MM.01.01.03: The practice safely manages high-alert and hazardous medications. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. 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. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. The first recommended action is to assign responsibility to a project team or department, such as your pharmacy and therapeutics committee, for smart infusion pump interoperability, developing and maintaining the DERS, changes to infusion protocols, and pump maintenance. The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. And recently The Joint Commission Top 10 Read more Joint Commission Top 10 Findings. Joint Commission Top 10 Findings Despite the pandemic and the year we thought would never end, we're already halfway through 2021! The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. It requires organizations to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Learn about the priorities that drive us and how we are helping propel health care forward. The Joint Commission is a registered trademark of the Joint Commission enterprise. The technical storage or access that is used exclusively for statistical purposes. Given the more intense focus on sterile compounding areas, this may be leading to some of these findings. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. Title: MOSHE Advocacy Update: Top 10 Joint Commission Findngs 1-6/2019 Author: Pamela Kelsey 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. 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. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. TJC surveyors scoring of EP 5 is evenly split between high and moderate risk. As with all ITM activities, documentation of these tasks must be current, accurate and made available to Joint Commission staff when requested on survey. 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. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. As you might expect, in the hospital accreditation program the issue that is most often scored with high or moderate risk is related to suicide safety. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. This is likely due to continuing feedback from CMS. Provided is a detailed look into scoring patterns identified last year (2020) for all accreditation programs. 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. 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. 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. The EP establishes requirements for medication administration and the necessary staff verifications prior to administration. These events affected a total of 14,731 patients (as multiple patients may be affected by a single event): An estimated fewer than 2% of all sentinel events are reported to The Joint Commission. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. We have followed for 15 years the press announcements about hospitals where insulin pens were shared between patients and the adverse media attention and survey attention these organizations have received. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. 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. EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste. Privacy Policy. 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. One of the flaws we often see with environmental risk assessments is a failure to document all observed and theoretical risks. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. However, this is not the case. The number of serious patient safety incidents reported to The Joint Commission jumped in 2021, reaching the highest annual level seen since the accrediting body started publicly reporting them in 2007, according to a report shared with Becker's Feb. 22. IC.02.01.01: The organization implements its infection prevention and control plan. 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. We develop and implement measures for accountability and quality improvement. 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, Top 5 most challenging requirements for 2021, Joint Commission asking healthcare staff to remain masked while interacting with surveyors, reviewers, Up in the blogosphere with The Joint Commission, Required Policies and Procedures in Suicide Prevention Program, Avoiding Unintended Retained Foreign Objects in Ambulatory Surgery Care. Sentinel Event Alert Infusion Pumps, Alternative Equipment Maintenance (AEM) Strategies According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. It is important to ensure that only manufacturer approved products are used and that all steps of the MIFU are followed for all items undergoing reprocessing, including equipment and accessories. Did you get a chance to read our May issue of the Patton Post? Given the lesser risk in this EP as compared to the prior issue about HLD and sterilization, the vast majority of these findings were scored in the moderate orange category rather than the highest risk in red. In this case, a specific consent must be obtained from the patient to send the notice to other providers. This is scored about twice as often in the red, high risk category rather than the moderate orange category. 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. One test usually handled by staff is the monthly inspection of fire extinguishers. They basically advise that given the increased supplies now available such reprocessing should no longer be needed. We have reproduced that link again for your use. 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. 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. Learn more about the communities and organizations we serve. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. Learn how working with the Joint Commission benefits your organization and community. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. We then noted the third column TJC published in this article titled Keywords/Topics. We help you measure, assess and improve your performance. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Learn more about the communities and organizations we serve. This applies to the cleanliness of the area in which items are directly stored (e.g., drawers or shelves). The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. If this rate continues in the second half of the year, total sentinel event reports will likely surpass the 1,197 sentinel events reported in 2021, which represented the highest annual level seen since the accrediting body started publicly reporting them in 2007. Learn how working with the Joint Commission benefits your organization and community. Herman McKenzie is currently the director, Department of Engineering in the Standards Interpretation Group at The Joint Commission. Drive performance improvement using our new business intelligence tools. 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. 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. We help you measure, assess and improve your performance. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. They're now conducting both . 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. 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. PC.01.03.01: The organization plans the patients care. We have noted on consultation surveys that organizations establish timeframes and use of a particular tool for assessment whereas reassessments are sometimes missed, or the required tool is not used. Many settings still dont have a meter, an alarm or even a ball in the wall device to identify the correct air pressure relationship. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. The last two months we provided the link to the data CMS is analyzing relative to Covid-19 test positivity in counties throughout the US. This would be an organizational decision and the organization will be surveyed to the process approved by leadership. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. It contains valuable information from ISMP and ECRI as to the root causes of infusion pump errors, such as bypassing the integrated software, or not integrating the pumps electronically with your medication orders in the EMR. Get more information about cookies and how you can refuse them by clicking on the learn more button below. 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. Information on all things ambulatory from The Joint Commission, By Hermann McKenzie, MBA, CHSP, director of engineering, Standards Interpretation Group; Elizabeth Even, MSN, RN, CEN, Associate Director, Clinical Standards Interpretation Group; and Tiffany Wiksten, MSN, RN-CIC, Associate Director, Standards Interpretation. You certainly would not want to be in a position of stating you have not seen the alert or have not considered the recommendations. However, with increased supplies and FDA guidance to move away from reprocessing, we wanted to highlight the last paragraph from this OSHA memo. IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies. Q1 through Q3 2018: Joint Commission Findings (average ndings per survey: 32) Subject EP Incidence (Approx.) 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. Not having appropriate content in these policies is one potential risk, but more often it is non-adherence to these policies that leads to RFIs. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. So, if you are still reprocessing, you may want to take a look at this EC News article and reconsider that decision. Whether you need help with fire protection, utility systems or means of egress, youll find the support you need to achieve compliance. 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 During 2020, there were shortages of the previously discussed staff respirators, ventilators, and oxygen. Interoperability Requirements. 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. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! 46% of sentinel events led to a patients death. Many organizations employ reminder files and may elect to maintain all providers on the same or rolling calendar date for renewals to stay on top of the process. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. The Joint Commission is a registered trademark of the Joint Commission enterprise. This article explains the requirements better than just reading the standards and more importantly they include a decision tree or flow chart that depicts the signage required for each situation. These are searchable keywords surveyors can use to help them find where to score a particular issue. 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. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Due to the pandemic, total survey volume was less than in prior years. 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. The hospital reduces the risk of infections associated with medical equipment, devices and supplies. We sometimes see these, and at times there is no awareness that radiology has a unique infusion pump that is not part of the hospital wide update process. Planning for an influx or surge has been a feature of the IC and EM standards for many years. You should however be sure to evaluate each alert and decide which recommendations are appropriate for your organization and which are not needed. 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. See how our expertise and rigorous standards can help organizations like yours. 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. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. 2. This portal will provide information to reduce findings of non-compliance. Learn how working with the Joint Commission benefits your organization and community. 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 Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Its important to document this activity to ensure there is a reconciliation for all extinguishers on the inventory. One tip often shared with organizations is that whenever there is a change in how they bring in providers, they should also evaluate the process approved by leadership to evaluate if changes need to be made to ensure both accreditation and organizational requirements are met. Environment of Care By not making a selection you will be agreeing to the use of our cookies. 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. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. 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. QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. QSA.02.11.01: The laboratory conducts surveillance of patient results and related records as part of its quality control program. 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. 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