The Joint Commission is now using its SAFER Matrix with all accredited organizations. The matrix replaces the old scoring method of categorizing risk using “A” and “C” rankings.
The SAFER matrix is a three-by-three grid labeling the level of risk and harm observed for a standard. The approach is meant to help organizations prioritize and focus their efforts on the direst areas of risk.
To see our previous Accreditation Insider on the SAFER Matrix, click here.
Briefing on Accreditation and Quality subscribers can view or the following stories.
- Joint Commission unveils revised scoring system
- Q&A: Joint Commission exec answers SAFER matrix questions
On January 9, 2017, Joint Commission Leadership (LD) standard 01.03.01,element of performance (EP) 12, for home health and hospice will be expanded to apply to hospitals, critical access hospitals, and ambulatory surgical centers.
The standard requires that the leadership/governance of a healthcare facility is the one ultimately held accountable for the facility’s safety, quality, and compliance. Previously, however, the Joint Commission standard didn’t have an EP that referred to leadership’s legal responsibility. In addition, the EPs varied between different types of facilities on what to do if leadership failed to meet its responsibilities.
The Joint Commission announced it was expanding EP 12 to the additional settings as a way to standardize compliance across all accredited facilities and to come into alignment with CMS’ Conditions of Participation.
Hard copy versions of accreditation manuals published after November 2016 will include the new EP, and the change will be made to the accreditor’s E-dition in January. For more information, contact Laura Smith, Joint Commission project director, at firstname.lastname@example.org.
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Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on catheter-associated urinary tract infections (CAUTI) for hospitals and critical access hospitals. It also created a new CAUTI NPSG for nursing care centers.
“An estimated 1 to 3 million healthcare-associated infections strike nursing home residents annually, and many of these are infections related to urinary catheters,” wrote David Baker, MD, MPH, FACP, Joint Commission executive vice president, in a blog post. “CAUTIs can lead to serious complications and hospitalizations. And, the rate of these infections is even higher for hospital patients. This is why The Joint Commission felt it was important to implement its new National Patient Safety Goal for nursing care centers and an updated goal for hospitals and critical access hospitals to reflect the latest scientific evidence.”
Among the new changes are requirements to:
• Educate staff on how to correctly use and insert indwelling catheters.
• Educate patients and family on CAUTI risks and prevention
• Use evidence-based guidelines to write catheter use policies.
• Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter.
• Maintain an up-to-date record of catheter use; who has one inserted, when was it implanted, etc.
All the changes go into effect on January 1, 2017 and are meant to improve staff training, educate patients, and update policies with evidence-based practices. In addition, the Department of Health and Human Services announced that it wants to see a 50% reduction in CAUTI by 2020.
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The Joint Commission just published its 2017 Survey Activity Guide, with information on how to prepare for your next survey. It also contains details on policy changes in 2017, such as the new antimicrobial stewardship program standard for hospitals, critical access hospitals, and nursing homes.
On January 1, 2017, hospitals will be able to submit applications for the Joint Commission’s new advanced Comprehensive Cardiac Center (CCC) certification. The certification will allow hospitals with cardiac care facilities to be evaluated and recognized for their CCC services. This program will help organizations:
- Comply with consensus-based standards
- Effectively integrate evidence-based clinical practice guidelines
- Create and organized approach to performance improvement and measurement
- Achieve and maintain the requirements for Advanced Disease-Specific Care certification
The certification program is completely voluntary and only offered to hospitals accredited by The Joint Commission. Qualified hospitals will also have to have a scope of care, treatment, and services that covers the management of:
- Ischemic heart disease
- Cardiac valve disease
- Advanced heart failure
- Cardiac arrest
- Cardiac rehabilitation
- Cardiovascular risk factor identification and cardiac disease prevention
For more info on the CCC certification program, you can go to the Comprehensive Cardiac Center Certification website or view the prepublication requirements at the Joint Commission website. You can also register for a free webinar on January 17, 2017.
The Joint Commission has published a list of the hospital National Patient Safety Goals (NPSG) that will go into effect on January 1, 2017. The new goals include:
- Improving patient identification
- Improving communication effectiveness amongst caregivers
- Improve safety of using medications
- Reducing the harm associated with anticoagulant therapy
- Medical reconciliation
The document also includes the rationales and Elements of Performance for all the goals.
Hospitals are making progress in healthcare quality, according to The Joint Commission’s recently published annual report, “America’s Hospitals: Improving Quality and Safety.” The report covers results from more than 3,300 accredited hospitals on measures covering:
- Children’s asthma
- Inpatient psychiatric services
- Venous thromboembolism care
- Stroke care
- Perinatal care
- Tobacco use treatment
- Substance use care
The report said that because of hospitals’ consistent and excellent quality performance over the past few years, the accreditor has been able to retire 20 accountability measures. Hospitals have been so diligent in using these measures that The Joint Commission no longer sees the need to survey for them. Meanwhile, 39 hospitals were declared Pioneers in Quality for their work in the evolution and utilization of electronic clinical quality measures.
“The results featured in The Joint Commission’s 2016 annual report are important because they show that accredited hospitals have continued to improve the quality of the care they provide, and the data that hospitals collect help them identify opportunities for further improvement,” said Mark R. Chassin, MD, FACP, MPP, MPH, Joint Commission president and CEO, in a press release. “The results also show it’s important to note that where a patient receives care makes a difference. Some hospitals perform better than others in treating particular conditions.”
As of today, CMS, The Joint Commission, and HFAP will be surveying hospitals to the 2012 Life Safety Code® (LSC). The LSC was adopted by CMS in June, with some of the big changes required under the final rule including:
- Facilities located in buildings taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
- Facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
- Greater flexibility for long-term care (LTC) facilities in what they can place in corridors. 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 ambulatory surgical centers, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
- Fire watches must be continuous, “constantly circulating” through impaired
- All side-hinged swinging fire doors must be tested annually.
- Once every five years, an internal inspection of sprinkler pipe is required.
- Fire hose valves must be inspected quarterly and tested annually/every three years, depending on size.
- 1-hour fire-rated barriers are required between non-sprinklered construction areas and occupied egress areas.
Visit the Federal Register to see the full list of changes
The Joint Commission Enterprise Content Library Index was updated this month with thousands of resources on hospital accreditation. The index includes articles, books, webpages, videos, webinars, podcasts, lessons, and FAQs on a myriad of topics. While much of the content is free, some of it is only available to paying Joint Commission customers.
On July 1, 2017, The Joint Commission’s prepublication requirements for the advanced certification for inpatient diabetes care (IDC) will go into effect. The update is part of the accreditor’s ongoing effort to keep its certification programs current. The IDC program has been updated using information from the 2016 American Diabetes Association’s Standards of Medical Care in Diabetes.
Some of the changes include:
- Educating healthcare staff and physicians on diabetes program policies, procedures, and patient management
- Identifying target glucose range for critically ill patients
- Following protocols regarding insulin therapy for persistent hyperglycemia and the treatment of patients with poor oral intake
- Scheduling follow-up appointments for patients who have had hyperglycemia during their hospitalization
- Including education in a newly diagnosed diabetes patient’s plan-of-care (see DSSE.3, EP 5a)
- Documenting insulin pumps for patients who use them in the hospital