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Joint Commission clarifies “observer” standards

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.

Joint Commission makes more revisions to EC, LS standards

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.

FAQs on Joint Commission antimicrobial stewardship standard

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:

Syringe

To help facilities with the new requirements, The Joint Commission has compiled a set of FAQs on antimicrobial stewardship, which can be viewed here.

SAFER Matrix goes into effect, new tool available

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.

Reminder: SAFER Matrix now in effect

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 Leadership standard now aligns with CMS

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 lsmith@jointcommission.org.

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Joint Commission targets CAUTIs with updated NPSG

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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Joint Commission publishes 2017 Survey Activity Guide

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.

New Comprehensive Cardiac Center certification offered in 2017 

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
  • Arrhythmias
  • 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.

Joint Commission lists 2017 National Patient Safety Goals

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.