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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.

C.diff infections linked to medical clinics

A February 25 report from the CDC suggests that the prevalence of Clostridium difficile, or C. diff, a bacterial infection of the gastrointestinal system primarily found in hospitals, is much higher than once thought, affecting up to half a million people annually.

Perhaps even more disturbing is the study’s revelation that up to 150,000 people who had not previously been in the hospital came down with C. diff in 2011. Of those, about 80% had visited a doctor’s or dentist’s office in the 12 weeks before their diagnosis. CDC officials say the revelation is so concerning that they’re starting a series of “case control studies” to try to assess nationally whether people are getting C. diff in medical offices.

If you’re a safety professional or someone in charge of infection control at a medical clinic, by now you’re asking yourself what you can do to help reduce the risk of an outbreak of C. diff. Our safety experts have shared a list of things you can do to prepare.

Read the full article on the OSHA Healthcare Advisor site.

Briefings on The Joint Commission feedback survey

I know, I know, we just had a survey, but we really like surveys here. They give us an opportunity to find out what’s happening in the accreditation field and then share it with the rest of you.

They also give us a chance to ask you, our readers, what you like or dislike (gasp) about some of our products. In this case, we would like your thoughts on the Briefings on The Joint Commission newsletter.

The survey is quick and should only take about five minutes of your time.

Click on the link to take the survey.

Opinions are like…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an excellent article about the changing accreditation regulations and I wanted to share it with you.

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectation (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance.
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during The Joint Commission surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

Continue reading the article at Mac’s Safety Space.

Editor’s Choice: Live accreditation training with Jean Clark

When: June 1-3, 2015

Where: Boston area

Are you in the New England Area? Jean Clark, RHIA, CSHA, is leading a two-and-a-half day boot camp in June and if you haven’t attended one of our boot camps yet, you won’t want to miss this experience.

The boot camp provides survey coordinators and accreditation professionals with best practices for survey prep, training, and overall management, focusing on CMS and Joint Commission requirements.

At the end of the boot camp, you’ll have learned:

  • Where to find resources to assist your survey prep and accreditation knowledge
  • How to interpret accreditation standards and regulations and measure your organization’s compliance
  • How to identify organizational weaknesses so you can fix them before accreditors arrive and therefore improve your survey results

I will be attending this boot camp and I’m looking forward to Jean’s practical and insightful teaching as well as meeting some of you!

Please feel free to send me an email if you would like to connect during the boot camp.

Sign up for the boot camp 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

The Joint Commission updates several standards for hospitals

In order to align with CMS’ Conditions of Participation, The Joint Commission has updated eight standards for hospitals and one standard for critical access hospitals. The majority of the updates apply to hospitals with swing beds.

The following standards have been updated:

  • Standard MS.01.01.01
  • Standard PC.02.02.01
  • Standard PC.04.01.03
  • Standard PC.04.01.07
  • Standard RC.02.04.01
  • Standard RI.01.01.01
  • Standard RI.01.06.03
  • Standard RI.01.07.07
  • Standard MS.01.01.01

The updates go into effect July 1, 2015.