Starting March 6, The Joint Commission will send email notifications to organizations about upcoming surveys/review events. For each event, The Joint Commission will post the letter of introduction, the survey/review agenda, and surveyor/reviewer biographies and photos on organizations’ Joint Commission Connect extranet site. Afterwards, an email will be sent to the CEO and contact person for the accreditation team, letting them know this information is now up on the extranet to view. The main difference is how far in advance notifications are sent:
- Announced events—30 days in advance, plus a second email the day of the event
- Short-notice Events—7 business days in advance, plus a second email the day of event
- Unannounced events (including all Medicare certification events)—Same day as the event
Additional information about the different types of events can be found in “The Accreditation Process” (ACC) chapter or “The Joint Commission Certification Process” chapter.
The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.
The SEA comes with an infographic on the “11 Tenets of a Safety Culture.”
The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.
“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”
The Joint Commission has updated Sentinel Event Alert, Issue 45: Preventing Violence in the Health Care Setting with new resources:
- Workplace Violence Prevention Resources Portal
- Quick Safety Issue 4: Preparing for active shooter situations, July 2014
- Quick Safety Issue 5: Preventing violent and criminal events, August 2014
In related news, The American Society for Healthcare Risk Management (ASHRM) has released multiple toolkits on how to assess workplace violence risks in healthcare settings. The toolkits also provide guidance and checklists on what to do if violence breaks out and how to protect staff. The toolkits cover five main areas:
- Staff-to-staff violence/harassment
- Physician- or third-party professional-to-staff violence/harassment
- Patient-to-staff violence
- Visitor/family-to-staff violence
- Stranger/nonemployee-to-staff violence
Read Briefings on Accreditation and Quality for more on workplace violence protection.
The Joint Commission announced an update of its “observer” definition in its accreditation and certification manuals. The new definition is meant to clarify the roles of surveyors and reviewer management staff during on-site surveys and reviews.
The new definition can be found under Accreditation Participation Requirement APR.07.01.01 and Certification Participation Requirement (CPR) 10, and goes into effect on July 1, 2017.
According to the new definition, observers will only participate in the survey/review process if they notice a potential finding or observation that they think the surveyor, reviewer, or organization needs to know about. Field directors are not included in this new definition and are still allowed to take part in the survey process.
The Joint Commission has announced additional revisions to its Environment of Care (EC) and Life Safety (LS) chapters. The revisions are meant to bring the accreditor in closer alignment with the National Fire Protection Association’s 2012 Life Safety Code® (LSC). The LSC was adopted by CMS and The Joint Commission last year. The revisions go into effect July 1, 2017 and apply to hospitals, critical access hospitals, ambulatory healthcare centers, home care, and nursing care centers.
In the wake of a CMS ruling that will make antibiotic stewardship programs (ASP) mandatory, The Joint Commission recently announced that it will roll out a similar standard. Effective January 1, 2017, the new Medication Management standard 09.01.01 requires facilities to create an effective ASP. The standard applies to:
To help facilities with the new requirements, The Joint Commission has compiled a set of FAQs on antimicrobial stewardship, which can be viewed here.
Accredited organizations now receive a new SAFER Matrix Tool and a user guide, following their first survey with the new matrix. The SAFER Matrix was announced last July as a replacement for the old “Category A and C” method of evaluating safety issues. As of January 1, all accredited organizations now receive the SAFER matrix after their surveys.
The new tool can be used to filters out specific portions of the SAFER report, such as Requirements for Improvement, which then can be saved and sent to people within the facility. The guide shows users how to:
- Use filters
- Select specific survey or review events to view
- Switch between different accreditation programs
- Switch between accreditation and certification
The tool and guide can be found on Joint Commission Connect in the “Post-Survey” section of the “Survey Process” tab.
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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