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.
Hospitals are making progress in healthcare quality, according to The Joint Commission’s recently published annual report, “America’s Hospitals: Improving Quality and Safety.” The report covers results from more than 3,300 accredited hospitals on measures covering:
- Children’s asthma
- Inpatient psychiatric services
- Venous thromboembolism care
- Stroke care
- Perinatal care
- Tobacco use treatment
- Substance use care
The report said that because of hospitals’ consistent and excellent quality performance over the past few years, the accreditor has been able to retire 20 accountability measures. Hospitals have been so diligent in using these measures that The Joint Commission no longer sees the need to survey for them. Meanwhile, 39 hospitals were declared Pioneers in Quality for their work in the evolution and utilization of electronic clinical quality measures.
“The results featured in The Joint Commission’s 2016 annual report are important because they show that accredited hospitals have continued to improve the quality of the care they provide, and the data that hospitals collect help them identify opportunities for further improvement,” said Mark R. Chassin, MD, FACP, MPP, MPH, Joint Commission president and CEO, in a press release. “The results also show it’s important to note that where a patient receives care makes a difference. Some hospitals perform better than others in treating particular conditions.”
As of today, CMS, The Joint Commission, and HFAP will be surveying hospitals to the 2012 Life Safety Code® (LSC). The LSC was adopted by CMS in June, with some of the big changes required under the final rule including:
- Facilities located in buildings taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
- Facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
- Greater flexibility for long-term care (LTC) facilities in what they can place in corridors. LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
- Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
- For ambulatory surgical centers, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
- Fire watches must be continuous, “constantly circulating” through impaired
- All side-hinged swinging fire doors must be tested annually.
- Once every five years, an internal inspection of sprinkler pipe is required.
- Fire hose valves must be inspected quarterly and tested annually/every three years, depending on size.
- 1-hour fire-rated barriers are required between non-sprinklered construction areas and occupied egress areas.
Visit the Federal Register to see the full list of changes
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.
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
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.
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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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.
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.
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.