RSSAll Entries in the "Joint Commission Changes" Category

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

The Joint Commission: Comments open on proposed suicide risk NPSG through May 7

Wishing you could weigh in on The Joint Commission’s expectations about suicide risk? You have your chance. Through May 7, The Joint Commission is accepting comment on proposed revisions to National Patient Safety Goal 15 on reducing the risk of patient self-harm.

The Joint Commission published the revisions on its Standards Field Reviews web page on March 26. The revisions, which will require hospitals to be more proactive in removing risks from the physical environment, include proposed changes to both the general Hospital and the Behavioral Health Care accreditations programs.

Under the Hospital Accreditation program, a revised Element of Performance (EP) 1 applies only to hospitals, whereas the rest of the now seven EPs — up from just three — will apply only to those patients in psychiatric hospitals or being treated for behavioral health problems in general hospitals, according to the field review information.

The other EPs for both programs outline expectations of conducting suicide assessment of patients, documenting a patient’s risk and the plan to deal with that patient’s suicidal ideation, the need for written policies and procedures and quality monitoring of the programs, among other things.

You can comment on the proposed revisions online or by mail. To read the full set of revisions, and for links and instructions on how to comment, go to the Field Reviews page, https://www.jointcommission.org/standards_information/field_reviews.aspx. — A.J. Plunkett (aplunkett@h3.group)

Joint Commission releases 2017 sentinel event stats

Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint Commission’s full list of reported sentinel events for 2017.

Every year, The Joint Commission complies a list of all the sentinel events that hospitals reported to them. Since the list only comes from self-reported data, it tends to underrepresent the real frequency of these problems. However, it’s useful in identifying trends, causes, and outcomes of adverse events. The top 10 sentinel events in 2017 were:

  1. Unintended retention of a foreign body
  2. Falls
  3. Wrong patient, wrong site, wrong procedure
  4. Suicide
  5. Delays in treatment
  6. Other unanticipated events
  7. Criminal events
  8. Medication errors
  9. Operative/postoperative complication
  10. Self-inflicted injury

The only new addition to the list since 2016 is “self-inflicted injuries,” which replaced “perinatal death/injury.” While a few hopped up or down one on the list, for the most part, there wasn’t much change.

Joint Commission changes for March 2018

Deleted: RI.01.01.01, EP 8

Effective immediately, The Joint Commission (TJC) has deleted element of performance (EP) 8 from Rights and Responsibilities of the Individual (RI) standard 01.01.01. While it’ll take some time to come out of the manual, surveyors can no longer survey for it. The EP said that a hospital must respect the patient’s right to pain management. The accreditor said that after reviewing its comprehensive pain assessment and management requirements, the EP was found to be irrelevant.

Revised: EC.02.03.05, EP 25

The point of this revision is to provide extra clarity on non-rated doors. TJC made the revision to make the Environment of Care (EC) chapter align with the Life Safety Code (LSC). This revision applies to ambulatory care, behavioral healthcare, critical access hospitals, home care, and hospitals. You can read the program-specific EPs here.

Revised: EC.02.05.01, EP 27

The purpose of this revision is to address environmental features of areas administering inhaled anesthetics. TJC made the revision to make the EC chapter align with the LSC. This revision applies to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices. You can read the program-specific EPs here.

Joint Commission plans to make new suicide prevention standards

This December, The Joint Commission (TJC) convened the fourth meeting of a suicide prevention expert panel. The accreditor announced in the March edition of Perspectives that the recommendations they came up with went beyond what’s in the standards. So they intend to convert some of them into new Elements of Performance in National Patient Safety Goal 15.01.01. When they are finished updating the NPSG, it will be sent out for national field review, just like it normally would.

The first and second panels were published in November and centered on inpatient psychiatric units, general acute inpatient settings, and emergency departments. The third panel discussed other behavioral healthcare settings and had its recommendations published in January.

Joint Commission updates LS, EC chapters

Three revisions to The Joint Commission’s Life Safety and Environment of Care chapters will go into effect on March 11. The respective changes add more clarity to requirements regarding non-rated doors, environmental features of anesthetics areas, corridor door latch. However, not all changes apply to all the same programs, so you should check to see which ones impact you. The changes are intended to improve alignment with CMS regulations. You can find the prepublication standards below:

•    Ambulatory Health Care
•    Behavioral Health Care
•    Critical Access Hospital
•    Hospital
•    Nursing Care Center
•    Office-Based Surgery
•    Home Care

Joint Commission to roll out new maternal care and infectious disease requirements

On July 1, 2018, The Joint Commission will implement three new elements of performance (EP.) The EPs are intended to reduce the risk of diseases like HIV and syphilis being passed from mother to child during birth. The accreditor made the announcement in the latest R3 Report, with the aim of protecting both the mother and child from harm.

“The requirements will help improve maternal and neonatal health in Joint Commission accredited hospitals and critical access hospitals across the country,” Kathy Clark, MSN, RN, Joint Commission associate project director specialist, Division of Health Care Quality Evaluation, said in a press release. “If left undiagnosed or untreated, infectious diseases can be extremely dangerous and even life-threatening, so it is critical that testing and treatment for both the woman and baby is completed according to clinical practice guidelines.”

The EPs require providers to test pregnant women for certain diseases that could be transmitted to the child during birth: HIV, hepatitis B, group B streptococcus and syphilis. The results are then documented in the patient’s medical record for providers to act upon.

CMS and Joint Commission change hospital eligibility requirements

Both organizations have changed their expectations on the defintion of a hospital. CMS’s new S&C Memo 17-44-Hospitals says that surveyors will use average daily census (ADC) and average length of stay (ALOS) data to determine if the hospital is primarily engaged in providing services to inpatients, and “a hospital must have inpatients at the time of survey in order for surveyors to directly observe the actual provision of care and services to patients, and the effects of that care” to determine if the facility is meeting the Conditions of Participation (CoP) in Medicare.

In addition, both CMS and The Joint Commission say that hospitals will need at least two active inpatients on site for an accreditation survey to be done. This change is effective immediately.

2018 version of “Patient Safety Systems” Chapter available

The Joint Commission has released the most recent versions of it’s PS Chapter for hospitals, nursing care centers, critical access hospitals, behavioral healthcare centers, laboratories, and more.

Joint Commission announces four survey focus areas

Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation Program (HFAP), and National Committee for Quality Assurance (NCQA) took the stage at the 2017 NAMSS Educational Conference & Exhibition to share what they have learned from this year’s accreditation surveys and to tell audience members about relevant standards changes

The Joint Commission announced four areas of focus:

1.    The SAFER Matrix: Implemented in January 2017, the SAFER Matrix has nine boxes that measure the likelihood to harm a patient on one axis and scope of occurrence (limited, pattern, widespread) on the other.

2.    Antimicrobial stewardship: The CDC reported that 20% to 50% of antibiotics were prescribed unnecessarily or inappropriately annually. Medical staffs must reduce their antimicrobial use and have a medical staff process to demonstrate an effective use of antibiotics or antimicrobials in their organizations.

3.    Ligature risks for behavioral healthcare units: Due to the increasing rise of inpatient suicides (1,200 to 1,500 each year), 70% of which are by hanging, ligature risks are no longer acceptable in areas specified for the treatment of behavioral healthcare patients with suicide risk.

4.    Culture of safety:Leaders must ensure a culture of safety and identify areas to improve culture of safety. Staff must be comfortable and able to report issues of safety to leadership. This is already a culture of safety standard in the Leadership chapter and the accreditor will unveil a related standard in the Medical Staff chapter in 2018.

According to Louis Goolsby, MD, FACOG, FACHE, the most common citations from the Medical Staff chapter still come from MS.01.01.01, specifically EP3 (specific requirements and associated details are included in the medical staff bylaws) and EP5 (the medical staff complies with the medical staff bylaws). Another common citation is MS.03.01.01 (practitioners only practice within their scope of privileges).

Editor’s note: 
The following article was originally published on the Credentialing Resource Center, October 24, 2017.