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Editor’s Choice: Proper GI Scope Disinfection: How to Avoid Becoming a Statistic

Thursday, July 14, 2015

1:00pm-2:30pm EST

Presented by Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC

Patient deaths related to improperly reprocessed endoscopes have hit the national media. If your endoscopes and other diagnostic GI scopes aren’t properly cleaned and disinfected, they can expose future patients to antibiotic-resistant diseases such as carbapenem-resistant Enterobacteriaceae or (CRE) that can kill up to 50% of infected patients.  Don’t let your facility be the next statistic. Join infection control experts Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC, as they discus everything your organization needs to know to ensure proper GI scope disinfection and protect the lives of your patients.  This 90-minute webcast covers the critical steps of high-level disinfection that must be met each and every day. Don’t miss out on this opportunity to ensure your organization complies with requirements set by The Joint Commission and CMS.

Learn more and register for the webcast here.

We need your feedback on Briefings on The Joint Commission!

Are you a subscriber to Briefings on the Joint Commission? We would like your feedback on our monthly newsletter. Is there something you wish had more coverage? Less coverage? Something you would like us to do differently? Now is your chance to let us know!

I am looking for subscribers to meet with me to discuss some potential changes to Briefings on the Joint Commission. I would love to have a 10-15 minute phone call with you getting your thoughts on BOJ.

As a thank-you for your time, I will be happy to send you a copy of the latest edition of j-mail: Tools for Ongoing Joint Commission Survey Prep, a $155 value.

Send me an email at if you would like to take advantage of this offer.

AHRQ teeters on brink of extinction

Editor’s note: My colleague Tinker Ready with HealthLeaders Media, recently wrote an article about the possible dissolution of the AHRQ, approved by a congressional subcommittee last week, that I thought you might find interesting.

The Agency for Healthcare Quality Research says its mission “is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable.” But that mission may soon be over.

This column was slated to be titled “Ten things you don’t know about the AHRQ.” But, in reality, there are probably a lot more than ten things you don’t about the agency, including its name: The Agency for Healthcare Quality Research.

The AHRQ says its mission “is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable.” But that mission may soon be over.

A congressional subcommittee wrote the agency out of the 2016 Health and Human Services budget last week, and the full committee approved the plan on Wednesday. Despite lobbying efforts by health service researchers and their supporter, the future of AHRQ, pronounced “ARK” by those in the know, is uncertain.

So why should people who run hospitals care? A search of a HHS grants database turns up 603 active projects funded by the AHRQ. A lot of them look as if they would be useful to providers looking for tools to improve quality in the pay-for-value age.

Read the full article at

Updated perinatal care performance measures

The Joint Commission extended the mandatory reporting of the Perinatal Care (PC) performance measure set from 1,100 births per year to a minimum of 300 births per year. All accredited hospitals will need to report on all five measures in the PC measure set. This change applies to over 80% of accredited hospitals with labor and delivery units.

While these changes are effective January 1, 2016, hospitals that meet these new requirements are encouraged to begin using the new PC set as soon as possible.

Read the full update here.

Joint Commission seeks comments on proposed requirements

The Joint Commission is looking for feedback on several updated requirements, including a new, advanced certification program that addresses integration and coordination of patient care in a Comprehensive Cardiac Center. The program is not required and is only applicable to accredited facilities.

To read more about the program and leave your comments by July 16, 2015, click here.

Additionally, The Joint Commission is looking for comments on new and revised diagnostic imaging requirements. The updates include changing the minimum qualifications for technologists who perform CT exams.

To read more about the updates as well as how to leave comments by June 25, 2015, click here.

Accreditation Q & A

From time to time, we’ll post a question and answer that will help you as you prepare for your next survey.


Each hospital is required to have a formal process to evaluate whether a drug should be added to the formulary. This process should include specific criteria for evaluating each drug. What criteria are utilized in your institution?


Each institution may have a slightly different list. Make sure you have criteria and that it includes at least the following criteria that The Joint Commission recommends be included:

  • Indications for use
  • Effectiveness
  • Interactions with other drugs
  • Potential for error in its use or for abuse of the medication
  • Known adverse drug reactions
  • Any sentinel event information or sentinel event alert information
  • Cost

Do you have a question you would like us to answer? Send an email to me at and we’ll do our best to answer your question.

Editor’s Note: The above question and answer are from j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep.

Sound the alarm…no, wait, silence the alarm…no, wait–what?!?

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an article about alarms and I wanted to share it with you as I know it is an area many are concerned about.

Now that we have almost reached the summer solstice, I guess it’s time to start thinking/talking about 2016 and what it might bring from an accreditation perspective—it will be here almost before we know it (time flies when you’re having fun—and we’re having too much fun, are we not?)

One of the developments that I am watching with a bit of interest (if only because it is not at all clear how this is going to be administered in the field) is the next step in the clinical alarm National Patient Safety Goal (for those of you keeping score, that NPSG.06.01.01 if you need to find it in your accreditation manual—and I’m sure you’re sleeping with that under your pillow…). Presumably at this point, you have covered the elements that are in full surveyability—establishment of alarm system safety as an organizational priority (pretty simple, that one) and identification of the most important alarm signals based on:

  • input from medical staff and clinical departments (Have you got documentation for that?)
  • risk to patients if the alarm signal is not attended or if it malfunctions
  • whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
  • potential for patient harm based on internal incident history
  • published best practices and guidelines (Can you say AAMI and ECRI? Sure you can!)

Everyone out there in radioland should have this much of the package in place. Now, it’s time to do something with that process.

Continue reading this post at Mac’s Safety Space.

Joint Commission issues changes to breast milk measures

The Joint Commission is issuing changes that affect perinatal care (PC) measures PC-05a and PC-05. Both measures relate to breastfeeding.

The Joint Commission is retiring the measure PC-05a, which covers breastfeeding exclusively per the mother’s initial plan. Obtaining accurate information on the mother’s wish to not nurse exclusively has been difficult to capture. Retiring this measure will allow hospitals to improving rates for PC-05, breastfeeding exclusively.

PC-05 has been revised to now include maternal medical conditions, similar to PC-02 related to caesarean birth with no excluded conditions. PC-05 will still be an accountability measure, but, The Joint Commission understands that compliance for this measure will fall below 100% as some mothers do not want to or are unable to breastfeed exclusively.

These changes go into effect October 1.

Read the Joint Commission article here for more information.


Joint Commission details how to comply with fire safety requirements

The Joint Commission last week, posted tips for complying with elements of performance (EP) 11-13 of EC.02.03.05, which require hospitals to properly maintain fire extinguishing equipment. The standards ranked sixth on the accreditor’s list of top-cited standards in 2014 with 48% of hospitals cited.

The Joint Commission article includes step-by-step instruction on how to comply with the three Eps. EP 11 requires testing of fire pumps in automatic sprinklers every 12 months, EP 12 calls for water-flow tests to be conducted every five years for standpipe systems, and EP 13 days that organizations must inspect any fire-extinguishing systems every six months.

Read the Joint Commission post for more information.

Editor’s Choice: The Joint Commission’s New Patient Safety Chapter: How to Comply and Promote a Culture of Safety

Wednesday, June 10, 2015

1:00pm-2:30pm EST

Presented by Sena Blickenstaff, BSN, MBA

Prepare for the new Patient Safety Systems chapter and redesigned Sentinel Events chapters with the practical advice and guidance presented in this 90-minute webcast. Accreditation and patient safety professionals will learn how The Joint Commission’s renewed focus on patient safety and quality will affect their organizations. The chapters went into effect on January 1, 2015 and surveyors will expect hospital leadership and staff to be able to explain how their facility is committed to patient safety and quality improvement.

Register for the webcast here.