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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.” 

Joint Commission to check for FDA powdered glove compliance

The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.

“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”

To learn more about the FDA’s decision, read our previous coverage on the ban.

Joint Commission makes more revisions to EC, LS standards

The Joint Commission has announced additional revisions to its Environment of Care (EC) and Life Safety (LS) chapters. The revisions are meant to bring the accreditor in closer alignment with the National Fire Protection Association’s 2012 Life Safety Code® (LSC). The LSC was adopted by CMS and The Joint Commission last year. The revisions go into effect July 1, 2017 and apply to hospitals, critical access hospitals, ambulatory healthcare centers, home care, and nursing care centers.

SAFER Matrix goes into effect, new tool available

Accredited organizations now receive a new SAFER Matrix Tool and a user guide, following their first survey with the new matrix. The SAFER Matrix was announced last July as a replacement for the old “Category A and C” method of evaluating safety issues. As of January 1, all accredited organizations now receive the SAFER matrix after their surveys.

The new tool can be used to filters out specific portions of the SAFER report, such as Requirements for Improvement, which then can be saved and sent to people within the facility. The guide shows users how to:

  • Use filters
  • Select specific survey or review events to view
  • Switch between different accreditation programs
  • Switch between accreditation and certification

The tool and guide can be found on Joint Commission Connect in the “Post-Survey” section of the “Survey Process” tab.

Joint Commission Leadership standard now aligns with CMS

On January 9, 2017, Joint Commission Leadership (LD) standard 01.03.01,element of performance (EP) 12, for home health and hospice will be expanded to apply to hospitals, critical access hospitals, and ambulatory surgical centers.

The standard requires that the leadership/governance of a healthcare facility is the one ultimately held accountable for the facility’s safety, quality, and compliance. Previously, however, the Joint Commission standard didn’t have an EP that referred to leadership’s legal responsibility. In addition, the EPs varied between different types of facilities on what to do if leadership failed to meet its responsibilities.
The Joint Commission announced it was expanding EP 12 to the additional settings as a way to standardize compliance across all accredited facilities and to come into alignment with CMS’ Conditions of Participation.

Hard copy versions of accreditation manuals published after November 2016 will include the new EP, and the change will be made to the accreditor’s E-dition in January. For more information, contact Laura Smith, Joint Commission project director, at lsmith@jointcommission.org.

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Joint Commission targets CAUTIs with updated NPSG

Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on catheter-associated urinary tract infections (CAUTI) for hospitals and critical access hospitals. It also created a new CAUTI NPSG for nursing care centers.

“An estimated 1 to 3 million healthcare-associated infections strike nursing home residents annually, and many of these are infections related to urinary catheters,” wrote David Baker, MD, MPH, FACP, Joint Commission executive vice president, in a blog post. “CAUTIs can lead to serious complications and hospitalizations. And, the rate of these infections is even higher for hospital patients. This is why The Joint Commission felt it was important to implement its new National Patient Safety Goal for nursing care centers and an updated goal for hospitals and critical access hospitals to reflect the latest scientific evidence.”

Among the new changes are requirements to:

•    Educate staff on how to correctly use and insert indwelling catheters.
•    Educate patients and family on CAUTI risks and prevention
•    Use evidence-based guidelines to write catheter use policies.
•    Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter.
•    Maintain an up-to-date record of catheter use; who has one inserted, when was it implanted, etc.

All the changes go into effect on January 1, 2017 and are meant to improve staff training, educate patients, and update policies with evidence-based practices. In addition, the Department of Health and Human Services announced that it wants to see a 50% reduction in CAUTI by 2020.

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