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Joint Commission seeks electronic quality measure success stories

As part of its new Pioneers in Quality portal, The Joint Commission is asking hospitals to give their stories on the electronic clinical quality measures (eCQM). Hospitals are asked to share the problems they overcame and the successes they had while implementing the eCQM and transmitting eCQM data.

Anyone interested in participating is encouraged to use The Joint Commission’s Core Measure Solution Exchange to submit their stories. Click here to get more information on the Core Measure Solution Exchange and to sign up.

How many will adopt the new CDC opioid guidelines?

After several months of debate, the Centers for Disease Control and Prevention (CDC) have finally published its Guideline for Prescribing Opioids for Chronic Pain on March 15. The agency’s recommendations are aimed towards primary care physicians, since family physicians alone account for 15.3 million opioid prescriptions annually. Currently, 44 Americans overdose and die each day after abusing prescription painkillers and the CDC hopes its recommendations can noticeably reduce the use of opioids in pain care.

However, the Guideline for Prescribing Opioids for Chronic Pain are voluntary and some question how many in the healthcare sector will adopt them.  Several healthcare professionals and patient groups protested the guidelines after their first draft was unveiled for comment, claiming they were too restrictive on pain care. The outcry was enough that the CDC had to organize an extra review process for the guidelines back in January.

Now it’s up to healthcare facilities, including those who protested the guidelines, to decide if they will follow the CDC’s recommendations and to what extent.  The guidelines consist of 12 recommendations total, including:

  1. Using non-pharmacologic and non-opioid therapy for chronic pain whenever possible.
  2. Establishing treatment goals before starting long-term opioid therapy. Physicians should only continue to prescribe opioids if there is “clinically meaningful improvement” that outweighs safety risks.
  3. Discussing the risks and benefits of opioids with patients before prescribing them.
  4. Using short-acting opioids instead of extended-release, long-acting drugs to treat chronic pain.
  5. Prescribing opioids in their lowest effective dosage.
  6. Using short-term opioid treatments instead of long-term treatments for acute pain care. Usually three days’ worth of opioids will be enough, though up to seven days is sometimes permissible.
  7. Patients should be evaluated within one to four weeks of beginning opioid therapy for chronic pain and be reevaluated at once every three months afterwards to assess the pros and cons of continued treatment.

Click here to read The Joint Commission’s “Facts about Pain Management” page and view its Sentinel Event Alert 49, dealing with safe use of opioids in hospitals.


Updated disease-specific care review process guide released

The Joint Commission has released an updated version of its Organization Review Process Guide for Disease Specific Care Certification. The update includes information on the new Advanced Certification for Total Hip and Total Knee Replacement program.

The updated information went into effect on March 1.


Joint Commission releases 2015 sentinel event stats

On March 2, The Joint Commission released its sentinel event statistics from 2015. Of the 936 sentinel events reported last year, the most common were unintended retention of a foreign body (116), wrong-site/wrong-side/wrong procedure surgery (111), falls (95), and suicides (95).

The most common root causes of sentinel events last year were human factors (e.g., staff supervision issues), leadership (e.g., organizational planning), and communication with either administration or patients.

The Joint Commission has been compiling sentinel event data since 2004. Of the 9,884 patient cases reported, more than 55% of patients died due to a sentinel event and 8.7% suffered from permanent loss of function.

To see the full chart, click here. 

New opioid treatment requirements added to Joint Commission’s behavioral standards

The Joint Commission has added new requirements for opioid treatment programs accredited under its Behavioral Health Care Program.

The requirements go into effect on July 1, 2016 and are aligned with the Substance Abuse and Mental Health Services Administration’s Federal Guidelines for Opioid Treatment Programs.

The changes are in the Care, Treatment, and Services, Emergency Management, Human Resources Management, Leadership, Medication Management, and Rights and Responsibilities of the Individual chapters in the Comprehensive Accreditation Manual for Behavioral Health Care Organizations.

Click here to read the prepublication standards.

Joint Commission releases Sentinel Event Alert on suicide screening

A new Sentinel Event Alert from The Joint Commission focuses on how primary, emergency, and behavioral healthcare facilities and staff can better identify and treat suicidal patients.

Suicides are the 10th leading cause of death in America, resulting in 41,149 deaths in 2013.  The Joint Commission’s Sentinel Event Database has logged 1,089 reports of patient suicides between 2010-2014, with the most common cause being failure to assess a patient as suicidal.

Sentinel Event Alert 56 advises physicians how to conduct screening, risk assessment, safety, treatment, discharge, and follow-up care recommendations for at-risk individuals.

Click here for the Joint Commission’s infographic on detecting and treating suicide ideation. 

And click here for Joint Commission requirements involving suicide.

Sure-footed surveyors: Lean Six Sigma tools reduce Joint Commission falls

A new report in the International Journal of Six Sigma and Competitive Advantage has found that by following the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology, there has been a significant decrease in falls and tripping among Joint Commission field staff. The report finds that since adopting DMAIC, Joint Commission field staff have reduced their falls per month by 64.8% for four years.

Some of the methods The Joint Commission used to reduce falls were seasonal emails about appropriate footwear for changing weather and a pamphlet on the risks associated with walking surface conditions, carrying work-related or personal items, and types of luggage.


Joint Commission posts prepublication standards online

The Joint Commission just posted prepublication standards for disease-specific care critical access hospitals, nursing care centers, laboratories and point-of-care testing. The standards have not been officially published in print or added to the Joint Commission’s collection of e-manuals.

Proposed requirements for Behavioral Health Home certification product

The Joint Commission is developing an optional Behavior Health Home Care certification product focused on integration and coordination of behavioral and physical health care with the goal of improving individual’s outcomes, and is seeking input from the field on proposed requirements.

Organizations seeking this certification must be accredited under the Behavioral Health Care program.

To read more about this standard field review, visit The Joint Commission website.


JCR launches JCCAP certification program

Last week while we were in Orlando preparing for the AHAP conference, Joint Commission Resources (JCR) announced the release of the Joint Commission Certified Accreditation Professional (JCCAP) program, a professional certification program designed specifically for Joint Commission accreditation professionals.

To get the JCCAP credential, accreditation professionals must pass an exam on topics surrounding The Joint Commission accreditation standards and processes. The exam focuses on the standards areas of Medical Staff, Environment of Care, and Leadership, as well as patient safety, ongoing performance and organizational analysis, and requirements of the Centers for Medicare & Medicaid Services (CMS) related to hospitals.

Eligibility for the JCCAP includes:

  • Baccalaureate degree or higher and current employment at a hospital or healthcare organization/system for a minimum of two years; or an associate’s degree or RN and five years experience in an accreditation preparation, assistance, coordination, management or maintenance role
  • Current job description of the applicant
  • Letter confirming current position and responsibilities from an organization executive
  • Maintaining certification requires 30 JCR continuing education credits during the three-year certification period, or successfully completing the recertification exam and 10 continuing education credits.

Application opens on September 5, 2012, and the exam will be offered quarterly, starting in January 2013. Visit Joint Commission Resources for a more information.

Certification programs are a great way to distinguish and recognize the accreditation profession and achieve individual professional growth. Did you know that the Certified Specialist in Healthcare Accreditation (CSHA) certification program covers all accrediting bodies and accepts a wide range of continuing education credits (JCR, HCPro, IHI, and more)? Click here to read more about the CSHA certification program.