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. 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. Did you get a chance to read our May issue of the Patton Post? Mr. McKenzie has more than 25 years of health care experience having held managerial and director level roles in clinical engineering, plant operations and facilities services throughout the Chicagoland area. Learn about the "gold standard" in quality. The breakdown is as follows: Ambulatory Health Care Infection control standards take the top two spots: 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. IC 02.02.01 This standard helps organizations reduce the risk of infections associated with medical equipment, devices and supplies. IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies. 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 LS and EC requirements have not changed significantly in recent years and yet hospitals continue to fall short with meeting compliance in these areas. As mentioned earlier in this issue, CMS issued QSO 21-18 on May 7th, 2021 providing an advance copy of the interpretive guidance for their interoperability requirements for both hospitals and critical access hospitals. The terminology and description of the different types of respirators is sometimes confusing, so we have included here a CDC infographic that identifies the different types of equipment in use throughout the nation. 46% of sentinel events led to a patients death. Learn about the development and implementation of standardized performance measures. 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. Learn about the "gold standard" in quality. 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. All Rights Reserved. IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 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.. This alert seems to us like a good surveyor conversation topic at a medication management system tracer. Failure to perform the minimum level of reprocessing based on intended use or follow the manufacturers validated instructions can lead to improperly disinfected or sterilized items. Learn about the priorities that drive us and how we are helping propel health care forward. 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. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. MM.01.01.03: The practice safely manages high-alert and hazardous medications. View them by specific areas by clicking here. The accrediting body received 832 reports of sentinel events in the first six months of 2022, 90 percent of which healthcare organizations voluntarily reported. In 2020, 809 total events were reported. 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. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. IC.02.01.01: The organization implements the infection prevention and control activities it has planned. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. 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. IC.02.01.01: The organization implements its infection prevention and control plan. We do have a preference for printed materials that a patient can refer to, but this video might be a valuable component of your patient education initiative. If you have further questions, please do not hesitate to contact your account executive or the Standards Interpretation Group. CMS also makes it clear in their guidance that emergency room notice must be sent regardless of the decision to admit or not. We must also consider where patients receive care, and minimize risks associated with the physical environment. LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services. 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 Compliance Challenges for Ambulatory Care Organizations in 2021, manufacturers instructions for use (MIFU) and/or processes, instruments used for surgery and/or procedures. 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 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. Rank Incidence of High Harm Percent High Harm Clinical or Environmental Association with ITL Clinical High-level disinfection and sterilization IC.02.02.01 EP02 2000 2 790 40% Clinical 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. 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. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. Q1 through Q3 2018: Joint Commission Findings (average ndings per survey: 32) Subject EP Incidence (Approx.) Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA Planning for an influx or surge has been a feature of the IC and EM standards for many years. 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. IC.02.01.01: The practice implements infection prevention and control plan. New Speak Up Video Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. Get more information about cookies and how you can refuse them by clicking on the learn more button below. 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 organization defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing 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. One of the keywords they have included from this element of performance is titration rates. As we have all seen for maybe the last five years, medication titration adjustments and documentation have been one of the more frequently scored issues on survey. This was identified at a high-risk level in 99 hospital surveys and at a moderate risk level in another 107 hospital surveys. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Patient falls were the most common sentinel event reported among hospitals in the first six months of 2022, according to a Sept. 7 report from The Joint Commission. 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. Remembering which sign is required in different situations is difficult. Previously we have seen a failure to adhere to the prescribed titration adjustment methodology scored under PC.02.01.03 for a failure to adhere to orders as prescribed. However, with increased supplies and FDA guidance to move away from reprocessing, we wanted to highlight the last paragraph from this OSHA memo. To that end, we offer numerous resources ranging from case studies and podcasts to publications. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! The 10 most frequently reported sentinel events for 2021: Fall 485 reported events Delay in treatment 97 Unintended retention of a foreign object 97 Wrong surgical site 85 Patient. 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 The eighth most frequently scored EP was NPSG.15.01.01, EP 5. 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. In this case, a specific consent must be obtained from the patient to send the notice to other providers. : This latest post in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the risk for suicide will discuss the element of performance (EP) focused on written policies and procedures addressing the care and follow-up for individuals at risk for suicide, writes Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group, and Stacey Paul, MSN, PMHNP-BC, Project Director, Healthcare Standards Development. The Joint Commission is a registered trademark of the Joint Commission enterprise. This is a very interesting recommendation in that you have an opportunity to potentially intervene in real time to prevent patient injury. 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. Learn how working with the Joint Commission benefits your organization and community. This portal will provide information to reduce findings of non-compliance. 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. The Joint Commission is a registered trademark of the Joint Commission enterprise. We help you measure, assess and improve your performance. The TJC change is noted in IM.02.02.07, EP 5 which discusses notifications the hospital must send to aftercare providers. JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. 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. Copyright © 2023 Becker's Healthcare. Most of these devices (e.g., pull stations, fire and smoke detectors) are typically not maintained by in-house staff. Interoperability Standard Revision Joint Commission Top 10 Findings Despite the pandemic and the year we thought would never end, we're already halfway through 2021! According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. 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