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Joint Commission announces new EP deletions

On January 1, 2017, The Joint Commission will delete 51 Elements of Performance (EP) from its hospital accreditation standards. The deletion is part of an ongoing effort to remove similar, duplicative, or unneeded EPs from the accreditation process.

Click here to see the deleted EPs. 

Joint Commission revises ‘notification of organization changes’

The Joint Commission has updated its “notification of organization changes” policy for accredited facilities.

Previously, organizations had 30 days to notify The Joint Commission that a significant change had been made. The updated policy now requires organizations alert the accreditor the moment the changes are confirmed (i.e., once leadership has decided to move ahead with a change and has created a timeline for completion).

The updated regulations go into effect on October 1. The changes apply to all Joint Commission-accredited programs. Click here to read the revised policy. 

2017 reporting requirements for ORYX

The Joint Commission released it’s 2017 reporting requirements for ORYX. Changes in include deletion of the measure set reporting requirement.

ORYX is a performance measurement and improvement initiative, for which facilities are  required to collect and submit data on six sets of core measures.

Click here to see the full document. 

Avoid fire drill citations with new matrix

Several months ago, Virginia Mason Medical Center (VMMC) in Seattle was denied full Joint Commission accreditation, in part due to its handling of fire drills. The facility received its citation for failing to vary the times and days when drills were conducted.

Now, The Joint Commission has released a new fire drill matrix for facilities to forestall confusion on survey day. The matrix tracks the day, date, time, and shifts when fire drills are conducted to ensure that they were conducted according to Joint Commission and CMS regulations. While they’ll still examine fire drill forms, surveyors will also give a copy of the matrix to hospitals when they arrive; although you can download an Excel copy of it here. 

The accreditor requires facilities to hold fire drills at random times to ensure that staff are ready when an actual emergency happens. Jim Kendig, The Joint Commission’s field director for surveyor management and development, said in a press release that hospitals are often unaware that they are conducting fire drills at similar times and days. The matrix helps them notice any patterns in scheduling that otherwise might escape notice.

“It becomes apparent,” Kendig said. “Hospitals can use this ahead of time, see patterns, and self-correct.”

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Joint Commission releases analysis of eCQM data

The analysis found that missing data was the biggest cause of discrepancies. Some examples of missing data are:

•    Missing data on medication route
•    Use of wrong template ID
•    Diagnosis Active is missing, which puts the case in denominator

The Joint Commission also unveiled its Core Measure Solution Exchange®,which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet.

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Three new Joint Commission questions for building tours

During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1. What type of fire-stopping is used in the facility?
2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
3. Which materials are used (e.g., glutaraldehyde, ortho-phthalaldehyde, peracetic acid) for high-level disinfection or sterilization?

“They’re pretty straight forward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”

Joint Commission and CDC team up on ambulatory infection prevention

The Joint Commission and the Centers for Disease Control and Prevention (CDC) are working on a new initiative to improve infection control in ambulatory care settings. The Adaptation and Dissemination Outpatient Infection PrevenTion (ADOPT) project will promote existing CDC infection prevention (IP) guidance while also making updates and alterations. The collaboration will involve:

•    Evaluating organizations’ infection prevention and control guidelines and materials to find gaps between what’s done in practice and what’s in the CDC materials.
•    Finding new ways and opportunities to raise awareness of IP guidance.
•    Adapting model infection control plans for outpatient-focused professional organizations.
•    Developing new ways of disseminating these materials and models to healthcare organizations to increase their reach, uptake, and adoption in outpatient settings.

There are 12 outpatient-focused professional organizations and 11 ambulatory healthcare systems participating in ADOPT. Other healthcare organizations or state health departments interested in learning more can reach out to Barbara Braun, PhD, at bbraun@jointcommission.org.

For examples of CDC ambulatory-focused infection prevention and control guidance, check out the following links:
•    CDC Guide to Infection Prevention for Outpatient Settings:  Minimum Expectations for Safe Care
•    CDC Outpatient Settings Policy Options for Improving Infection Prevention
•    CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
•    The CDC One and Only Campaign
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Share the trials and tribulations of eCQM success

Are you wondering how you’ll ever be prepared for the CMS’ updated Electronic Clinical Quality Measures (eCQM) due for release February 28, 2017? Don’t worry, you don’t have to face it alone.

The Joint Commission recently unveiled its Core Measure Solution Exchange®, which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet. There is already an eCQM solution posted by Wooster Community Hospital for viewing.

Joint Commission updates Integrated Care Program standards

The Joint Commission has updated and released its Integrated Care (ICC) Program standards, which will go into effect on January 1, 2017. The standards are aimed at improving key ICC processes and promoting the use of common patient risk screening criteria. The standards also try to eliminate duplicative care coordination and case management efforts.

Electronic Clinical Quality Measures survey results published

The Joint Commission, American Hospital Association, and the Federation of American Hospitals sent out a survey to 886 hospitals this March asking for feedback on the Electronic Clinical Quality Measures (eCQM). The eCQMs, which deal with data from electronic health records and health information technology system, are due for release on February 28, 2017. This July, the organizations heard back from 319 hospitals and released the survey results:

•    86% of hospitals say they plan on submitting eCQMs to CMS by the February 2017 deadline.
•    While 76% of hospitals say they have the skill level and knowledge to implement eCQMs, only 64% can afford health IT support. Many said they’ll have to change electronic health record vendors to stay compliant.
•    More than 85% have never successfully submitted eCQM patient level data to CMS.
•    58% haven’t or don’t know if they can generate a Quality Reporting Document Architecture [QRDA] 1 document.
•    79% haven’t or don’t know if they’ve ever successfully generated a QRDA1 doc.
•    Surveyed hospitals asked The Joint Commission for more forums, webinars, and a comprehensive library of eCQM resources to help with the transition.

The Joint Commission’s Pioneers in Quality program is using these results to determine the best way to help facilities comply with the eCQMs. The Joint Commission plans to follow up with a second survey on the eCQMs this fall. Click here to see the full survey results.