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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.

Joint Commission joins White House to reduce antibiotic overuse

The Joint Commission announced Monday that it was joining the White House effort to reduce antibiotic overuse.

More than 150 healthcare organizations, food companies, and animal health organizations met at the White House Forum on Antibiotic Stewardship on Monday and pledged to incorporate changes over the next five years to slow the growth of antibiotic-resistant bacteria, preserve the effectiveness of antibiotics, and prevent the spread of resistant infections.

The CDC estimates at least two million illnesses and 23,000 deaths in the United States each year are caused by antibiotic-resistant bacteria and 20 to 50% of all antibiotics prescribed in acute care hospitals are either unnecessary or inappropriate.

For its part, The Joint Commission will begin reviewing current standards and work with accredited organizations to determine where new standards may be needed. The Joint Commission plans to simultaneously develop new standards as quickly as possible and provide new tools to help providers use antibiotics appropriately.

The Joint Commission currently has 16 standards and one National Patient Safety Goal related to antimicrobial stewardship.

Read the full release here.

The Joint Commission has revised accreditation policies concerning facilities that discontinue services

The Joint Commission has revised their policies regarding facilities that no longer provide services. The policies pertain to facilities that have closed as a result of disaster and facilities that no longer have patients.

A facility closed as a result of a disaster will retain accreditation for 30 days. After that time, if the facility reopens, The Joint Commission will conduct either an extension survey (up to 90 days) or a full site survey (after 90 days to six months).

If a facility has no patients, it will retain accreditation for 60 days. If it does not have patients for up to six months, it can retain accreditation but only if it applies for an extension survey.

In both cases, if services or patient care do not resume after a six month period, the facilities will lose accreditation. They will need to reapply for accreditation if they resume services.

The policies are effective immediately and can be read in full here.

Advisory panel determines endoscopes unsafe

A federal advisory panel deemed the endoscopes linked to the carbapenem-resistant Enterobacteriaceae (CRE) outbreak earlier this year in two Los Angeles area hospitals, but did not call for the discontinuation of their use, according to a recent report in the L.A. Times.

In spite of the risks associated with the endoscopes, the panel said they should remain available as there is currently not a suitable replacement.

The panel also took both the FDA and Olympus Corp., the manufacturer of the scopes, to task for not providing suitable safety measures to prevent the contamination.

Read the full article at the L.A. Times.

Physicians urged to take more active leadership role to improve quality and patient safety

Earlier this week, an article appeared in The Journal of the American Medical Association (JAMA) released an article calling on physicians to work together and take a more active leadership role in the hopes that the action will help improve quality and patient safety.

This request doesn’t mean that the authors think physicians don’t work together, rather they’re saying that our current health care system is complicated for a single physician to be able to achieve higher levels of quality and safety on their own.

Traditionally, physicians and healthcare systems are judged on their compliance by identifying areas that need improvement or correction altogether.  The article suggests that physicians, healthcare providers, and accrediting bodies should go one step further and develop programs that identify excellence within healthcare systems.

The authors issue three challenges to achieve this goal:

  • No harm for either patient or healthcare worker
  • Healthcare systems should employ methods and management that have been successful, such as Lean, Six Sigma
  • Accrediting and certifying bodies should develop programs identifying excellence in both healthcare workers and systems

Read the full article here.

What do you think about this proposal? Is this something that has already been implemented within your healthcare system or something you’re currently working towards? We would like to hear your thoughts. Please leave a note in the comments or email me directly at