The Joint Commission has released an R3 Report to provide the rationale and references employed in the development of new requirements; the most recent R3 report relates to patient flow through the emergency department. The Joint commission has revised standards LD.04.03.11 and PC.01.01.01 with an increased focus on the importance of patient flow in hospitals. Most of the revised elements of performance (EP) went into effect on January 1, 2013, though two EPs–LD.04.03.11 EP 6 and EP 9 –will not go into effect until January 1, 2014.
Standard LD.04.03.11 requires an organization to manage the flow of patients throughout the hospital. The EPs for this standard mentioned in the R3 report focus on measuring and setting goals for the components of a the patient flow process and the boarding of patients who come through the emergency department, determining whether goals are achieved, and involving leadership actions to improve patient flow processes when goals are not achieved.
Standard PC.01.01.01 requires the hospital to accept the patient for care, treatment, and services based on its ability to meet the patient’s needs. EP 4 requires hospitals that do not provide psychiatric or substance abuse services primarily to have a written plan for defining the care, treatment, and services or referral process for those patients. EP 24 requires hospitals to provide a safe and monitored location and to conduct assessments and reassessments for patients waiting for care for emotional illness or substance abuse, as well as providing orientation and training for staff in these situations.
Keep those contest entries coming in!
Danna W. Taylor, medical staff coordinator at Medical Center of South Arkansas in El Dorado sent in her master form for ongoing professional practice evaluation (OPPE).
I have developed the attached tool for use in meeting the requirements for OPPE as required by The Joint Commission. . . I have developed one for each specialty. All data collected is compiled on one spreadsheet and reviewed by the chief of the department each quarter. Trends can be easily identified. We use the physician dictation number rather than the name to eliminate any bias.
You can download the OPPE master form (Excel) here.
The Joint Commission has released its list of least complied with standards for the first half of 2010. You can find the list in the September issue of Joint Commission’s Perspectives. Hospitals can use this list as a starting point for assessing their own compliance levels. If a standard is a problem area for a number of hospitals, it may be a problem for yours, too. It’s best to evaluate the problem and look for solutions before your next Joint Commission survey.
The following are notable standards from the least compliance list that MSPs may want to watch out for.
It’s great that the Centers for Medicare & Medicaid Services (CMS) expanded its telemedicine requirements, but they haven’t gone far enough, says the American Hospital Association (AHA).
Last week, AHA sent CMS a letter commending proposed changes which would allow hospitals to credential and privilege by proxy those telemedicine providers from hospitals in compliance with CMS’s Conditions of Participation (CoP). However, the AHA points out that CMS should go a step further and allow hospitals to privilege by proxy providers coming from organizations other than hospitals as long as the other organization, such as a radiology group, complies with the Medicare Conditions of Coverage.
AHA states that these proposed changes will benefit all hospitals, especially rural organizations which are frequent users of telemedicine services, but often lack the resources to adequately credential and privilege these providers on their own.
Log onto our sister site, www.HealthLeadersMedia.com, for the latest information about the ever changing telemedicine standards.
Joint Commission standard MS.01.01.01, the long awaited standard that defines what content belongs in bylaws versus supplemental documents will go into effect on March 31, 2011.
Visit The Joint Commission Web site to view the prepublication standard.
Congratulations to Linda Ford, CPMSM, CPCS, our February contest winner! Her innovative MS.01.01.01 gap analysis tool won her free registration to the Credentialing Resource Center Symposium.
(Keep those contest entries coming! Our next contest drawing is at the end of March. Click here to read the contest rules in full.)
Here’s a description of the tool in Linda’s own words: The gap analysis was developed utilizing the new Joint Commission Standards for MS.01.01.01 in an effort to find any gaps in our bylaws and associated documents. It creates an organized view of what we have and what we need to develop. I have used this tool for many of the standards throughout the year with great success.
The Joint Commission posted a draft of standard MS.01.01.01 (formerly MS.1.20) on its Web site for field review. The revised standard MS.1.20 sparked controversy because critics said it included confusing language regarding the term “organized medical staff” and appears to diminish the responsibility and authority of the hospital board and medical executive committee.
MSPs and other interested parties are welcome to comment on the draft standard during the field review period, which ends January 28, 2010.
Check back on the blog for more updates as they occur.
The Centers for Medicare and Medicaid Services (CMS) has granted deeming status to The Joint Commission’s hospital accreditation program, according to a November 30 press release. The deeming status is valid through July 15, 2014.
“The Joint Commission is proud of its tradition of collaboration with CMS to provide quality oversight of hospitals,” Mark Pelletier, R.N., M.S., executive director of Accreditation and Certification Services for The Joint Commission said in a press release. “Accreditation is a proven method for improving the care of Medicare beneficiaries.”
The Joint Commission also has federal deeming authority for:
- Ambulatory surgery centers
- Critical access hospitals
- Durable medical equipment suppliers
- Home health
Previous research has suggested that medical staffs don’t report practitioners to the National Practitioner Data Bank (NPDB) as often as they should. But why? One factor might be confusing peer review laws, according to an AMNews article.
The NPDB requires medical staffs to report practitioners if it restricted or revoked the practitioner’s privileges for more than 30 days based on competency problems or professional misconduct.
However, hospitals choose to deal with competency problems and professional misconduct in different ways, and if they don’t involve privilege suspension, they may not be reported to the NPDB.