to improve the quality and safety of their physical environments,” a spokesperson for The Joint Commission said in an email.

The confirmation came after HCPro’s resident hospital safety expert, Steve MacArthur, safety consultant for The Greeley Company, blogged Thursday on murmurings of an impending Mills exit. The Joint Commission also confirmed MacArthur’s report that John D. Maurer, SASHE, CHFM, CHSP, will take over as acting director of engineering on an interim basis.

“I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process,” MacArthur wrote, noting that he has always found Maurer to be “thoughtful, helpful, and equitable.”

Beginning October 9, Maurer will serve as acting director while a search for Mills’ successor is undertaken, the spokesperson said. Mills declined Thursday to comment on his forthcoming departure, and Maurer could not be reached.

 

Joint Commission deletes ORYX standard

The Joint Commission will delete performance improvement standard PI.02.01.03 and its single element of performance on January 1, 2018. The standard had required facilities to receive a composite performance rate of 85% or higher on the ORYX accountability measures.

The accreditor announced that it was deleting the standard because it wasn’t possible for facilities to accurately calculate their composite rates.

So many chart-based measures were retired to maintain alignment with CMS that there weren’t enough left relevant to this requirement. Also, since hospitals can submit data in several different ways, it threw off the composite rate calculations.

https://www.jointcommission.org/assets/1/18/Baking_Deletion_Prepublication.pdf

The measure had been suspended since 2015.

Crucial accreditation deadlines on the horizon for pain management and emergency preparedness

Time is running out to meet the new emergency management (EM) Conditions of Participation (CoP) and The Joint Commission’s revised pain management standards. The EM Interpretive Guidelines go into effect on November 15 while the pain management standards go into effect January 1.

Emergency management

The new EM CoPs fill gaps CMS’ previous regulations by compelling hospitals to communicate and coordinate their emergency plans with other healthcare organizations and government agencies. They also require regular emergency preparedness training with staff and disaster contingency planning.

Steve MacArthur, a safety consultant at The Greeley Company, pointed out that a lot of the new requirements include things that hospitals should have already been doing.

“While this rule is new to the ‘marketplace,’ there are really no new concepts contained therein,” he says. “This may provide some guidance for CMS surveyors as they drill down on organizational preparedness activities. But none of this is groundbreaking or in any way representative of a change in how hospitals have done, and will continue to do, business. [It’s] just another set of official ‘eyes’ looking through the compliance microscope.”

Pain management

The Joint Commission prepublished its new pain management standards back in June. The accreditor said it used the revision to address disparities between its standards and what the literature recommended. Some of the changes include:

•    Enabling clinician access to prescription drug monitoring program databases

•    Performance improvement activities focusing on pain assessment and management to increase the safety and quality for patients

•    Identifying the leader or leadership team responsible for pain management and safe opioid prescribing

•    Involving patients in developing their treatment plans and setting realistic expectations and measurable goals

•    Identifying and monitoring high-risk patients as a way to promote safe opioid use

Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and deter¬mining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

The annual fire and smoke door testing requirements will also be due by January 2018.

CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (aplunkett@h3.group)

Resource:

Maintaining security during a Joint Commission survey

Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions.

Access to Computer Systems: Surveyors will sign security agreements with the facility in order to receive a user ID and password to access a computer system (for example, in order to review policies and medical records) if the facility requires it.

Confidentiality Agreements: If a facility wants surveyors to sign a confidentiality agreement, then that agreement has to be sent to the Joint Commission Central Office for review before the survey.

That said, asking surveyors or reviewers to sign an agreement is unnecessary, according to The Joint Commission. Accreditation and certification contracts, plus the Business Associate Agreement between The Joint Commission and the facility, already bind individual surveyors and reviewers to confidentiality.

Security Sign-In: If a facility requires visitors to sign into the building as part of the organization’s regular security process then surveyors will sign in too. In lieu of asking to copy a surveyor’s driver’s license, Joint Commission badge, or any other form of ID, facilities should refer to surveyors’ pictures and biographies on the Joint Commission Connect™ secure extranet site.

Videotaping Survey Activities: Videotaping or recording any part of a survey or review, including the exit conference is forbidden.

Joint Commission: Six EPs deleted for Critical Access Hospitals

Later this year The Joint Commission will delete six elements of performance (EPs) from the Distinct Part Unit (DPU) standards for Critical Access Hospitals. The accreditor says this will streamline the standards and the changes go into effect on September 24, 2017.

The deleted EPs are from the Medical Staff, Leadership, and Rights and Responsibilities of the Individual chapters. You can read all six standards at the Joint Commission website. Those with questions can contact Laura Smith, MA, Joint Commission project director at lsmith@jointcommission.org.

https://www.jointcommission.org/standards_information/prepublication_standards.aspx