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Joint Commission releases Easy-to-Read 2012 NPSGs

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.

For more information, visit The Joint Commission Website.

Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

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.

Click here to download the Sentinel Event Alert and the full list of recommendations.

Joint Commission teams up with ASHI

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.

Hospitals failing on communication compliance

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.

Joint Commission updates sentinel event statistics

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:

  1. Wrong-site surgery: 956
  2. Suicide: 832
  3. Operative/post-operative complication: 775
  4. Delay in treatment: 611
  5. Medication error: 563
  6. Patient fall: 461
  7. Unintended retention of foreign body: 421
  8. Assault, rape, or homicide: 270
  9. Perinatal death or loss of function: 229
  10. 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.

Joint Commission releases new website

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.

Joint Commission’s Targeted Solutions Tool™ makes headway

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.

Click here to find out more information.

Joint Commission announces field review for med rec

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.

Joint Commission releases annual report, sees improvements to patient care quality

According to The Joint Commission’s annual report, the US has seen a steady improvement over the past seven years in patient care quality, the organization said in an official announcement this week.

The annual report, “Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2009,” looks at heart attacks, heart failures, pneumonia, and surgical conditions and provides evidence of improvements made.

“In addition to saving lives and improving health, improved quality reduces healthcare costs by eliminating preventable complications,” Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission, said in a prepared statement. “Quality improvement is an important aspect of the ongoing reform effort to make healthcare accessible to more Americans and ‘bend the curve’ on increasing costs.”

The Joint Commission, like CMS, has focused its energies on preventable conditions in recent years. Chassin related preventable conditions with improving the cost of healthcare nationwide.

“By eliminating the preventable complications that today drive up the cost of care, we would easily save billions of dollars lawmakers are struggling so hard to locate,” said Chassin.

The Joint Commission now tracks 31 measures in the annual report—five more were added for the calendar year 2008. More than 3,000 Joint Commission accredited hospitals contributed data to the report. This year’s report showed significant growth since the first report issued in 2002. For example:

  • The overall results of heart attack care have seen great improvement from 2002, rising from 86.9% in the 2002 report to 96.7% in 2008.
  • Overall heart failure care has improved massively since 2002, from 59.7% to 91.6% in 2008.
  • Pneumonia care results have also improved significantly, rising from 72.3% to 92.9%.

However, The Joint Commission reported that some areas finished 2008 with low rates of performance—specifically the percent of hospitals providing fibrinolytic therapy within 30 minutes of arrival, and providing antibiotics to intensive care pneumonia patients within 24 hours of arrival.

Additional results can be found online at, and a complete copy of the report can be downloaded at

Joint Commissions opens proposed version of MS.01.01.01 (formerly MS.1.20) for comment

The Joint Commission (TJC) has released a proposed version of MS.01.01.01 (formerly MS.1.20) and it is seeking comment on the proposed version between yesterday (Dec. 17) and January 28.  TJC convened a task force beginning in January 2008 after it received negative feedback from hospitals and physicians about the proposed standard. The task force consisted of professionals from the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals, and National Association Medical Staff Services.

The new MS.01.01.01 attempts to improve the current standard using the following principles (according to TJC):

  • A well-functioning relationship between the governing body, hospital leadership, and the medical staff is essential to the delivery of high quality, safe care.
  • Effective communication is the lubricant that keeps relationships functioning well; it therefore is important that structures and processes support it.
  • Well-functioning relationships also depend on all parties knowing what is expected of them, and being able to live up to those expectations

You can read the proposed standard by clicking here and you can access the survey about the proposed standard by clicking here.