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. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. 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. 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. We frequently refer to this EP as the eyewash EP where a lack of access to an eyewash, an improper eyewash, or failure to test an eyewash could potentially be scored. The TJC change is noted in IM.02.02.07, EP 5 which discusses notifications the hospital must send to aftercare providers. Find evidence-based sources on preventing infections in clinical settings. All Rights Reserved. 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. She is also on staff in the emergency department at Northwestern Memorial Hospital. JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. Due to the pandemic, total survey volume was less than in prior years. 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. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. Learn how working with the Joint Commission benefits your organization and community. We must also consider where patients receive care, and minimize risks associated with the physical environment. Introduction. Cookie Policy. All Rights Reserved. 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. He was part of the team that opened the first new hospital in Illinois in over 25 years. We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. CMS also makes it clear in their guidance that emergency room notice must be sent regardless of the decision to admit or not. 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. In 2020, 809 total events were reported. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. This was identified at a high-risk level in 99 hospital surveys and at a moderate risk level in another 107 hospital surveys. Find the exact resources you need to succeed in your accreditation journey. New Joint Commission Requirements Effective 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21. This EP requires documentation of the overall risk for suicide and the plan to mitigate that risk. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. Its important to document this activity to ensure there is a reconciliation for all extinguishers on the inventory. 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. Many organizations are under the false impression that because the providers they hire are employed elsewhere they do not have to credential and privilege them at their organization. HR.02.01.03 This standard is again a challenge for many of our accredited organizations. Learn about the "gold standard" in quality. The decision on who an organization brings in to care for its patients is arguably the most important decision an organization makes. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The bad news is we see some slippage in end of April data with more red and yellow counties, and fewer green counties. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. We develop and implement measures for accountability and quality improvement. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. Learn how working with the Joint Commission benefits your organization and community. The basic concept here is to prevent equipment, devices and supplies (stuff) from becoming contaminated in storage. The purpose of this portal is to provide guidance and education to reduce instances of non-compliance with the top Environment of Care/Life Safety standards. Many settings still dont have a meter, an alarm or even a ball in the wall device to identify the correct air pressure relationship. 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. By not making a selection you will be agreeing to the use of our cookies. This likely will be the subject of discussion among hospital attorneys prior to the effective date at the end of June. Protecting patients from harm involves more than safe treatments and procedures. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. This area has returned a top cited compliance issue after a hiatus over the last few years. 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. Whether these tasks are performed by in-house staff or a contractor, the responsible party must have a working knowledge of the EPs and the intent of the code requirements. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. 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. 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. 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. Tiffany Wiksten, MSN, RN-CIC, is Associate Director, Standards Interpretation Department. 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. During 2020, there were shortages of the previously discussed staff respirators, ventilators, and oxygen. New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. Learn about the priorities that drive us and how we are helping propel health care forward. EC.02.05.01: The critical access hospital manages risks associated with its utility systems. The Becker's Hospital Review website uses cookies to display relevant ads and to enhance your browsing experience. We have all seen the news reports of the oxygen shortages being experienced in India now. According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. In this case, a specific consent must be obtained from the patient to send the notice to other providers. See how our expertise and rigorous standards can help organizations like yours. 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. 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. The Joint Commission is a registered trademark of the Joint Commission enterprise. IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. IC.02.01.01: The practice implements infection prevention and control plan. Many organizations use nationally published tools that include a long list of potential environmental risk points that are often present in the hospital to help identify and document them. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. We hope that you have all gotten a chance to check out our NEW WEBSITE to view all the new and reformatted tools available to you! There are many opportunities surrounding the credentialing and privileging process that are identified during survey due to the fact that care is delivered by: Organizations that have expanded their provider hiring process may be following Joint Commission requirements, but not their own policies as described under EP 1 which states, The organization follows a process, approved by its leaders, to grant initial, renewed, or revised privileges and to deny privileges.. The ninth most frequently scored EP was again from NPSG.15.01.01, EP 4. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. MM.06.01.01: The hospital safely administers medications. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. 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