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Joint Commission redesigns standards FAQs

After listening to feedback from clients and readers, the Joint Commission has updated its standards FAQ format. The accreditor uses its FAQs to clarify common patient safety and healthcare quality questions and the new design is intended to help users find important information quickly and easily.

The highest-rated FAQs will now be listed by chapter and there will only be one question and answer per FAQ. As part of the new changes, site users can now:

  • Filter search results by manual, chapter, or keyword.
  • See new and featured FAQs for two weeks.
  • Print out individual FAQs, or by chapter or manual.
  • Vote thumbs up or down on FAQs
  • Submit comments about individual FAQs

The Joint Commission encourages users to look at existing FAQs before sending in a question of their own, in case it’s already been answered.

Questions that CMS surveyors will now ask about CT services

CMS surveyors are no longer required to determine a facility’s compliance with Advanced Diagnostic Imaging (ADI) supplier requirements or hospital outpatient department requirements. Accrediting organizations like HFAP will still evaluate compliance on these requirements, though they won’t audit billings submitted by providers.

ADI suppliers and hospital outpatient areas with computed tomography (CT) services must meet safety requirements under NEMA Standard XR-29-2013. The ruling applies to hospitals and critical access hospitals and went into effect on January 1, 2016.

Although none of the standards have been changed, surveyors will now ask facilities:

  • Does the facility have outpatient areas providing CT services?
  • If yes, the surveyors will request the manufacturer’s certification of NEMA XR-29 compliance.

CMS has published a FAQ on this new policy and its impact on healthcare facilities. 

Joint Commission rebuts criticism of pain management standards

The Joint Commission released a defense of its pain management standards on April 18. The response came five days after the accreditor received a petition by the Physicians for Responsible Opioid Prescribing (PROP), which claimed the pain management standards were linked to excessive opioid prescriptions. The petition asked The Joint Commission to reexamine pain management standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and was signed by over 60 medical experts and nonprofit organizations.

“The Pain Management Standards foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families and communities,” according to PROP’s petition. It also said that opioid prescriptions rates and opioid addiction rates were linked, with more than 200,000 Americans dying due to prescription opioid overdoses since the pain management standards came into effect in 2001.

In a press release, The Joint Commission said that in the midst of the opioid epidemic, people are looking for someone to blame. The accreditor encouraged critics to look at the pain management standards along with their historical context to understand what they actually require facilities to do.

“The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain,” the press release said. “The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.”

The Joint Commission went on to rebut what it claims are five major misconceptions about its pain management standards, namely:

  1. The Joint Commission endorses pain as a vital sign
  2. The Joint Commission requires pain assessment for all patients.
  3. The Joint Commission requires that pain be treated until the pain scorereaches zero.
  4. The Joint Commission standards push doctors to prescribe opioids
  5. The Joint Commission pain standards caused a sharp rise in opioid prescriptions.

Read the Physicians for Responsible Opioid Prescribing letter to The Joint Commission here, along with the accreditor’s defense of its pain management standards.




Petitions ask Joint Commission and CMS to change pain management policies

More than 60 medical experts and nonprofit organizations sent petitions this week to The Joint Commission and CMS asking for changes in their respective pain management policies. The petitions say that making physicians routinely ask patients about their pain level encourages excessive prescriptions of opioids.

“Mandating routine pain assessments for all patients in all settings is unwarranted and can lead to overtreatment and overuse of opioid analgesics,” they wrote to The Joint Commission. “Healthcare professionals are capable of using their clinical judgment to determine when to assess patients for pain.”

Specifically, petitioners are asking for changes to The Joint Commission standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and for CMS to remove pain treatment questions from its Hospital Consumer Assessment of Healthcare Providers and Systems survey.

The petitions were headed by the Physicians for Responsible Opioid Prescribing and are co-signed by the heads of the National Center on Addiction and Substance Abuse, the National Women’s Health Network, the American Society of Addiction Medicine, and health commissioners from Vermont, Pennsylvania, Alaska, and Rhode Island.

Opponents try to delay five-star CMS rating system

This month, CMS plans to add a new “five-star” hospital rating system to its Hospital Compare website.  Under the system, hospitals would receive more stars for better compliance with a set of 62 measures that focus on mortality, safety, hospital readmissions, and the timeliness and effectiveness of care.

Complaints that CMS's new rating system is oversimplified

Complaints that CMS’s new “five star” rating system is oversimplified

The plan has come under fire, however, with many saying the rating system is too simplified to show true quality and puts too much emphasis on patient satisfaction. So far, 60 senators, two congressmen, and the American Hospital Association (AHA) have sent or published letters to criticizing the rating system.

“While the AHA supports the concept of providing an easier way for patients and communities to understand quality data, we are concerned that an overall hospital star rating oversimplifies the complexity of delivering high-quality care,” the organization wrote in a press release. “This is especially true because the measures in the [inpatient quality reporting program] and [outpatient quality reporting program] were not chosen with the intention of creating a single score reflecting all aspects of quality.”

Using the rating system to look at past data, CMS said that out of 3,647 hospitals, 142 would get one star, about 1,881 would get three stars, and 87 would get five. 

Update: CMS has announced it will delay the release of the five star rating system until July.

Winners of Eisenberg patient safety and quality award announced

The National Quality Forum (NQF) and The Joint Commission today announced the 2015 winners of the John M. Eisenberg Patient Safety and Quality Award. The award, named after the former head of the Agency for Healthcare Research and Quality, recognizes those who have made great achievements in the arena of patient safety and quality.

Individual Achievement Award—Pascale Carayon, PhD, Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, University of Wisconsin-Madison
Pascale Carayon was honored for her work advancing both human factors engineering concepts and methods, and the Systems Engineering Initiative for Patient Safety model. She also was recognized for mentoring new leaders in this arena at the national and international level.

Local Level Award—Mayo Clinic Hospital-Rochester, Minnesota
By engaging its staff, using a multidisciplinary team approach, identifying possible interventions, and developing an effective toolkit, the Mayo Clinic Hospital-Rochester was able to cut catheter-associated urinary tract infections rates by 70% in its facility.

National Level Award—Premier, Inc., Charlotte, North Carolina
In 2008 Premier developed the national quality improvement initiative QUEST® (Quality, Efficiency, Safety and Transparency) to help health systems reliably deliver an efficient, effective, and caring experience for every patient. In the eight years since its inception, the QUEST program has enabled easy data sharing between 350 volunteer health systems and saved 176,000 lives and more than $15 billion in healthcare costs.

Read more about the 2015 John M. Eisenberg Awards here. 

Worries about proposed CT certification changes

Since The Joint Commission released its prepublication standards for diagnostic imaging requirements, the accreditor says several customers have expressed concerns over the new minimum qualifications for computed tomography (CT) technologists. The concerns were about Note No. 1 of HR.01.02.05, Element of Performance 19, which would require all CT technologists have advanced-level CT certification.

The standards will go into effect on September 1 and The Joint Commission noted that all standards would be open to public comment before they’re finalized. The accreditor also said that it will do further research on the new CT certification requirements before the 2018 deadline.

Comments open for Joint Commission inpatient diabetes care certification

The Joint Commission plans to update its Advanced Certification for Inpatient Diabetes Care program and is asking the public for input. The move is part of an effort to enhance certification programs regarding disease-specific care. The current advanced certification for diabetes care is based on the American Diabetes Association’s 2014 “Standards of Medical Care in Diabetes.”

The comment period closes on May 17. Those interested in participating are asked to read the Advanced Certification for Inpatient Diabetes Care Proposed Requirements before responding via online survey, online form, or traditional mail.


Time’s running out to sign up for the Drug Diversion Webcast!

HCPro Webcast IconPreventing the theft of controlled substances at hospitals continues to be an tremendous issue even with increased security measures. Failed drug diversion programs in hospitals have led to record fines and in the midst of heightened scrutiny over drug security, hospitals must improve their processes to avoid litigation.

On Thursday, April 26 from 1–2:30 p.m. Eastern Time, join us for a live webinar with expert speaker Kimberly New, JD, a nurse, attorney, and consultant who specializes in helping hospitals prevent, detect, and respond to drug diversion.

During this program, New will discuss drug diversion by healthcare personnel and present specific steps facilities can take to minimize the risk of patient harm. She will discuss fundamental components of a diversion prevention, detection, and response program through an overview of the scope of the problem, including case studies. New will also review regulatory standards and best practices relating to controlled substance security and diversion responses. She will additionally provide tips on how to promote a culture in which all employees play a significant role in the deterrence effort.

At the conclusion of this program, participants will be able to:

  • Identify risk factors and signs of employee drug diversion
  • Fully comply with regulatory requirements of the DEA and other accrediting organizations
  • Train staff on how to report suspected abuse and who to report it to
  • Create a culture of accountability and develop an effective drug diversion prevention plan

Don’t miss this opportunity to hear practical advice and have complex regulations simplified in this program suitable for your whole organization. For more information or to order the webcast on demand, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.

Safety issues dominate Joint Commission list of most-cited standards of 2015  

The Joint Commission’s latest list of most-cited standards was dominated by safety issues. Following a multi-year trend, eight of the top 10 cited standards came from the Environment of Care, Life Safety or Infection Control chapters, with most of them merely swapping places within the top 10.

The standards are those most frequently found not compliant by surveyors. Percentages indicate the number of organizations that were given Requirements for Improvement for the standards.

The top 10 most-cited standards of 2015 are as follows, based on 1,447 hospital surveys:

  • EC.02.06.01 (maintenance of a safe environment), 62%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 59%
  • EC.02.05.01 (management of utility system risks), 58%
  • LS.02.01.20 (maintenance of egress integrity), 51%
  • LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 47%
  • LS.02.01.35 (fire extinguishment features provided and maintained), 46%
  • LS.02.01.10 (minimization of fire, smoke, and heat damage via building and fire protection features), 45%
  • PC.02.01.03 (lawful provision of care, services, and treatment), 40%
  • EC.02.02.01 (management of hazardous materials and waste risks), 39%

For more information, visit or see the April issue of Joint Commission Perspectives.