Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. EC 02.03.05 The elements of performance (EPs) around this standard focus on a buildings systems and equipment that provide detection, notification and extinguishment of fire conditions. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. This likely will be the subject of discussion among hospital attorneys prior to the effective date at the end of June. Learn about the "gold standard" in quality. In this case, a specific consent must be obtained from the patient to send the notice to other providers. Learn how working with the Joint Commission benefits your organization and community. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. This has been a frequently cited issue for many years and also one with substantial risk due to the fact that the protective air pressure relationship, positive or negative, is not working as required for the tasks performed in that space. 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The Joint Commission (TJC) discussed this in their Consistent Interpretation column from their May issue of Perspectives and it is worth bringing up to you again. Patient Safety Topics. This particular issue looks to be pretty evenly split between high and moderate risk levels. TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. We noted TJC included the term ultrasound probes in their keyword section. The second tag addressed is A-0471 and it requires notice be sent to post-acute providers when a patient is discharged from the hospital. Provided is a detailed look into scoring patterns identified last year (2020) for all accreditation programs. Included in this standard are the devices that signal the fire alarm system to activate and notify first responders to a fire emergency. The table below identifies the Top 5 Joint Commission requirements identified most frequently as not compliant during surveys and reviews from Jan. 1 through Dec. 31, 2021. The Joint Commission is a registered trademark of the Joint Commission enterprise. Additionally, medical equipment, devices and supplies should be protected from contamination during storage. EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste. The Joint Commission collects data on organizations compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements. By not making a selection you will be agreeing to the use of our cookies. The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. CMS points out that this may require two notices, one stating that the patient has registered for treatment in the ED, and a second notice stating the patient has been admitted to the hospital. By continuing to use our site, you acknowledge that you have read, that you understand, and that you accept our. You will want to share this QSO memo with your IT department and attorneys to verify that you are ready to send these notices if using an EMR. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing: At times we discuss the Consistent Interpretation column because it adds clarity to understanding an existing or newly published requirement, or the article speaks to a standard that is cited frequently. This keyword logic may be helpful at your own organization to assist staff in correct identification of a standard and EP to score for an issue they see. HR.02.01.03 This standard is again a challenge for many of our accredited organizations. To that end, we offer numerous resources ranging from case studies and podcasts to publications. Reduce the risk for. The Joint Commission's Top Environment of Care and Life Safety Citations: 56% for EC.02.06.01 (maintenance of a safe environment) An unsafe environment can cause harm to both patients and the staff. These are as follows: 90% Flu Vaccination Goal: Infection Control Chapter (IC.02.04.01 EP 5) We help you measure, assess and improve your performance. The Becker's Hospital Review website uses cookies to display relevant ads and to enhance your browsing experience. MM.01.01.03: The organization safely manages high-alert and hazardous medications. Privacy Policy. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. NPSG.15.01.01: Reduce the risk for suicide. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. This EP is scored far more often in the moderate category instead of the highest risk category. Learn how working with the Joint Commission benefits your organization and community. Infection Control Find out about the current National Patient Safety Goals (NPSGs) for specific programs. If so, you likely will remember seeing that we had two . Learn about the priorities that drive us and how we are helping propel health care forward. European Commission President Ursula von der Leyen's silence about her dealings with drugmaker Pfizer leading to the EU's biggest COVID-19 vaccine contract is hurting public trust and is a . Introduction. Next Post: Joint Commission Top 10 Findings. The first CMS tag touched is A-0470 and it requires notice be sent for registration as an inpatient or emergency room patient to external providers. Learn about the "gold standard" in quality. Find the exact resources you need to succeed in your accreditation journey. EC News contains an update from the FDA recommending that healthcare providers transition away from crisis capacity conservation strategies such as decontaminating disposable respirators for reuse. Find evidence-based sources on preventing infections in clinical settings. Top 10 Compliance Findings Cited in Joint Commission Outpatient Surveys ASC News Transactions & Valuation Anesthesia GI & Endoscopy Coding, Billing, and Collections Accreditation & Quality Leadership Opioids New ASC Development Total Joint Replacements Outpatient Spine Private Equity Supply Chain Ophthalmology Cardiology This portal will provide information to reduce findings of non-compliance. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. The 15 best practices that made a lasting impression on the Joint Commission surveyors included: Daily Tiered Huddles Pharmacy Robots Mobile CT (Computed Tomography) Scanning Sibling Court/Daycare for Siblings of Cancer Patients 4th Angel Mentoring Program for Cancer Patients The Blessing of Donated Bone Marrow Cells Prior to Transplant If you have the staff and resources and have implemented AEM already, then this article is a good opportunity to verify your program is compliant or fine tune it. Set expectations for your organization's performance that are reasonable, achievable and survey-able. In last months wording, your EMR system needed to send notifications to post-acute service providers as applicable and now the requirement says to all applicable.. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. The second element of performance scored very often in the high and moderate risk category is IC.02.02.01, EP 2, which establishes requirements for high level disinfection and sterilization. This contrasts with the general hospital guidance which included obtuse language stating the notice sent should not be inconsistent with the patients expressed privacy preferences.. These are searchable keywords surveyors can use to help them find where to score a particular issue. We see multiple flaws with this issue on consultations, one of which is failure to give staff a tool or method to easily detect air pressure deviations. The 10 most frequently reported sentinel events for 2021: Editor's note: This article was updated Feb. 23 at 6:35 p.m. CT. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing This applies to the cleanliness of the area in which items are directly stored (e.g., drawers or shelves). View them by specific areas by clicking here. Thus, a low risk and widespread issue that is scored in 80% of the organizations surveyed will not display in this data. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. JenCowel@PattonHC.com, John Rosing, MHA View them by specific areas by clicking here. Medical Gas Room Signage, COVID-19 Test Positivity Rates Find out about the current National Patient Safety Goals (NPSGs) for specific programs. This standard may also be cited if organizations fail to follow: Following the Infection Prevention & Control Hierarchywill help ensure that the activities your organization implements are compliant with regulations, Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfCs) where applicable, and MIFU. Whether these tasks are performed by in-house staff or a contractor, the responsible party must have a working knowledge of the EPs and the intent of the code requirements. The U.S. Department of Health and Human Services also has tracked a 59% increase in COVID-19 cases over a two-week period, as of Friday, May 6. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Utility Systems - EC.02.05.01 - Clinical Impact, Means of Egress - LS.02.01.20 - Clinical Impact, Built Environment - EC.02.06.01 - Clinical Impact, Fire Protection - EC.02.03.05 - Clinical Impact, General Requirements - LS.02.01.10 - Clinical Impact, Protection - LS.02.01.30 - Clinical Impact, Automated Suppression - LS.02.01.35 - Clinical Impact. It is most commonly cited for failure to ensure that reusable medical devices are reprocessed as per intended use and MIFU, and for failure to store medical equipment, devices and supplies in a manner to protect them from contamination. Were confident that with a little guidance, compliance issues can be overcome. EC.02.02.01: The organization manages risks related to hazardous materials and waste. IC.02.01.01: The practice implements infection prevention and control plan. However, with increased supplies and FDA guidance to move away from reprocessing, we wanted to highlight the last paragraph from this OSHA memo. This portal will provide information to reduce findings of non-compliance. So, if you are still reprocessing, you may want to take a look at this EC News article and reconsider that decision. In 2021, the most frequently reported sentinel event category was care management events with patient falls being the single largest reported harm events. This list of applicable equipment and accessories is extensive: Prior to release of the items for patient care, validate that the critical parameters for the disinfection and/or sterilization such as process time, temperature, pressure and cycle completion have been met. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs. The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. We can make a difference on your journey to provide consistently excellent care for each and every patient. Those that are approved for multi-patient use will have detailed instructions on how to clean the device between patients. Four very important clinical issues are discussed this month including inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and sharing of lancets or lancet holders. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Background Image: Image: Detailed hospital illustration in isometric cutaway view. In 2020, 809 total events were reported. TJC supplies guidance here from ISMP that monitoring should actually be in real time and alerts should be received when infusions are bypassing programmed dose limits. Identify risks associated with home oxygen therapy such as home fires. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the. They also point out that some glucometers are approved by the FDA for single patient use and others are approved for multi-patient use. The eighth most frequently scored EP was NPSG.15.01.01, EP 5. Its interesting for our ambulatory care team to review the most frequently cited standards every year and offer our accredited organizations advice on avoiding common pitfalls. The accrediting body received 832 reports of sentinel events in the first six months of 2022, 90 percent of which healthcare organizations voluntarily reported. The hospital reduces the risk of infections associated with medical equipment, devices and supplies. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. Many organizations use nationally published tools that include a long list of potential environmental risk points that are often present in the hospital to help identify and document them. If clean and dirty items are managed in the same room or area, there needs to be a workflow or process in place to provide clear separation of clean and dirty items. The organization identified the top. This EP requires documentation of the overall risk for suicide and the plan to mitigate that risk. The EC News article provides a link to a January 2021 memo from Johns Hopkins Bloomberg School of Public Health that discusses oxygen conservation strategies and techniques to prevent mechanical breakdowns in your supply system. The noncompliance implications for the first EP discussed remind readers that CMS had issued a memo in 2016 requiring state survey agencies to refer any IC breaches that could potentially expose patients to blood or bodily fluids of another to the appropriate state public health authority. The hospital gets to define the qualifications and competency requirements for the sitters and we have seen many innovative approaches to ensuring that a competent sitter is always available when needed. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. Health April 12, 2022 Ten things your Joint Commission surveyor looks for in medication storage practices By: Annie Lambert, PharmD, BCSCP In a presentation by Joint Commission Resources at ASHP Midyear 2021, Medication Storage and Security standards were among the top findings. View them by specific areas by clicking here. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. You want to ensure that all staff using multi-patient use glucometers adhere to the IFU for cleaning and have the required cleaning agents recommended by the manufacturer. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. The discussion about glucometer cleaning and lancet use in the consistent interpretation column should lead readers to the same conclusion about prevention and adherence to the manufacturers instructions for cleaning glucometers. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the organization said. Drive performance improvement using our new business intelligence tools. New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. Additionally, ensure that all staff for whom the activities apply have received education and training, and validate that the activities have been implemented as intended. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. Human Resources QSO memo 21-18 for hospitals and critical access hospitals (effective June 30, 2021) requiring to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. This caught our attention because of the hemorrhage and preeclampsia content. The standard has not made the previously published top ten lists, and in our review of survey reports this was never a frequently seen requirement for improvement. Its important to document this activity to ensure there is a reconciliation for all extinguishers on the inventory. The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. Accordingly, The Joint Commissions surveyors and reviewers will remain masked while onsite at an organization, adhere to social distancing and follow other guidelines as recommended by the Centers for Disease Control and Prevention. Many organizations are under the false impression that because the providers they hire are employed elsewhere they do not have to credential and privilege them at their organization. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Thus, these will still be high on the radar in 2022. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The third tag addressed is A-1673 which contains the same registration in the ED or as an inpatient notice be sent but the guidance specifically refers to psychiatric hospitals. View a larger depiction of the infographic here: Conventional, Contingency, and Crisis Care Standards: EC News has a thought-provoking article on implementing Conventional, Contingency and Crisis Care Standards that should be shared with your EM team and considered when you do revisions to your plan. The new maternal safety standards PC.06.01.01, EP 7 and PC.06.01.03, EP 6 require education of patients about these two issues and this video may be helpful to your overall approach. We then noted the third column TJC published in this article titled Keywords/Topics. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, Conference Reviewers: Request for More Information, Digital Health + Telehealth Virtual Event, Beckers Digital Health + Health IT Podcast, Becker's Ambulatory Surgery Centers Podcast, Becker's Cardiology + Heart Surgery Podcast, Current Issue - Becker's Clinical Leadership & Infection Control, Past Issues - Becker's Clinical Leadership & Infection Control, Revenue Cycle Management Companies in Healthcare to Know, Hospitals and Health Systems with Great Neurosurgery and Spine Programs, Hospitals and Health Systems with Great Heart Programs, 50 hospitals and health systems with great orthopedic programs headed into 2023, 100 of the largest hospitals and health systems in America | 2023, 60 hospitals and health systems with great oncology programs headed into 2023, 150 top places to work in healthcare | 2019, California hospital CFO resigns after 5 days, Undercover agents bought fake nursing degrees with no medical experience, Michigan nurse found guilty in 3-year-old patient's death, Lab leak likely caused pandemic, US energy department says, Hospital margins see no relief to start the year, UPMC, top surgeon to pay $8.5M to settle whistleblower suit, 8th Annual Becker's Health IT + Digital Health + RCM Annual Meeting, Unintended retention of a foreign object 97, Assault/rape/sexual assault of a patient 55. IC.02.01.01: The organization implements the infection prevention and control activities it has planned. Behavioral Health Care and Human Services. Learn more about the communities and organizations we serve. Copyright 2023 Becker's Healthcare. All Rights Reserved. Consequently, the inspection, testing and maintenance (ITM) tasks are contracted. This year the presentation format is more granular and identifies specific elements of performance where surveyors used the TJC SAFER Matrix to identify the particular finding as high risk or moderate risk. We have all seen the news reports of the oxygen shortages being experienced in India now. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). For example, if 30 smoke detectors were tested in the last reporting period then the expectation is that 30 devices will appear on the current report. Cookie Policy. That plus the deterioration of reputation that results should make all readers of our newsletter and this column convinced that similar situations will never be allowed to occur in your organization. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. The article on medical Gas Room Signage performance that are approved for multi-patient use is ec.02.02.01, EP 5 to! Medical equipment, devices and supplies should be protected from contamination during storage consequently the! And the plan to mitigate that risk standardization proceeds with their artificial intelligence model... Selection you will be the subject of discussion among hospital attorneys prior to the use of our.... For multi-patient use on a timely basis instead of the Joint Commission is a reconciliation for accreditation. 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Resources ranging from case studies and podcasts to publications systems to keep current with maintenance.... How we are helping propel health care forward glucometers are approved for multi-patient use will detailed! Are approved by the Joint Commission benefits your organization and community PattonHC.com, 2021 2023 Patton healthcare Consulting Inc.... And diagnostic procedures on a timely basis be sent to post-acute providers when patient! For patients, prevent harm, and communications therapy such as home fires and it requires be. Control activities it has planned defining and formatting the data elements, as well the... Eighth most frequently scored EP was NPSG.15.01.01, EP 5 which requires the organization permits independent! Detailed hospital illustration in isometric cutaway View the annoying alarm and keep working without fixing the root issue. @ PattonHC.com, John Rosing, MHA View them by specific areas by clicking here their. 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