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Joint Commission’s Targeted Solutions Tool™ makes headway

The Joint Commission’s Target Solutions Tool™ (TST) launched in September has made progress in the area of hand hygiene. Over 700 hand hygiene projects are currently running, over 6,500 hand hygiene observations have been entered into the TST, and more than 2,500 download requests have been received so far for the tools and videos that the TST provides to support these projects.

The TST looks at measurement processes, barriers to success, and methods for implanting solutions, and was designed to smooth the process of solving healthcare’s most stubborn quality and safety issues.

The organization has teamed up with some of the top hospitals in the country to develop these solutions and is still seeking more.

Click here to find out more information.


Joint Commissions opens proposed version of MS.01.01.01 (formerly MS.1.20) for comment

The Joint Commission (TJC) has released a proposed version of MS.01.01.01 (formerly MS.1.20) and it is seeking comment on the proposed version between yesterday (Dec. 17) and January 28.  TJC convened a task force beginning in January 2008 after it received negative feedback from hospitals and physicians about the proposed standard. The task force consisted of professionals from the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals, and National Association Medical Staff Services.

The new MS.01.01.01 attempts to improve the current standard using the following principles (according to TJC):

  • A well-functioning relationship between the governing body, hospital leadership, and the medical staff is essential to the delivery of high quality, safe care.
  • Effective communication is the lubricant that keeps relationships functioning well; it therefore is important that structures and processes support it.
  • Well-functioning relationships also depend on all parties knowing what is expected of them, and being able to live up to those expectations

You can read the proposed standard by clicking here and you can access the survey about the proposed standard by clicking here.


Joint Commission asking for more input on standards

If you’ve got any opinions or concerns about the Joint Commission’s proposed staffing effectiveness requirements, you’ve got about five weeks to make your voice heard. Field review of the proposed Elements of Performance (EP) for hospitals and long-term care facilities is underway, with the Joint asking for comments to be submitted by July 10 (although the field review will remain open until July 22).

The changes are in response to complaints that compliance with the current staffing effectiveness requirements (standard PI.04.01.01 for hospitals and HR.1.30 for long-term care) consumes substantial resources without providing significant improvement in quality and patient safety. The proposed EPs fall under PI.02.01.01 (currently PI.2.10 for LTC) and are as follows:

  • EP 12 focuses on the use of outcomes data to guide staffing effectiveness analysis
  • EP 13 calls for leadership to review analyses of data related to staffing issues

Click here to review and comment on the proposed EPs.

Joint Commission requests feedback on cultural, communication standards

The Joint Commission asked yesterday for review from the field of its newly released proposed standards in effective communication, cultural competence, and patient-centered care. The standards, which would not be implemented until January 2011 at the earliest, represent an effort by The Joint Commission to place a greater emphasis on addressing disparities in care for certain patient populations. The standards also recognize how important solid communication is to delivering safe patient care, and that often communication can be ineffective with patients who face language, cultural, or physically debilitating barriers.

For the most part, the ideas behind these proposed standards are not completely new to The Joint Commission. There are existing standards that target the need for effective communication, patient-centered care, and cultural sensitivity. However, this will be the first time that these are specifically called out as an area of focus. The proposed standards encompass revisions and additions to 17 chapters for hospitals.

The proposed revisions can be found on The Joint Commission’s Web site.

Seems to me that this is more positive change coming from The Joint Commission. What are your thoughts? Do more standards not always mean good things? In this case, I think it will be a welcome addition to the existing standards.

Check out this HealthLeaders Media article on the topic as well, it provides some more detail, and is written by AHAP’s own Matt Phillion!

Joint Commission changes standards as part of deeming authority application

The Joint Commission announced yesterday that, as part of its application to the Centers for Medicare & Medicaid Services (CMS), a number of changes will be made to the accreditation process.

Industry experts have noted that many of the changes are requirements hospitals already meet due to existing state or other regulatory requirements. According to The Joint Commission’s announcement, many of the requirements are already being met by accredited facilities.

“A lot of these [requirements] are current law or regulation,” says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.

Di Giacomo-Geffers suggests facilities compile a list of the changes to see which changes the hospital already complies with–a checklist of yes, no, or not applicable.

“If the answer is no, you’re not complying with the requirement, then ask, what do we need to make this happen?” she says.

Many of the changes have resulted in added specificity to existing standards, though others have required the creation of entirely new standards. All changes go into effect immediately. These requirements will not be scored, however, until July 2009. The Joint Commission has a policy that it will, when possible, give its accredited organizations six months notice for new requirements.

The Joint Commission’s official announcement can be found here. The new requirements can be downloaded here.

Stay tuned to the AHAP Blog for further analysis on this issue in the coming days.