A Handful of New FAQs

Over the last month or so the Joint Commission posted a handful of new or revised frequently-asked questions or FAQs to help clarify expectations of the standards. You can find these under the “Standards” then “Standards FAQs” tab at the Joint Commission website (http://www.jointcommission.org). The following is a synopsis of the changes. (We encourage you to read the official FAQs for yourselves.) Overall, we found these limited revisions to be quite helpful and on target.

• Emergency Management: 96-hour Rule (New on March 9, 2009). This FAQ adds clarity and is not drastically different from prior interpretations. It recognizes that organizations may not have enough supplies of all kinds to last through the first 96 hours of an emergency (disaster). However, it requires organizations to plan at least 96 hours ahead should the supply chain be broken.
• Environment of Care: Maintaining Supplies During An Emergency (New on March 9, 2009). This FAQ corresponds with the FAQ on the 96-hour rule (above) and recommends that agreements for just-in-time supplies be tested during emergency / disaster drills.
• Environment of Care: Mounting Sharps Boxes / Containers (Revised March 9, 2009). This FAQ emphasizes that the Joint Commission does not decide where sharps boxes should be stationed and whether they should be wall-mounted or free-standing: this is left to OSHA for enforcement; NIOSH and CDC for recommendations; and your employee safety / infection control program for the ultimate decision.
• Environment of Care: Use of Fans (New March 9, 2009). The use of fans is not prohibited by the Joint Commission … it never has been. However, this FAQ reminds us that extra fans often raise safety or infection issues. It also reminds us of the implications of using an extra fan: If you must use extra fans to move the air, what’s wrong with the organization’s mechanical system?
• Medical Staff and Provision of Care: Permission to Administer Moderate Sedation (Updated February 11, 2009). This revised FAQ (listed under both the Medical Staff and Provision of Care sections of the Table of Contents) confirms that permission to administer sedation may come in many forms and need not involve a separate sedation privilege (e.g. it can be included in the privilege to perform a procedure that has sedation as a necessary component) and it need not be based on the results of a sedation quiz.
• Procedure Site Marking: Exceptions to Site Marking (Updated February 12, 2009). This further clarifies that site marking is not required for single organ procedures or where the insertion point is not determined prior to the procedure. It is also clear that the organization must specify which procedures do / do not require site marking in such a way that involved staff members are clear.
• Procedure Site Marking: Bilateral Procedures (New March 11, 2009). This FAQ clarifies that marking is not required for procedures involving both of two bilateral sites (e.g. left and right ovary).
• Procedure Site Marking: Residents (Updated February 17, 2009). This further clarifies which residents (members of the house staff) may perform site marking … only residents who will be actually performing the procedure.
• Procedure Time Out: Documentation of Time Out (New March 11, 2009). This FAQ reiterates that the time out documentation need not capture all the steps performed during the time out or the exact time the time out occurred: documentation can be as simple as a single check box on an operating room flow record or a procedure form.
• Provision of Care: Preprocedure Verification (New January 13, 2009). NOTE: Although this FAQ addresses the universal protocol, it is not currently referenced in the Safety Goal section of the FAQ table of contents.For procedures where the patient is taken from an inpatient bed directly to the operating room (rather than a preprocedure area), the checklist of preprocedure verifications may be reviewed in the operating room. This is an interesting FAQ since a reading of the standard alone might lead one to erroneously believe that the checklist requirement did not apply to patients who bypass preprocedure holding (UP.01.01.01 EP.2).
• Record of Care, Treatment and Services (Updated February 9, 2009). This FAQ merely clarifies that, except in emergencies, a dictated history and physical examination must be transcribed and in the medical record (which may include an electronic copy in an electronic medical record) prior to surgeries or other procedures for which an H and P is required.