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We are celebrating Patient Safety Week!

This week is organized by the National Patient Safety Foundation (NPSF) to increase awareness on patient safety issues. The goal is to educate and engage healthcare professionals and the general public through web events, social media, educational programs, and materials.
Patient Safety Week 2017
In an effort to expand your staff’s participation and excitement for the special week, I would like to make you aware of an important article from PSQH and our sister publication Patient Safety Monitor Journal – Plan Staff Activities for National Patient Safety Awareness Week. This article highlights some of the special events to take advantage of, as well as ways to engage your staff for the event!

“It is a very popular event, because it is a chance for learning, improving, but also having fun,” says Sara Valentin, NPSF assistant vice president of event management and strategy. Read the article now and get ready to motivate your team!

I hope that you find the article helpful. Happy Patient Safety Week!

Sincerely,

Michelle L. Clarke,  PSQH Editor

Brian T. Ward, Patient Safety Monitor Journal Associate Editor

AHRQ: 1% of ED visits are for suicide ideation

The Agency of Healthcare Research and Quality (AHRQ) reports that the number of patients sent to the emergency department (ED) for suicidal thoughts has doubled. As of 2013, 1% of all ED visits are related to suicide ideation, which is up from 0.4% in 2006. This is an average increase of 12% annually.AHRQ logo

Of the 1% brought in for suicidal thoughts, more than 71% were admitted to the same hospital or transferred to another facility. ED patients with suicidal thoughts often had these behavioral health conditions:

  • Mood disorders
  • Substance-related disorders
  • Alcohol-related disorders
  • Anxiety disorders
  • Schizophrenia and other psychotic disorders

Visit HealthLeaders Media for more details. And read more on our previous coverage of suicide ideation and prevention.

Measures of Success still apply for sentinel events

Due to the adoption of the SAFER Matrix, The Joint Commission announced that it was discontinuing its post-survey measures of success (MOS) process. However, the accreditor clarified that the sentinel event MOS process is still in effect and unchanged.

Changes to post-survey categories

The Joint Commission has eliminated its post-survey category of “Contingent Accreditation.” Now organizations can only receive one of four decisions: Accredited, Accredited with Follow-up Survey, Preliminary Denial of Accreditation, or Denial of Accreditation.

Accreditation— Given to a facility that’s compliant with all applicable standards or has successfully addressed all Requirements for Improvement (RFI). Once the Evidence of Standards Compliance (ESC) is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.

Accreditation with follow-up survey— Given to a facility that isn’t in compliance with specific standards that require a follow-up survey within 30 days to six months. Also requires that problem areas listed in an ESC submission are corrected. Once the ESC is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.

Preliminary denial of accreditation— Given to a facility when there’s evidence of one or more of the following:
•    An immediate threat to health or safety to patients or the public
•    Falsified documents or misrepresented information was given to surveyors
•    The facility is missing a required license or certification
•    The facility is significantly out of compliance with Joint Commission standards

Additional rules for receiving a “Preliminary Denial of Accreditation” ranking have been listed in the “important updates” section of Joint Commission Connect and are as follows:
•    Failing to fix all Requirements for Improvement (RFI) after two opportunities to submit ESCs have passed
•    Failing a second Medicare Deficiency Survey for not meeting a Condition of Participation or a Condition Level Deficiency
•    Evidence reveals patients have been put in jeopardy due to potential fraud or abuse committed by the organization

A Preliminary Denial of Accreditation (PDA 02) decision is made; organizations are now expected to submit a Plan of Correction (POC) within 10 business days of the final report’s posting. After which, there’ll be a survey within two months to validate the implementation of the POC.  This will be done in lieu of submitting ESC within 60 days.

For PDAs, facilities can appeal The Joint Commission to review this decision.

Denial of accreditation - A facility is completely denied accreditation. This happens when a facility:
•    Doesn’t to pay its survey or annual fees
•    Refuses to let The Joint Commission conduct a survey
•    Fails to address the conditions of their Accreditation with Follow-up Survey status
•    Fails to submit an ESC

At this point, there are no more appeals or reviews that a facility can use to stay accredited.

Finally, The Joint Commission’s governance structure has changed. Now, decisions on accreditation matters will be made by an executive team rather than an Accreditation Committee. The executive team is now in charge of making accreditation decisions, considering survey reports, follow-up activities, staff recommendations, and any unusual problems raised by the organization seeking accreditation.
Check out Briefings on Accreditation and Quality to learn more about the importance of avoiding denial of accreditation.

Joint Commission: Facilities now to receive email notifications about upcoming surveys/reviews

Starting March 6, The Joint Commission will send email notifications to organizations about upcoming surveys/review events. For each event, The Joint Commission will post the letter of introduction, the survey/review agenda, and surveyor/reviewer biographies and photos on organizations’ Joint Commission Connect extranet site. Afterwards, an email will be sent to the CEO and contact person for the accreditation team, letting them know this information is now up on the extranet to view. The main difference is how far in advance notifications are sent:

  • Announced events—30 days in advance, plus a second email the day of the event
  • Short-notice Events—7 business days in advance, plus a second email the day of event
  • Unannounced events (including all Medicare certification events)—Same day as the event

Additional information about the different types of events can be found in “The Accreditation Process” (ACC) chapter or “The Joint Commission Certification Process” chapter.

Joint Commission surveyors to focus on suicide, self-harm, and ligature

The Joint Commission announced that as of March 1, its surveyors will place special focus on suicide, self-harm, and ligature observations in psychiatric hospitals and units. Now, surveyors will document any and all observations of ligature or self-harm risks in the environment during the survey. Each observation will be documented, classified as a requirement for improvement, scored at EC 02.06.01 element of performance 1, and placed on the facility’s SAFER Matrix.

See our previous Accreditation Insider and Briefings on Accreditation and Quality coverage on suicide risks.

Joint Commission issues new Sentinel Event Alert about culture of safety

The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.

The SEA comes with an infographic on the “11 Tenets of a Safety Culture.” 

Sentinel Events for 2016

In the March issue of Perspectives, The Joint Commission announced that it had added 2016’s sentinel event data to its database. There were 824 sentinel events reported to The Joint Commission between January 1 and December 31, 2016. And 81% of those events were submitted voluntarily by the organization that experienced them. The most often reported events were:

  1. Unintended retention of a foreign object – 120
  2. Wrong patient, wrong site, or wrong procedure – 104
  3. Falls – 92
  4. Suicide – 87
  5. Delay in treatment – 54
  6. Other unanticipated events – 47
  7. Operative/postoperative complication – 45
  8. Medication error – 33
  9. Criminal event – 32
  10. Perinatal death/injury – 23

 

Readers should note that less than 2% of all sentinel events are reported to The Joint Commission, and these numbers can’t show the actual frequency of these events.

“In 2016 the trend for the most frequently reported sentinel events continued to be unintended retention of foreign objects, ‘wrong-patient, wrong-site, wrong procedure’ events, patient falls, patient suicides, and delays in treatment,” wrote Gerard M. Castro, PhD, MPH, Joint Commission project director, in Perspectives. “These are not new problems to health care, which indicates that organizations continue to struggle with how to prevent them.

Medication Compounding Certification now available

Medicine and pills

The new certification draws on USP’s General Chapters

As of January 1, all compounding pharmacies are eligible to enroll in The Joint Commission’s new Medication Compounding Certification (MCC) program, including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:

  • Ensure pharmacies are compliant with United States Pharmacopeial Convention (USP) and Joint Commission standards
  • Reduce the risk and harm stemming from drug compounding
  • Uncover and fix problems in existing compounding policies and procedures
  • Train personnel on the correct use of PPE and aseptic techniques
  • Ensure the physical environment meets guidelines for cleaning and documentation
  • Ensure the proper labeling, dating, and sterility of compounded products

In the March edition of The Joint Commission’s Perspectives, the accreditor writes that the program was created in part as a response to national outbreaks from contaminated compounded medicines. The Joint Commission has eligibility requirements and free 90-day access to the MCC standards on its website and in the E-dition® of the Medication Compounding Certification Manual. Their website also will be updated with a list of U.S. states that require compliance with USP General Chapter <795> and USP General Chapter <797>. The MCC standards have also been updated to reflect USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings which was reported on previously in the Patient Safety Monitor Journal.

For more information on the certification contact either:

Hospital-based pharmacies: Brian R. Johnson, 630-792-5144 or bjohnson@jointcommission.org.

Home care pharmacies: Cynthia Cook,  630-792-5121 or ccook@jointcommission.org