Transcript Joint Commission Update 2014

Nancy Claflin RN PhD CCRN NEA-BC CPHQ FNAHQ VHA-CM
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The way health care conducts improvement is
itself in need of improvement
Help health care make progress toward high
reliability
Achievement of extremely high levels of
safety maintained over long periods of time
Safety comparable to that demonstrated by
the commercial air travel, nuclear power, and
amusement park industries
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1. Eliminate Overuse of Health Services
Avoiding tests, treatments, and procedures
that do not provide significant benefit has the
potential to both improve quality and reduce
costs
Examples:
Antibiotics for colds
Early elective deliveries without a medical
indication
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2. Recognize that one size does not fit all
Using process improvement tools and
methods such as Robust Process
Improvement™ (RPI) enables health care
organizations to find unique solutions
Approach differs from long-standing efforts
that emphasize evidence-based guidelines,
checklists, and toolkits that typically are not
customized
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3. Create a culture of safety
Stopping intimidating & disrespectful
behaviors could help encourage candid
reporting of and dialogue about errors, close
calls, and unsafe conditions
Reporting and learning from blameless errors
and unsafe conditions doesn’t eliminate need
for personal responsibility
Accountability for adhering to agreed-upon
safe practices is also a key component of a
culture of safety
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Joint Commission began requiring organizations
accredited under ambulatory care, behavioral
health care, home care, hospital, and laboratory
programs to submit Focused Standards
Assessment (FSA) in February 2013
Critical access hospitals and nursing homes are
required to submit the FSA effective January 1,
2014
While office-based surgery practices can still use
the FSA for self-assessment, they are not
required (or able) to submit an FSA
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Change to Contingent Accreditation
Modified Contingent Accreditation (CONT)
CONT01
Accreditation Committee will determine if the
organization’s corrective action is sufficient
to change the decision from Preliminary
Denial of Accreditation (PDA) to Contingent
Accreditation
Occurs after Immediate Threat to Life (ITL)
finding at survey and follow up visit verified
sufficient corrective action to remove ITL
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Added the failure to successfully address all
Requirements for Improvement (RFIs) in
submitting an Evidence of Standards
Compliance (ESC) or Measure of Success
(MOS) to CONT05
Introduced new certification decision rules
due to a revised decision process in which the
only two possible outcomes are Certified or
Not Certified
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The Joint Commission’s reinvented Long
Term Care Accreditation Program new name
Nursing Care Center Accreditation Program
Reflects reinvented program’s focus on
organizations that provide complex nursing
care, which could include post-acute care and
other services for both short-stay patients
and long-term residents
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Behavioral Health Home (BHH) certification
accredited under the Behavioral Health Care
Accreditation Program effective January 1, 2014
Focuses on coordinating & integrating behavioral
& physical health care for individuals with serious
mental illness, children with serious emotional
disturbances, adults with developmental/
intellectual disabilities, & patients in opioid
treatment programs
People with serious mental illness die 25 years
earlier than general population
Suicide &injury account 30% to 40%
60% due to medical conditions (cardiovascular,
pulmonary, infectious)
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Increased ORYX® performance measure
reporting requirements for accredited general
medical/surgical hospitals
From a minimum of four (4) sets of core
measures to at least six (6) sets of core
measures for discharges
Effective January 1, 2014
Additional measure set selections include
both mandatory & discretionary measure sets
Acute myocardial infarction (AMI)
 Heart failure (HF)
 Pneumonia (PN)
 Surgical Care Improvement Project
(SCIP)
 Perinatal care (PC)—for hospitals with
1,100 or more live births per year
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Discretionary sixth measure set
 (Or fifth and sixth measure sets, for
hospitals with fewer than 1,100 births
per year)
 Can be chosen from among the
remaining complement of core
measure sets
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Children’s asthma care (CAC)
Hospital-based inpatient psychiatric services
(HBIPS)
Hospital outpatient (OP)
Immunization (IMM)
Emergency department (ED)
Venous thromboembolism (VTE)
Stroke (STK)
Tobacco treatment (TOB)
Substance use (SUB)
Perinatal care (PC)—for hospitals with fewer
than 1,100 live births per year
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Revision to Quality System Assessment for
Nonwaived Testing (QSA) Standard
QSA.05.01.01 (EP) 4
How frequently policies/procedures of blood
transfusion services are reviewed for
laboratory accreditation program
Revised requirement allows blood transfusion
service director/technical supervisor to review
blood transfusion policies/procedures every
two years instead of annually
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Requirements for Emergency Management
Oversight
Hospital effectively manages its programs,
services, sites, or departments
EP 12 Leaders identify an individual to be
accountable for the following:
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Staff implementation of 4 phases of emergency
management (mitigation, preparedness,
response, & recovery)
Staff implementation of emergency management
across 6 critical areas (communications,
resources & assets, safety & security, staff
responsibilities, utilities, and patient clinical &
support activities)
Collaboration across clinical & operational areas
to implement emergency management hospital
wide
Identification of & collaboration with community
response partners
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Hospital evaluates effectiveness of its
emergency management planning activities
EP 4 The annual emergency management
planning reviews are forwarded to senior
hospital leadership for review (See also
LD.04.01.01 EP 25)
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Hospital evaluates the effectiveness of its
Emergency Operations Plan
EP 13
Based on all monitoring activities &
observations, including relevant input from
all levels of staff affected, hospital evaluates
all emergency responses exercises and all
responses to actual emergencies using a
multidisciplinary process (which includes
Licensed Independent Practitioners (LIPs))
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EP 15
The deficiencies & opportunities for
improvement identified in the evaluation of
all emergency response exercises and all
responses to actual emergencies, are
communicated to the improvement team
responsible for monitoring environment of
care issues and to senior hospital leadership.
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Leaders establish priorities for performance
improvement
Senior hospital leadership directs
implementation of selected hospital-wide
improvements in emergency management
based on the following:
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Review of the annual emergency management
planning reviews
Review of the evaluations of all emergency
response exercises and all responses to
actual emergencies
Determination of which emergency
management improvements will be
prioritized for implementation
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Revisions approved June 2012
Most became effective January 2013
Two EPs became effective January 2014
Standards impacted
LD.04.03.11 The hospital manages the flow
of patients throughout the hospital
PC.01.01.01 The hospitals accepts the
patient for care, treatments, and services
based on its ability to meet the patients’
needs (Perspectives, July 2012)
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Revisions address the following:
Leadership use of data and measures to
identify, mitigate, and manage issues
affecting patient flow throughout the hospital
(effective January 2014)
Management of the Emergency Department
throughput as a system-wide issue
Safety for boarded patients
Leadership communication with behavioral
health providers and authorities to enhance
coordination of care
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All EPs related to risk
Patient flow throughout organization
including boarding
Not just Emergency Department
Monitoring
Managing
Anticipating and mitigating
Observing for trends
Clear goals & accountability for improvement
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Revision addresses safety for boarded
patients with behavioral health emergencies
in the following areas:
Environment of care, location
Staffing and orientation/training
Assessment, reassessment, and the care
provided
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Behavioral patients boarded for extended
periods of time may not receive the safe,
quality care needed
Staff may not be prepared to deal with this
vulnerable, challenging population
Environment may not be suited to the needs
of the behavioral health population
Policies and practices in the community may
contribute to making this a complex issue
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NPSG.06.01.01 Improve the safety of clinical
alarms
Implementation in two phases
Phase I beginning January 2014
Hospitals required to establish alarms as an
organization priority and identify the most
important alarms to manage based on their
own internal situations
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NPSG.06.01.01 Improve the safety of clinical
alarms
Phase II beginning January 6
Hospitals expected to develop and implement
specific components of policies and
procedures
Education of those in the organization about
alarm system management will also be
required
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NPSG.06.01.01
1. As of July 1, 2014, leaders establish alarm
system safety as a hospital priority
2. During 2014, identify the most important
alarm signals to manage based on the
following:
Input from medical staff and clinical
departments
Risk to patients if the alarm signal is not
attended to or if it malfunctions
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NPSG.06.01.01
2. During 2014, identify the most important
alarm signals to manage based on the
following:
Whether specific alarm signals are needed or
unnecessarily contribute to alarm noise &
alarm fatigue
Potential for patient harm based o internal
incident history
Published best practices and guidelines
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3. As of January 1, 2016, establish policies/
procedures for managing alarms identified in
EP 2 that at a minimum address the following:
Clinically appropriate settings for alarm
signals
When alarm signals can be disabled
When alarm parameters can be changed
Who in the organization has the authority to
set alarm parameters
Who in the organization has the authority to
change alarm parameters
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3. As of January 1, 2016, establish policies/
procedures for managing alarms identified in
EP 2 that at a minimum address the following:
Who in the organization has the authority to
set alarm parameters to “off”
Monitoring and responding to alarm signals
Checking individual alarm signals for accurate
settings, proper operation, and detectability
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Staffing patterns
Care model
Patient population
Technology capabilities & configuration
Architectural layout
Alarm coverage model
Ancillary technology
Delineation of responsibility
Culture
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Sentinel Event Alert Issue 51
How to avoid leaving items (sponges, towels,
instruments) in a patient’s body after surgery
Unintended retention of foreign objects (URFOs)
or retained surgical items (RSIs) serious patient
safety issue may cause death or physical and
emotional harm
>770 voluntary reports of URFOs, 16 resulting in
death during past 7 years
95% additional care and/or extended stay
$200,000 in medical and liability payments each
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Soft goods (sponges and towels)
Small miscellaneous items, including
unretrieved device components or fragments
(such as broken parts of instruments), stapler
components, parts of laparoscopic trocars,
guidewires, catheters, and pieces of drains
Needles and other sharps
Instruments, most commonly malleable
retractors
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Wrong-patient, wrong-site, or wrongprocedure—60
Unintended retention of a foreign object—56
Delay in treatment—56
Falls—48
Other unanticipated events—40
Operative/postoperative complication—37
Suicide—35
Criminal event (assault/rape/homicide)—26
Medication error—20
Perinatal death/injury—15
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Human factors (such as fatigue or
distraction)—314
Communication (such as among staff, across
disciplines, or with patients)—292
Leadership (regarding lack of performance
improvement infrastructure or community
relations)—276
Assessment (such as patient observation
processes or its documentation)—246
Information management (such as patient
identification of confidentiality)—101
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Physical environment (such as emergency
management or hazardous materials)—70
Care planning (planning and/or
interdisciplinary collaboration)—49
Continuum of care (includes transfer and/or
discharge of patient)—48
Medication use (such as storage/control or
labeling)—48
Operative care (such as blood use or patient
monitoring)—45
Standard
55%
RC.01.01.01
The hospital maintains complete and accurate
medical records for each individual patient.
54%
LS.02.01.20
The hospital maintains the integrity of the means
of egress.
47%
IC.02.01.01
The hospital reduces the risk of infections
associated with medical equipment, devices, and
supplies.
46%
EC.02.05.01
The hospital manages risks associated with its
utility systems.
45%
LS.02.01.10
Building and fire protection features are
designed and maintained to minimize the effects
of fire, smoke,
and heat.
Standard
44%
EC.02.03.05
The hospital maintains fire safety equipment
and fire safety building features.
43%
LS.02.01.30
The hospital provides and maintains building
features to protect individuals from the hazards
of fire and smoke.
38%
LS.02.01.35
The hospital provides and maintains systems for
extinguishing fires.
36%
EC.02.06.01
The hospital establishes and maintains a safe,
functional environment.
33%
MM.03.01.01
The hospital safely stores medications.
Standard
53%
EC.02.03.05
The critical access hospital maintains fire safety
equipment and fire safety building features.
49%
LS.02.01.10
Building and fire protection features are
designed and maintained to minimize the effects
of fire, smoke, and heat.
47%
EC.02.05.01
The critical access hospital manages risks
associated with its utility systems.
43%
IC.02.02.01
The critical access hospital reduces the risk of
infections associated with medical equipment,
devices, and supplies.
43%
LS.02.01.20
The critical access hospital maintains the
integrity of the means of egress.
Standard
40%
Ec.02.02.01
The critical access hospital manages risks
related to hazardous materials and waste.
40%
Ls.02.01.30
The critical access hospital provides and
maintains building features to protect
individuals from the hazards of fire and smoke.
36%
LS.02.01.35
The critical access hospital provides and
maintains systems for extinguishing fires.
34%
EC.02.05.09
The critical access hospital inspects, tests, and
maintains medical gas and vacuum systems.
30%
MM.03.01.01
The critical access hospital safely stores
medications.
Standard
35%
HR.02.01.04
The organization permits licensed independent
practitioners to provide care, treatment, and
services.
23%
PC.02.03.01
The organization provides resident education
and training based on each resident’s needs
and abilities.
22%
NPSG.07.01.01 Comply with either the current Centers for
Disease Control and Prevention (CDC) hand
hygiene guidelines or the current World Health
Organization (WHO) hand hygiene guidelines.
17%
IC.02.04.01
The organization offers vaccination against
influenza to licensed independent practitioners
and staff.
17%
WT.03.01.01
Staff and licensed independent practitioners
performing waived tests are competent.
Standard
15%
MM.03.01.01
The organization safely stores medications.
15%
RC.02.01.21
Clinical record documentation includes resident
education.
14%
MM.01.01.03
The organization safely manages high-alert and
hazardous medications.
14%
PC.01.02.03
The organization assesses and reassesses the
resident and his or her condition according to
defined time frames.
14%
PC.01.03.01
The organization plans the resident’s care.
Standard
49%
HR.02.01.04
The organization permits licensed independent
practitioners to provide care, treatment, and
services.
33%
NPSG.07.01.01
Comply with either the current Centers for
Disease Control and Prevention (CDC) hand
hygiene guidelines or the current World Health
Organization (WHO) hand hygiene guidelines.
17%
PC.02.03.01
The organization effectively manages the
collection of health information.
17%
IM.02.02.01
The organization effectively manages the
collection of health information.
16%
WT.04.01.01
The organization provides resident education and
training based on each resident’s needs and
abilities.
Standard
15% MM.01.02.01
The organization addresses the safe use of
look-alike/sound-alike medications.
13% IC.02.04.01
The organization offers vaccination against
influenza to licensed independent
practitioners and staff.
12% PC.01.02.07
The organization assesses and manages the
resident’s pain.
12% WT.03.01.01
Staff and licensed independent practitioners
performing waived tests are competent.
10% HR.02.02.01
The organization provides orientation to
licensed independent practitioners.
10% NPSG.03.05.0
1
Reduce the likelihood of resident harm
associated with the use of anticoagulant
therapy.
Standard
24%
HR.01.02.05
The organization verifies staff qualifications.
24%
PC.01.03.01
The organization plans the patient’s care.
21%
PI.02.01.01
The organization compiles and analyzes data.
19%
RC.02.01.01
The patient record contains information that
reflects the patient’s care, treatment, or services.
18%
EM.03.01.03
The organization evaluates the effectiveness of
its Emergency Operations Plan.
15%
LD.04.03.09
Care, treatment, or services provided through
contractual agreement are provided safely and
effectively.
Standard
37%
PC.02.01.03
The organization provides care, treatment, or
services in accordance with orders or
prescriptions, as required by law and regulation.
26%
IC.02.04.01
The organization offers vaccination against
influenza to licensed independent practitioners
and staff.
25%
HR.01.06.01
Staff are competent to perform their
responsibilities.
25%
NPSG.07.01.01
Comply with either the current Centers for
Disease Control and Prevention (CDC) hand
hygiene
guidelines or the current World Health
Organization (WHO) hand hygiene guidelines.
Standard
37%
CTS.03.01.03
The organization has a plan for care, treatment,
or services that reflects the assessed needs,
strengths, preferences, and goals of the
individual served.
23%
HR.02.01.03
The organization assigns initial, renewed, or
revised clinical responsibilities to staff who are
permitted by law and the organization to
practice independently.
15%
CTS.02.01.05
For organizations providing care, treatment, or
services in non–24-hour settings: The
organization implements a written process
requiring a physical health screening to
determine the individual’s need for a medical
history and physical examination.
Standard
15%
HR.01.06.01
Staff are competent to perform their
responsibilities.
15%
NPSG.15.01.01
Identify individuals at risk for suicide.
14%
EC.02.06.01
The organization establishes and maintains a
safe, functional environment.
13%
HR.01.02.05
The organization verifies staff qualifications.
13%
MM.03.01.01
The organization safely stores medications.
13%
CTS.04.03.33
For organizations providing food services: The
organization has a process for preparing and/or
distributing food and nutrition products.
13%
CTS.02.01.11
The organization screens all individuals served
for their nutritional status.
Standard
50%
HR.02.01.03
The organization grants initial, renewed, or
revised clinical privileges to individuals who are
permitted by law and the organization to
practice independently.
38%
MM.03.01.01
The organization safely stores medications.
37%
IC.02.02.01
The organization reduces the risk of infections
associated with medical equipment, devices, and
supplies.
28%
IC.01.03.01
The organization identifies risks for acquiring
and transmitting infections.
23%
MM.01.01.03
The organization safely manages high-alert and
hazardous medications.
Standard
22%
EC.04.01.01
The organization collects information to monitor
conditions in the environment.
21%
MM.01.02.01
The organization addresses the safe use of
look-alike/sound-alike medications.
21%
EC.02.02.01
The organization manages risks related to
hazardous materials and waste.
20%
EC.02.04.03
The organization inspects, tests, and maintains
medical equipment.
19%
WT.03.01.01
Staff and licensed independent practitioners
performing waived tests are competent.
Standard
71%
QSA.01.01.01 The laboratory participates in Centers for Medicare
& Medicaid Services (CMS)–approved proficiency
testing programs for all regulated analytes.
41%
QSA.08.04.01 The laboratory establishes workload limits for staff
who perform primary cytology screening.
37%
HR.01.06.01
35%
QSA.02.03.01 The laboratory performs calibration verification.
29%
DC.02.03.01
27%
QSA.01.02.01 The laboratory maintains records of its
participation in a proficiency testing program.
Staff are competent to perform their
responsibilities.
The laboratory report is complete and is in the
patient’s clinical record.
Standard
26%
QSA.08.02.01
The laboratory performs correlations to evaluate
the results of the same test performed with
different methodologies or instruments or at
different locations.
22%
TS.03.01.01
The organization uses standardized procedures
for managing tissues.
22%
WT.05.01.01
The organization maintains records for waived
testing.
21%
EC.02.04.03
The laboratory inspects, tests, and maintains
laboratory equipment.
Standard
60%
HR.02.01.03
The practice grants initial, renewed, or revised
clinical privileges to individuals who are
permitted by law and the organization to
practice independently.
26%
IC.02.02.01
The practice reduces the risk of infections
associated with medical equipment, devices, and
supplies.
25%
MM.01.01.03
The practice safely manages high-alert and
hazardous medications.
25%
MM.03.01.01
The practice safely stores medications.
22%
NPSG.03.04.01
Label all medications, medication containers,
and other solutions on and off the sterile field in
perioperative and other procedural settings.
Standard
20%
EC.02.05.07
The practice inspects, tests, and maintains
emergency power systems.
17%
MM.01.02.01
The practice addresses the safe use of lookalike/sound-alike medications.
15%
EC.02.03.05
The practice maintains fire safety equipment and
fire safety building features.
15%
EM.03.01.03
The practice evaluates the effectiveness of its
Emergency Management Plan.
15%
IC.02.04.01
The practice offers vaccination against influenza
to licensed independent practitioners and staff.
15%
WT.03.01.01
Staff and licensed independent practitioners
performing waived tests are competent.
Standard
28%
DSDF.2
The program develops a standardized process
originating in clinical practice guidelines (CPGs)
or evidence based practice to deliver or facilitate
the delivery of clinical care.
16%
DSDF.3
The program is designed to meet the
participant’s needs.
13%
DSSE.3
The program addresses participants’ education
needs.
12%
DSDF.1
Practitioners are qualified and competent.
12%
DSCT.5
The program initiates, maintains, and makes
accessible a health or medical record for every
participant.
Standard
8%
DSPR.1
The program defines its leadership roles.
7%
DSPM.6
The program evaluates participant perception of
the quality of care.
6%
DSPM.1
The program has an organized, comprehensive
approach to performance improvement.
5%
DSPR.8
The program communicates to participants the
scope and level of care, treatment, and services
it provides.
3%
DSSE.1
The program involves participants in making
decisions about managing their disease or
condition.
Standard
15% HSHR.1
The HCSS firm confirms that a person’s
qualifications are consistent with his or her
assignment(s).
10% HSLD.9
The HCSS firm addresses emergency management.
7%
HSHR.6
The HCSS firm evaluates the performance of
clinical staff.
6%
CPR 5
The HCSS firm evaluates the performance of
clinical staff.
6%
HSLD.5
The services contracted for by the HCSS firm are
provided to customers.
5%
HSPM.4
The HCSS firm analyzes its data.
5%
HSHR.3
The HCSS firm provides orientation to clinical staff
regarding initial job training and information.
Standard
5%
CPR 11
Any staffing firm employee or independent
contractor who has concerns about the quality and
safety of patient care provided by the staffing firm’s
employees or independent contractors can report
these concerns to The Joint Commission without
retaliatory action from the staffing firm.
5%
CPR 6
The staffing firm notifies the public it serves about
how to contact the firm’s management and The Joint
Commission to report concerns about the quality and
safety of patient care provided by the staffing firm’s
employees or independent
contractors.
4%
HSHR.4
The HCSS firm assesses and reassesses the
competence of clinical staff and clinical staff
supervisors.
Standard
69%
PCPC.4
The interdisciplinary program team assesses and
reassesses the patient’s needs.
31%
PCPM.7
The program has an interdisciplinary team that
includes individuals with expertise in and/or
knowledge about the program’s specialized care,
treatment, and services.
25%
PCPC.3
The program tailors care, treatment, and services to
meet the patient’s lifestyle, needs, and values.
19%
PCPI.2
The program collects data to monitor its performance.
13%
PCPM.6
Program leaders are responsible for selecting,
orienting, educating, retaining, and providing
incentives for staff.
6%
PCIM.2
The program maintains complete and accurate medical
records.