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 Joint Commission is a registered trademark of the Joint Commission enterprise. 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 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. He was part of the team that opened the first new hospital in Illinois in over 25 years. 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. Learn about the development and implementation of standardized performance measures. Find evidence-based sources on preventing infections in clinical settings. For example, it is not common to have a basketball hoop in a gym area and such a potential hazard is not typically going to be on a national environmental risk assessment tool. If you have further questions, please do not hesitate to contact your account executive or the Standards Interpretation Group. 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. Sentinel Event Alert Infusion Pumps, Alternative Equipment Maintenance (AEM) Strategies Next Post: Joint Commission Top 10 Findings. Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. Environment of Care Linking and Reprinting Policy. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. Copyright 2023 Becker's Healthcare. 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. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. However, this is not the case. Find the exact resources you need to succeed in your accreditation journey. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. 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.. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. 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. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. They're now conducting both . EC.02.06.01: The hospital establishes and maintains a safe, functional environment. This would be an organizational decision and the organization will be surveyed to the process approved by leadership. All Rights Reserved. All Rights Reserved. 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. CMS and Joint Commission have been examining this data to determine suitability for survey. 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 By not making a selection you will be agreeing to the use of our cookies. TJC in the guidance advises its surveyors to contact the Standards Interpretation Group for an escalation evaluation. We will be extra blunt: the issues discussed in this column could lead to adverse determinations such as immediate jeopardy and preliminary denial of accreditation. The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. 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. NPSG.15.01.01: Reduce the risk for suicide. MM.01.01.03: The practice safely manages high-alert and hazardous medications. Privacy Policy. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. In 2021, the most challenging ambulatory care standards fell in the realm of: environment of care (EC) infection control (IC) human resources (HR) We've gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. 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 . She is also on staff in the emergency department at Northwestern Memorial Hospital. They're as follows: Life Safety Requirements for Business Occupancies 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. Building is shaped like the Star of Life. 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. Reader Interactions. MM.06.01.01: The critical access hospital safely administers medications. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. Set expectations for your organization's performance that are reasonable, achievable and survey-able. 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. By continuing to use our site, you acknowledge that you have read, that you understand, and that you accept our. 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. All Rights Reserved. Home > Resources > News & Multimedia > News Releases > 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. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. 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. Jennifer Cowel, RN MHSA TJC announced a new Speak Up video they have developed for new parents. Whether you need help with fire protection, utility systems or means of egress, youll find the support you need to achieve compliance. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Patient Safety Topics. We hope this post helps you avoid some of the problems that have impacted other ambulatory care organizations. 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. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! There is also a link to the OSHA guidance that was issued during the height of the pandemic in April 2020 that had discussed reprocessing of respirators. Learn about the priorities that drive us and how we are helping propel health care forward. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. Staff who are responsible for accessing clean medical equipment, devices and supplies need to do so in a manner to prevent contamination. Please contact us soon! Find the exact resources you need to succeed in your accreditation journey. We help you measure, assess and improve your performance. Learn about the "gold standard" in quality. 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. According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. 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. HRM.01.02.01: The organization verifies and evaluates staff credentials. contains information that reflects the patients care, treatment, or services. Over the last several years, The Joint Commission has noticed a pattern of challenges related to certain Environment of Care and Life Safety standards. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. Find the exact resources you need to succeed in your accreditation journey. Due to the pandemic, total survey volume was less than in prior years. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The second most common issue falls into the maintenance of provider files, including issues related to licensure verification prior to the expiration date and renewal of privileges prior to when the current privileges expire. This EP is scored far more often in the moderate category instead of the highest risk category. Interoperability Standard Revision IC 02.02.01 This standard helps organizations reduce the risk of infections associated with medical equipment, devices and supplies. JenCowel@PattonHC.com, John Rosing, MHA This portal will provide information to reduce findings of non-compliance. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. 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. In 2021, the most frequently reported sentinel event category was care management events with patient falls being the single largest reported harm events. This was scored by TJC in the red, high risk category more than twice as often as in the moderate. 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. 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. Learn how working with the Joint Commission benefits your organization and community. 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