Official position of SIG Engineering on challenging standards and EPs. By not making a selection you will be agreeing to the use of our cookies. And recently The Joint Commission Top 10 Read more Interoperability Standard Revisions Did you get a chance to read our May issue of the Patton Post? 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. Drive performance improvement using our new business intelligence tools. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. HRM.01.02.01: The organization verifies and evaluates staff credentials. In 2021, the most challenging ambulatory care standards fell in the realm of: Weve gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. So, if you are still reprocessing, you may want to take a look at this EC News article and reconsider that decision. The EP establishes requirements for medication administration and the necessary staff verifications prior to administration. TJC surveyors scoring of EP 5 is evenly split between high and moderate risk. Find evidence-based sources on preventing infections in clinical settings. Your email address will not be published . It requires excellent record keeping, literature review and risk assessment, and the potential that a future surveyor is going to disagree with your analysis. Learn about the development and implementation of standardized performance measures. We can make a difference on your journey to provide consistently excellent care for each and every patient. In 2020, 809 total events were reported. QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. It is very informative, and while AEM is acceptable to TJC and CMS, it is not a program we see many organizations choosing to implement. In this case, a specific consent must be obtained from the patient to send the notice to other providers. Utility Systems - EC.02.05.01 Means of Egress - LS.02.01.20 Built Environment - EC.02.06.01 Fire Protection - EC.02.03.05 Then in 2020 we experienced a pandemic that stressed the system and really tested the effectiveness of our planning efforts in the extreme. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. New Joint Commission Requirements Effective 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. The memo indicates that the requirements will become effective as of June 30, 2021. This has historically been another catch all EP where just about any defect in the environment from torn furniture to suicide hazards have been scored. These are searchable keywords surveyors can use to help them find where to score a particular issue. OSHA will, on a case-by-case basis, exercise enforcement discretion related to the reuse of FFRs that have been decontaminated using the methods recommended above when considering issuing citations under 29 CFR 1910.134(d) and/or the equivalent respiratory protection provisions of other health standards in cases where: The importance of this guidance is that discretion is a two-way street. See how our expertise and rigorous standards can help organizations like yours. Bear in mind that far more than just eyewash issues can be scored here, such as failure to provide or use appropriate PPE for handling hazardous chemicals. We develop and implement measures for accountability and quality improvement. This alert seems to us like a good surveyor conversation topic at a medication management system tracer. IC.02.01.01: The organization implements infection prevention and control activities. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. However, this is not the case. The fourth most frequently scored EP is MM.06.01.01, EP 3, which somewhat surprised us. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The 2020 scoring data is also evenly split between high risk and moderate risk. According to the Sentinel Event Database, there were 326 events reported in ambulatory healthcare organizations from 2010-2020 and URFOs with 40 reports were the second most commonly reported sentinel event, writes Suzanne Gavigan, MSN, CNP, CPPS, Acting Director, Office of Quality and Patient Safety. Doing thorough PI on these processes is really the key to preventing TJC surveyors from identifying gaps in adherence to safety measures designed to protect patients at risk for suicide. 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. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. Many ambulatory and office-based surgery sites are led by a clinical staff member, so it is important to develop a relationship with someone who can offer general guidance on EC accountabilities. 46% of sentinel events led to a patients death. Copyright 2023 Becker's Healthcare. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. The keywords TJC has now built into their survey report tool now include safe environment, interior spaces, dirty ceiling tiles, porous surfaces and sterile compounding area. CMS and Joint Commission have been examining this data to determine suitability for survey. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. Interoperability Standard Revision Take a look at a second article they published in this May issue of Perspectives on page 25 discussing artificial intelligence. This searchable keyword methodology helps a surveyor find where to score a particular issue and helps to standardize placement of findings. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Set expectations for your organization's performance that are reasonable, achievable and survey-able. 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. The technical storage or access that is used exclusively for statistical purposes. Learn about the "gold standard" in quality. See how our expertise and rigorous standards can help organizations like yours. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Patient Safety Topics. These tools are a great start, but remember if you find an additional item that could be a ligature hazard, you need to add it to the risk assessment tool. 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. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. 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. You certainly would not want to be in a position of stating you have not seen the alert or have not considered the recommendations. The eighth most frequently scored EP was NPSG.15.01.01, EP 5. MM.06.01.01: The critical access hospital safely administers medications. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. They also point out that some glucometers are approved by the FDA for single patient use and others are approved for multi-patient use. Human Resources 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. Ensure compliance when reprocessing reusable medical devices, including but not limited to: Following the MIFU for any devices, instruments, products, accessories or equipment used ensures they are being cleaned and disinfected or sterilized as per intended use. 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. Q1 through Q3 2018: Joint Commission Findings (average ndings per survey: 32) Subject EP Incidence (Approx.) Conventional, Contingency, and Crisis Care Standards IC.02.01.01 This standard, requiring organizations to implement IC activities, is commonly cited for failure to implement IC activities or required evidence-based guidance such as Standard Precautions. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. Top 5 most challenging requirements for 2021 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. 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. 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 . Consequently, the inspection, testing and maintenance (ITM) tasks are contracted. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. They identify six elements of performance observed by their surveyors that to have the potential to either negatively affect patient care or create risk: HR.01.05.03, EP 1; HR.01.06. Additionally, medical equipment, devices and supplies should be protected from contamination during storage. 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. We would encourage all readers to carefully review this months consistent interpretation column with hospital quality, infection prevention, nursing, and education staff to assess your own risks on these critically important issues. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. Learn about the development and implementation of standardized performance measures. The key to success would appear to be not letting budgets or staffing shortages get in the way of ensuring that each patient identified to be at high risk to have the required 1:1 supervision. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The technical storage or access that is used exclusively for anonymous statistical purposes. Prior to this position she managed the emergency department at Northwestern Memorial Hospital and was a clinical educator at Northwestern University Feinberg School of Medicine. If contractors are used, they need to provide service for the entire complement of devices and provide detailed reports to the organization on each item that has successfully passed its test. The Joint Commission survey reports four of the top-10 findings were related to creating and following a complete and accurate home health plan of care; three were related to infection control; and the remaining findings related to not maintaining a complete, reconciled and accurate medication list. View them by specific areas by clicking here. This can be a wide range of issues from adhesive residue on medical equipment to, dust in patient care areas, to improper equipment cleaning. Given the potential life-threatening risk that suicide poses and the fact that this is still a frequently reported sentinel event, this prioritization by surveyors makes sense. PC.01.03.01: The organization plans the patients care. Learn about the priorities that drive us and how we are helping propel health care forward. View them by specific areas by clicking here. Were confident that with a little guidance, compliance issues can be overcome. View them by specific areas by clicking here. If so, we have important feedback about current high focus areas we're seeing in 2021 surveys. Get more information about cookies and how you can refuse them by clicking on the learn more button below. WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent. The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. It requires organizations to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Patient safety specialists in the Office of Quality and Patient Safety help organizations to conduct a credible and thorough analysis of sentinel events to identify causative factors and implement relevant system solutions to prevent future harm. They basically advise that given the increased supplies now available such reprocessing should no longer be needed. Whether you need help with fire protection, utility systems or means of egress, youll find the support you need to achieve compliance. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. 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. Introduction. This is a very interesting recommendation in that you have an opportunity to potentially intervene in real time to prevent patient injury. Learn more about the communities and organizations we serve. We hope this post helps you avoid some of the problems that have impacted other ambulatory care organizations. The Joint Commission is a registered trademark of the Joint Commission enterprise. Infection Control IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. We develop and implement measures for accountability and quality improvement. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. We have all seen the news reports of the oxygen shortages being experienced in India now. MM.01.01.03: The organization safely manages high-alert and hazardous medications. Learn how working with the Joint Commission benefits your organization and community. 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. Planning for an influx or surge has been a feature of the IC and EM standards for many years. Protecting patients from harm involves more than safe treatments and procedures. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing Please contact us soon! IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. Find evidence-based sources on preventing infections in clinical settings. IC.02.01.01: The organization implements its infection prevention and control plan. We help you measure, assess and improve your performance. The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. 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. Find the exact resources you need to succeed in your accreditation journey. 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. By not making a selection you will be agreeing to the use of our cookies. Crisis care planning is not yet a requirement of the standards, but we have read that TJC will be revising the standards in the near future. The LS and EC requirements have not changed significantly in recent years and yet hospitals continue to fall short with meeting compliance in these areas. Top 10 High & Moderate Risk Findings for 2020: This month we will not be breaking our discussion into high or lower priorities since Perspectives has some good information about scoring practices experienced in 2020. Tiffany Wiksten, MSN, RN-CIC, is Associate Director, Standards Interpretation Department. 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. Given the increased supplies now available such reprocessing should no longer be needed EP is,! Joint Commission news, blog posts, webinars, and maintains medical equipment, devices and supplies be... Is also evenly split between high risk and moderate risk standards Interpretation Department utility room and is!, an HBS Company is also evenly split between high and moderate risk the organization implements its prevention! 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