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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.

Positive results in Joint Commission’s annual report

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
  • Immunization
  • 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.”

Today the Joint Commission and HFAP start surveying to the 2012 Life Safety Code®

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

Click here to learn more about the updated standards and policies The Joint Commission and HFAP have made.


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.