Archive for August, 2009
Joint Commission releases Sentinel Event Alert
The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)
The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.
The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.
You can read the full list of recommendations, as well as the Sentinel Event Alert here.
Former Joint Commission president to join Awarepoint
Dennis O’Leary, MD, former president and current president emeritus of The Joint Commission, will take on the role of chief strategy officer for Awarepoint Corporation.
O’Leary’s tenure as president of the accreditation organization lasted 21 years.
Awarepoint is a provider of real-time location systems, and is currently expanding its presence in the healthcare environment. Additional information can be found in this press release.
Joint Commission response to new follow-up survey questions
A few weeks back, The Joint Commission announced a new type of follow-up survey–occurring when CMS Conditions of Participation are out–to be instituted in 2010. Briefings on The Joint Commission submitted a series of questions to find out more on this new follow-up survey. I’ve included the responses below. Take a look at the upcoming issue of BOJ for more analysis!
Q: What follow up documentation will be required of organizations receiving this decision?
A: The documentation to be reviewed will depend upon the issue. If it was policy related, then the policy could be reviewed. If it was a medical record entry, then medical records could be reviewed. Other things such as board meeting minutes may be reviewed. Surveyors will be comparing the corrective action that the organization documented in its ESC against actual practice.
Q: What is the time frame for the follow-up survey when a facility receives this decision?
A: Condition level deficiency follow-up surveys will be scheduled to occur approximately 90 days after an acceptable ESC has been received.
Q: Is a corrective plan of action required by The Joint Commission similar to what is required by CMS for deficient CoPs found during a CMS survey?
A: An ESC submission, which must document that the organization has implemented corrective action as of the ESC submission date, will be required. A separate Plan of Correction (POC) will not be required.
Q: In the event the hospital triggers a follow-up survey from The Joint Commission based on both Joint Commission standards and CMS CoPs, will this result in two follow-up surveys, or will the two be coordinated? What if the timelines are incompatible?
A: If multiple follow-up events are triggered, such as a Conditional Accreditation follow-up survey for non-compliant Joint Commission requirements and a Condition level deficiency follow-up survey in follow-up to non-compliant COPs, the timing of the follow-up events will be handled on a case-by-case basis. When possible, we will make every attempt to coordinate the timing of both events.
Stroke certification
This summer, we’ve really stepped up our coverage of Joint Commission stroke certification. I just wanted to remind everyone that we’ve added a number of items to the AHAP Web site lately on the topic, including:
And two working group call recordings!
Also, on Wednesday, August 12, two fantastic speakers, Lori Massaro and Chris Thompson, will be presenting a follow-up program to their April audioconference on stroke certification. This time around, there will be a full 45 minutes for a question and answer period. Also, it will be moderated by yours truly! More information, including a massive list of tools and sample documents which will be included with the program, can be found here.
