Recent Articles
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.
Life safety deficiencies top 2008 citation list
Thought this might be of interest–a write-up on Life Safety Code’s rise to the top of the list of cited standards in 2008 (summarized wonderfully by my colleague Scott Wallask at Healthcare Life Safety Compliance):
Life Safety Code® (LSC) violations became the top cited standard in all surveyed hospitals in 2008, The Joint Commission reports.
According to the July 2009 Joint Commission Perspectives, 45% of surveyed hospitals received a citation for EC.5.20, the old 2008 standard for LSC compliance. That standard has since expanded into 10 life safety standards introduced in 2009.
Also, the old EC.5.40–which sets a variety of provisions for the inspection, testing, and maintenance of fire protection equipment–was the sixth most-cited standard last year, affecting 26% of hospitals. EC.5.40 has since been renumbered EC.02.03.05.
LSC deficiencies haven’t topped The Joint Commission’s most-cited standards list in at least a decade, if ever. There is little doubt that this ranking is the culmination of the commission adding life safety specialists to survey teams back in 2005.
The addition of the specialists was prompted by a U.S. Government Accountability Office report that revealed Medicare validation surveys at hospitals had uncovered serious fire safety deficiencies that Joint Commission surveyors hadn’t identified in earlier visits.
Any thoughts? Have you been hit hard by LSC RFIs in your most recent survey? Figured out new best practices to achieve compliance?
Newest AHAP Insider is available
Members: keep an eye out for the latest AHAP Insider newsletter in your email inbox today. All of this quarter’s top stories are available on the AHAP Web site as well (along with all previous issues of the Insider) right here.
New video on DNV accreditation
Neat little video available through DNV with some feedback from key figures at hospitals that have made the switch. It’s a well-crafted little presentation–definitely worth a look if you’ve been following DNV’s progress since receiving deemed status.
Have any AHAP members recently made the swithch? Looked into it but decided against changing accrediting organizations?
Opening in SIG?
Just came across the following opening via Twitter:
We have an opportunity for a health care engineering professional to join our Standards Interpretation Group as an Associate Director. The Associate Director will be responsible for providing interpretation of all the Joint Commission’s standards with special emphasis on standards issues related to Environment of Care and Life Safety Code. You will participate in the development and revision of standards and survey process, and in support of ongoing accreditation services and special projects, and you will serve as faculty for surveyor and other education programs, representing the Joint Commission as liaison to various professional organizations.
It’s an interesting read if only to take a look at the qualities and qualifications The Joint Commission looks for in this type of role. Definitely worth taking a look for anyone involved in hospital accreditation! The complete listing can be found here.
New contest: Conflict of Interest
Hello, everyone. Following the success of our AHAP Conference giveaway, we’ve decided to sponsor further contests during the year. Next up, we’ll be giving away a free seat to the upcoming audioconference, The New Joint Commission Conflict of Interest Standards: Comply at Every Level.
All you have to do to enter is share a tip or tool related to conflict of interest policies. Recently updated your policy and think it’s worth sharing? Havea particularly interesting or unusual case where you had to deal with conflict of interest in an unexpected way? Share your stories with other AHAP members here on the blog.
A little bit about the show:
HCPro presents a live 90-minute audio conference, The New Joint Commission Conflict of Interest Standards: Comply at Every Level on Tuesday, July 28 at 1 p.m. (Eastern), featuring speakers Richard A. Sheff, MD, CMSL (chairman and executive director of The Greeley Company), and Brenda Summers, MBA/MHA, MSN, RN, NEA-BC, CSHA (senior consultant with The Greeley Company) will help participants identify how conflicts of interest can seep into hospital operations, decision making, and patient care. Participants will receive a sample organization-wide conflict of interest policy and procedure and will learn how to customize it to effectively meet both The Joint Commission’s new leadership standards and their own hospital’s needs.
A complete agenda and learning objects can be found here.
To submit a tip or tool for the contest, either click below to leave a comment, or email me at mphillion@hcpro.com. We will select a winner at random on Friday, July 24th.
Stroke Certification working group calls
I just wanted to let you know that we’ve posted both of the recent working group calls on Joint Commission Stroke Certification to the AHAP Web site. Stop by and have a listen if you weren’t able to attend either calls-they were some of our most successful working group calls to date, featuring presentations by Dean Pearson, Heather Sudduth and Regina Floyd at Memorial Hospital at Gulfport (on June 30) and Deborah Bergman from Northwestern Memorial in Chicago (on July 8).
I’d recommend listening to both-the guest speakers did a marvelous job and the discussion following the presentations was informative and lively.
Here’s a link to all of our working group call recordings.
2010 Accreditation Requirements Chapters: Pre-Publication Preview
This might be of some interest to you: The Joint Commission has released its 2010 Accreditation Requirements Chapters: Pre-Publication Preview for the following programs:
- Behavioral Heath Care
- Laboratory
- Long Term Care
They’re available on The Joint Commission’s site.
