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Joint Commission updates Enterprise Content Library Index

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.

Joint Commission revises advanced certification requirements for inpatient diabetes care

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

Joint Commission seeks input on infection prevention NPSG

Between October 4 and November 15, hospitals and critical access hospitals (CAH) are being asked to give input on newly proposed requirements for the healthcare-associated infections (HAI) National Patient Safety Goal (NPSG). The proposed requirements now cover central line-associated bloodstream infections (CLABSI) and surgical site infections (SSI). The Joint Commission is asking that hospitals and CAHs read the proposed requirements then provide feedback via online survey, online form, or traditional mail.


Joint Commission unveils 2017 requirements for ORYX reporting

The Joint Commission released its 2017 reporting requirements for ORYX, a performance measurement and improvement initiative for which facilities are required to collect and submit data on six sets of core measures. As of January 1, 2017, hospitals and critical access hospitals (CAH) will be expected to:

•    Report on five required chart-abstracted measures.
•    Report on six of the 13 available electronic clinical quality measures. Facilities will get to choose which six they want to report on.
•    Report on all of the chart-abstracted perinatal care measures if the facility has at least 300 live births annually.
•    Hospitals with an average daily census of 10 patients or fewer and CAHs will report on a choice of six available measures.

Meanwhile, freestanding children’s hospitals, long-term acute care hospitals, and inpatient rehabilitation facilities won’t have to follow these requirements. However, freestanding psychiatric hospitals will have to document and report back on four required hospital-based inpatient psychiatric measures.

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Joint Commission announces new EP deletions

On January 1, 2017, The Joint Commission will delete 51 Elements of Performance (EP) from its hospital accreditation standards. The deletion is part of an ongoing effort to remove similar, duplicative, or unneeded EPs from the accreditation process.

Click here to see the deleted EPs. 

Joint Commission revises ‘notification of organization changes’

The Joint Commission has updated its “notification of organization changes” policy for accredited facilities.

Previously, organizations had 30 days to notify The Joint Commission that a significant change had been made. The updated policy now requires organizations alert the accreditor the moment the changes are confirmed (i.e., once leadership has decided to move ahead with a change and has created a timeline for completion).

The updated regulations go into effect on October 1. The changes apply to all Joint Commission-accredited programs. Click here to read the revised policy. 

2017 reporting requirements for ORYX

The Joint Commission released it’s 2017 reporting requirements for ORYX. Changes in include deletion of the measure set reporting requirement.

ORYX is a performance measurement and improvement initiative, for which facilities are  required to collect and submit data on six sets of core measures.

Click here to see the full document. 

Avoid fire drill citations with new matrix

Several months ago, Virginia Mason Medical Center (VMMC) in Seattle was denied full Joint Commission accreditation, in part due to its handling of fire drills. The facility received its citation for failing to vary the times and days when drills were conducted.

Now, The Joint Commission has released a new fire drill matrix for facilities to forestall confusion on survey day. The matrix tracks the day, date, time, and shifts when fire drills are conducted to ensure that they were conducted according to Joint Commission and CMS regulations. While they’ll still examine fire drill forms, surveyors will also give a copy of the matrix to hospitals when they arrive; although you can download an Excel copy of it here. 

The accreditor requires facilities to hold fire drills at random times to ensure that staff are ready when an actual emergency happens. Jim Kendig, The Joint Commission’s field director for surveyor management and development, said in a press release that hospitals are often unaware that they are conducting fire drills at similar times and days. The matrix helps them notice any patterns in scheduling that otherwise might escape notice.

“It becomes apparent,” Kendig said. “Hospitals can use this ahead of time, see patterns, and self-correct.”

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Joint Commission releases analysis of eCQM data

The analysis found that missing data was the biggest cause of discrepancies. Some examples of missing data are:

•    Missing data on medication route
•    Use of wrong template ID
•    Diagnosis Active is missing, which puts the case in denominator

The Joint Commission also unveiled its Core Measure Solution Exchange®,which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet.

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Three new Joint Commission questions for building tours

During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1. What type of fire-stopping is used in the facility?
2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
3. Which materials are used (e.g., glutaraldehyde, ortho-phthalaldehyde, peracetic acid) for high-level disinfection or sterilization?

“They’re pretty straight forward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”