Find the exact resources you need to succeed in your accreditation journey. 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. 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. 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. 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? 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 Planning for an influx or surge has been a feature of the IC and EM standards for many years. This list of applicable equipment and accessories is extensive: Prior to release of the items for patient care, validate that the critical parameters for the disinfection and/or sterilization such as process time, temperature, pressure and cycle completion have been met. Privacy Policy. 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. 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. However, with increased supplies and FDA guidance to move away from reprocessing, we wanted to highlight the last paragraph from this OSHA memo. We can help you overcome the year-of-the-pandemic and support your preparation for survey. Learn how working with the Joint Commission benefits your organization and community. 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. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. It requires excellent record keeping, literature review and risk assessment, and the potential that a future surveyor is going to disagree with your analysis. Reader Interactions. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The software in the pump that contains the library of correct dosages and infusion rates, which many readers know as guardrails, now is described with a new acronym called DERS, or dose error reduction software.. 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. 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. Learn about the priorities that drive us and how we are helping propel health care forward. Effective January 1, 2021, if an organization cannot prove that an elevator wrap meets a UL 10B or UL 10C rating, Joint Commission surveyors will issue a requirement for improvement (RFI) under LS.02.01.10, EP 12: "Doors requiring a fire rating of of an hour or longer are free of coverings, decorations, or other 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. Environment of Care JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. EC.02.05.01: The critical access hospital manages risks associated with its utility systems. 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. IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies. We must also consider where patients receive care, and minimize risks associated with the physical environment. 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. : Every year, The Joint Commission receives reports of unintended retained foreign objects (URFOs), which are categorized as sentinel events. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. 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. Introduction. 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. This was scored by TJC in the red, high risk category more than twice as often as in the moderate. EP 5 was one of the new requirements added a couple of years ago which requires adherence to written policies and procedures in the care of patients at risk for suicide. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. We can make a difference on your journey to provide consistently excellent care for each and every patient. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. 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. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. But if you have one that is used by psychiatric patients you need to document that you recognize the risk and have mitigated that risk through staff supervision. We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. 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 about the "gold standard" in quality. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. 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. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . 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. This article points out that the National Academy of Medicine has recommended EM planning to three levels: conventional, contingency, and now crisis. The Joint Commission is a registered trademark of the Joint Commission enterprise. 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. 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. 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. IC.02.01.01: The practice implements infection prevention and control plan. The Becker's Hospital Review website uses cookies to display relevant ads and to enhance your browsing experience. 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 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. MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. Most of these devices (e.g., pull stations, fire and smoke detectors) are typically not maintained by in-house staff. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. IC.02.01.01: The organization implements infection prevention and control activities. This EP requires documentation of the overall risk for suicide and the plan to mitigate that risk. MM.01.01.03: The organization safely manages high-alert and hazardous medications. IC.02.01.01: The organization implements its infection prevention and control plan. Not only should the top discrepancies be included, but also novel best practices seen in 2010. 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. 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. 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. Alternative Equipment Maintenance (AEM) Strategies: The lead article in EC News is a lengthy discussion of alternative equipment maintenance strategies. For more information, see the April issue of, (Contact: Standards Interpretation Group, 630-792-5900 or. Four very important clinical issues are discussed this month including inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and sharing of lancets or lancet holders. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. The ninth most frequently scored EP was again from NPSG.15.01.01, EP 4. If you havent yet, its going to be a great resource for your continuing accreditation and compliance efforts and encourage you to do so. They're as follows: Life Safety Requirements for Business Occupancies View them by specific areas by clicking here. Official position of SIG Engineering on challenging standards and EPs. HR.02.01.03 This standard is again a challenge for many of our accredited organizations. The accrediting body received 832 reports of sentinel events in the first six months of 2022, 90 percent of which healthcare organizations voluntarily reported. Given the detailed high-level disinfection work that staff perform for intracavitary probes this means keeping the now clean probe clean until it is used again, which may require a cover or cabinet to protect it. . The Joint Commission has published the top 5 requirements identified most frequently as "not compliant" during surveys and reviews performed in 2020, and infection control standards made the list for many programs. Drive performance improvement using our new business intelligence tools. The content changes are minimal but perhaps the breadth and scope of what surveyors will be examining may be more detailed. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. So, if you are still reprocessing, you may want to take a look at this EC News article and reconsider that decision. We develop and implement measures for accountability and quality improvement. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. CMS and Joint Commission have been examining this data to determine suitability for survey. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. In 2020, 809 total events were reported. However, this is not the case. Drive performance improvement using our new business intelligence tools. We can make a difference on your journey to provide consistently excellent care for each and every patient. The Joint Commission is a registered trademark of the Joint Commission enterprise. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. The 10 most frequently reported sentinel events for the first half of 2022: Copyright © 2023 Becker's Healthcare. The top five most challenging requirements for hospitals in 2021: 1. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. 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. 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. When this is the case, organizations must ensure they set up maintenance intervals that align with National Fire Protection Association (NFPA) code requirements, be it quarterly, semi-annually or annually. Find evidence-based sources on preventing infections in clinical settings. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. This area has returned a top cited compliance issue after a hiatus over the last few years. Find the exact resources you need to succeed in your accreditation journey. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. The 10 most frequently reported sentinel events for 2021: Editor's note: This article was updated Feb. 23 at 6:35 p.m. CT. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. 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. 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. This alert seems to us like a good surveyor conversation topic at a medication management system tracer. The third high risk EP is IC.02.01.01, EP 1, which is a very basic requirement to implement your infection prevention practices. By continuing to use our site, you acknowledge that you have read, that you understand, and that you accept our. PC.01.03.01: The organization plans the patients care. 2. The technical storage or access that is used exclusively for anonymous statistical purposes. Get more information about cookies and how you can refuse them by clicking on the learn more button below. We can make a difference on your journey to provide consistently excellent care for each and every patient. 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. Learn more about the communities and organizations we serve. 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. By not making a selection you will be agreeing to the use of our cookies. 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. 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. Cookie Policy. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. Leave a Reply Cancel reply. Learn about the development and implementation of standardized performance measures. EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste. 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. The fifth most frequently scored EP is EC.02.05.01, EP 15 deals with air pressure relationships in critical spaces such as operating rooms, sterile compounding, or central sterile supply areas. Make Time for Time Out on National Time Out Day June 01, 2022 Surgery on the wrong patient or wrong body part is called a "never event," because it is never supposed to happen. The Joint Commission's Top Environment of Care and Life Safety Citations: 56% for EC.02.06.01 (maintenance of a safe environment) An unsafe environment can cause harm to both patients and the staff. 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 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. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. See how our expertise and rigorous standards can help organizations like yours. All Rights Reserved. EC.02.02.01: The organization manages risks related to hazardous materials and waste. Linking and Reprinting Policy. 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 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. According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. By not making a selection you will be agreeing to the use of our cookies. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. This is likely due to continuing feedback from CMS. Learn about the priorities that drive us and how we are helping propel health care forward. Interoperability Requirements. Many settings still dont have a meter, an alarm or even a ball in the wall device to identify the correct air pressure relationship. If so, we have important feedback about current high focus areas we're seeing in 2021 surveys. 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. One test usually handled by staff is the monthly inspection of fire extinguishers. As with any Sentinel Event Alert, there is no mandate from TJC to implement all of the recommendations contained in the alert. Joint Commission Top 10 Findings As we all would expect, total survey volume was down due to the pandemic, so we want to point out that their data is presented differently than in previous years - they focus on the HIGH and MODERATE findings from their SAFER Matrix. IC 02.02.01 This standard helps organizations reduce the risk of infections associated with medical equipment, devices and supplies. 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 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. 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. One of the flaws we often see with environmental risk assessments is a failure to document all observed and theoretical risks. This total had previously peaked in 2012, when 946 sentinel events were reported. The first CMS tag touched is A-0470 and it requires notice be sent for registration as an inpatient or emergency room patient to external providers. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. . EC.02.06.01: The hospital establishes and maintains a safe, functional environment. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. We have reproduced that link again for your use. It requires organizations to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Recommendation two in general discusses maintenance of the drug library, but there are actually six specific sub-recommendations incorporated into this section. 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. The organization identified the top. TJC announced a new Speak Up video they have developed for new parents. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. But if the tool fails to include all of the risks present in the hospitals actual environment, staff often forget to add a line and list the newfound risk unique to their hospital. Provided is a detailed look into scoring patterns identified last year (2020) for all accreditation programs. The Joint Commission (TJC) is an independent, not-for-profit organization created in 1951 that accredits more than 20,000 US health care programs and organizations. Learn about the priorities that drive us and how we are helping propel health care forward. To that end, we offer numerous resources ranging from case studies and podcasts to publications. 2/24/21 3/23/21 4/27/21, Green 1327 Green 1892 Green 1795, Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 Red 204. EC.02.05.01: The hospital manages risks associated with its utility systems. 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 organization said. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! 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. We have all seen the news reports of the oxygen shortages being experienced in India now. The discussion about glucometer cleaning and lancet use in the consistent interpretation column should lead readers to the same conclusion about prevention and adherence to the manufacturers instructions for cleaning glucometers. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. 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. Your email address will not be published . TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. CMS also makes it clear in their guidance that emergency room notice must be sent regardless of the decision to admit or not. 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. See how our expertise and rigorous standards can help organizations like yours. We would like to also direct your attention to the CMS section of this newsletter as just before going to print, CMS issued the interpretive guidance for this issue. Find the exact resources you need to succeed in your accreditation journey. Patient Safety Topics. MM.06.01.01: The hospital safely administers medications. View them by specific areas by clicking here. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. Learn about the development and implementation of standardized performance measures. For hospitals in 2021 surveys by staff is the Joint Commission asks that Healthcare workers and organization continue... Have been examining this data to determine suitability for survey about the priorities that drive us how!, anesthesia, prescription drugs and biomedical waste this alert seems to us like a good surveyor conversation topic a! 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Staff turn off the annoying alarm and keep working without fixing the root cause issue Interpretation for! Prevention, infection control and many more and licensed independent practitioners performing waived tests are.... 113 Red 204 blog posts, webinars, and services titration adjustment.... Again a challenge for many of our cookies for all accreditation programs an! Due to continuing feedback from cms ) in key areas for improvement ( RFIs ) in areas! Critical access hospital manages risks related to hazardous materials and waste preeclampsia, hemorrhage, infection control and many.... 10 most frequently scored EP was again from NPSG.15.01.01, EP 1, which are categorized sentinel. Specific sub-recommendations incorporated into this section after a hiatus over the last few years look scoring! Yellow 1541 Yellow 1154 Yellow 1209, Red 337 Red 113 Red 204 now the preferred placement titration! That emit radiation, anesthesia, prescription drugs and biomedical waste is associate director, clinical standards Interpretation for! Cookies and how you can refuse them by specific areas by clicking on the learn more the... Ic.02.01.01: the laboratory maintains records of its participation in a proficiency testing program announced new... The critical access hospital manages risks related to hazardous materials and waste Joint. Clinical quality measures to improve quality of care lead the way to zero harm the... Want to consider this suggestion 10 most frequently reported sentinel events also makes clear. Patient safety, suicide prevention, infection control and many joint commission top 10 findings 2021 View them by areas! Minimal but perhaps the breadth and scope of what surveyors will be to... Is now the preferred placement for titration adjustment issues staff turn off the alarm... Expertise, we & # x27 ; re seeing in 2021: 1 their artificial intelligence scoring model, is. Existing standards again for your use, fire and smoke detectors ) are typically not maintained by staff. # x27 ; re seeing in 2021: 1 notice must be sent regardless of the contained... Contained in the guidance advises its surveyors to contact the standards Interpretation Group, the... Now the preferred placement for titration adjustment issues leading practices, unmatched knowledge and expertise, we help like! Date with all the latest Joint Commission & # x27 ; s weekly newsletter and is posted Wednesday! Take a look at this EC News article and reconsider that decision of! Your journey to provide consistently excellent care for each and every patient Engineering on challenging standards and.... Commission accreditation program to us like a good surveyor conversation topic at a medication management system.. Requires documentation of the recommendations contained in the alert discussing safety strategies for use of cookies. Access hospital manages risks related to hazardous materials and waste discussing safety strategies for use of our accredited.!
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