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New name for Briefings on The Joint Commission

Briefings on The Joint Commission has a new name: Briefings on Accreditation and Quality!

For the last few years, in addition to covering the latest Joint Commission happenings, we’ve also included a broad focus on CMS compliance and quality improvement. We think our new name better reflects the quality content we strive to bring you each month. You’ll still be able to access prior issues of Briefings on The Joint Commission on our website.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

We’re excited about this change and hope you will be too. If there are any topics you would like to see covered in upcoming editions of Briefings on Accreditation and Quality, please email me at mclarke@hcpro.com.

 

New Sentinel Event Alert focuses on patient falls prevention

Sentinel Event Alert (SEA) #55, issued by The Joint Commission today, urges healthcare facilities to take action to prevent falls and fall-related injuries.

Falls are routinely in the top 10 sentinel events reported to The Joint Commission each year. The most common causes of falls or fall-related injuries, include poor patient assessment, lack of communication, failure to follow healthcare facility protocols and safety practices, and the absence of strong leadership, according to the SEA.

The Joint Commission recommends the following actions under the command of a strong leadership:

  • Raise awareness of the need to prevent falls
  • Create an interdisciplinary falls injury prevention team
  • Implement a standardized tool to assess possible fall risks
  • Develop patient-specific plans of care based on possible fall and injury risks
  • Create standardized practices and interventions for healthcare professionals and patients
  • Perform a root cause analysis after a fall

Read the SEA for further information on The Joint Commission’s recommendations to prevent falls and fall-related injuries.

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space.

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

Reduce clinical alarm fatigue with new HCPro webcast

The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission created a new National Patient Safety Goal to address it. With so many device alarms going off, staff may tune them out and miss important warnings that can lead to adverse patient events.

In this webcast scheduled for Wednesday, October 14 at 1 p.m. Eastern, Deborah Whalen and Jim Piepenbrink of Boston Medical Center will explain how their facility successfully reduced alarm fatigue through process management, collaboration, and governance. Register today for “Clinical Alarm Management: Reduce Alarm Fatigue and Meet The Joint Commission’s National Patient Safety Goal” and get the knowledge you need to improve alarm management in your facility.

Visit here for more information.

Joint Commission launches leadership module on Physical Environment portal

The Joint Commission posted the leadership portion of the management of utility systems (EC.02.05.01) on its Physical Environment portal earlier this week. The first part of the module discussed the impact noncompliance of utility systems has on patient care safety.

The next modules to be released on the portal, in October and November, will cover maintenance of egress integrity (LS.02.01.20) and management of hazardous materials and waste risks (EC.02.02.01).

The Joint Commission and American Society for Healthcare Engineering (ASHE) launched the portal in July to provide hospitals with online resources and tools to comply with the most challenging Life Safety (LS) and Environment of Care (EC) standards.

Visit the Physical Environment Portal.

Joint Commission seeks comments on proposed changes to National Patient Safety Goal on Catheter-Associated Urinary Tract Infections

The Joint Commission is calling for comments on proposed changes to existing NPSG.07.06.01 on Catheter-Associated Urinary Tract Infections (CAUTI). The proposed changes including educating, patients and their families on the importance of preventing CAUTI. Additional proposed changes include requiring consistent documentation methods for indwelling catheter use.

The Joint Commission is also seeking comments on this NPSG for nursing care centers. This is a new NPSG for those facilities.

The comment period for both ends on October 14.

Read more about the proposed changes here.

Healthcare organizations urge CMS to suspend new sepsis management measure

Four major healthcare organizations have asked CMS to postpone implementation of the severe sepsis and septic shock management bundle measurement that is scheduled to go into effect October 1, 2015. The measure as currently written, calls for the use of broad spectrum antibiotics to treat severe sepsis and septic shock.

The group consisting of the American Health Association (AHA), America’s Essential Hospitals, AAMC, and the Federation of American Hospitals, is urging CMS to refine the measure so that it more closely aligns with the antimicrobial stewardship put forth by the CDC and the White House earlier this summer.

“By encouraging the use of broad spectrum antibiotics when more targeted ones will suffice, this measure promotes the overuse of the antibiotics that are our last line of defense against drug-resistant bacteria,” the group wrote in a letter to CMS.

Read the full letter here.

Joint Commission identifies top five most-cited standards first half of 2015

The Joint Commission released the top five standards most cited during the first half of 2015, yesterday. There aren’t any surprises in the list, but there has been a slight change in the order of the standards with infection control creeping into the second spot.

The top five trouble spots:

  • EC.02.06.01 (maintenance of a safe environment), 59%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 54%
  • EC.02.05.01 (management of utility system risks), 53%
  • LS.02.01.20 (maintenance of egress integrity), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 48%

View the full table here.

Read about the top 10 most-cited standards in Briefings of The Joint Commission.

Try not to breathe

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.

Accreditation Q & A: How and what should the HVA be used for?

Question: How and what should the HVA be used for?

Answer: (Answers may vary).  To understand your level of preparedness for the emergency events most likely to occur at your facility; to communicate your concerns and weaknesses to community response agencies; to define your focus for improvement so you can improve your preparedness and mitigate your vulnerabilities.

Do you have a question you would like us to answer? Send an email to me at mclarke@hcpro.com 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.