Nancy Claflin RN PhD CCRN NEA-BC CPHQ FNAHQ VHA-CM.

Joint Commission Update 2014

Nancy Claflin RN PhD CCRN NEA-BC CPHQ FNAHQ VHA-CM

The way health care conducts improvement is itself in need of improvement

Help health care make progress toward high reliability

Achievement of extremely high levels of safety maintained over long periods of time

Safety comparable to that demonstrated by the commercial air travel, nuclear power, and amusement park industries

New Approaches Necessary toImprove Health Care

1. Eliminate Overuse of Health Services Avoiding tests, treatments, and procedures

that do not provide significant benefit has the potential to both improve quality and reduce costs

Examples: Antibiotics for colds Early elective deliveries without a medical

indication

Improve Healthcare

2. Recognize that one size does not fit all Using process improvement tools and

methods such as Robust Process Improvement™ (RPI) enables health care organizations to find unique solutions

Approach differs from long-standing efforts that emphasize evidence-based guidelines, checklists, and toolkits that typically are not customized

Improve Healthcare

3. Create a culture of safety Stopping intimidating & disrespectful

behaviors could help encourage candid reporting of and dialogue about errors, close calls, and unsafe conditions

Reporting and learning from blameless errors and unsafe conditions doesn’t eliminate need for personal responsibility

Accountability for adhering to agreed-upon safe practices is also a key component of a culture of safety

Improve Healthcare

Joint Commission began requiring organizations accredited under ambulatory care, behavioral health care, home care, hospital, and laboratory programs to submit Focused Standards Assessment (FSA) in February 2013

Critical access hospitals and nursing homes are required to submit the FSA effective January 1, 2014

While office-based surgery practices can still use the FSA for self-assessment, they are not required (or able) to submit an FSA

Focused Standards Assessment

Change to Contingent Accreditation Modified Contingent Accreditation (CONT)

CONT01 Accreditation Committee will determine if the

organization’s corrective action is sufficient to change the decision from Preliminary Denial of Accreditation (PDA) to Contingent Accreditation

Occurs after Immediate Threat to Life (ITL) finding at survey and follow up visit verified sufficient corrective action to remove ITL

Changes to Accreditation Decisions

Added the failure to successfully address all Requirements for Improvement (RFIs) in submitting an Evidence of Standards Compliance (ESC) or Measure of Success (MOS) to CONT05

Introduced new certification decision rules due to a revised decision process in which the only two possible outcomes are Certified or Not Certified

Changes to Accreditation Decisions

The Joint Commission’s reinvented Long Term Care Accreditation Program new name

Nursing Care Center Accreditation Program

Reflects reinvented program’s focus on organizations that provide complex nursing care, which could include post-acute care and other services for both short-stay patients and long-term residents

Nursing Care Center Accreditation Program

Behavioral Health Home (BHH) certification accredited under the Behavioral Health Care Accreditation Program effective January 1, 2014

Focuses on coordinating & integrating behavioral & physical health care for individuals with serious mental illness, children with serious emotional disturbances, adults with developmental/ intellectual disabilities, & patients in opioid treatment programs

People with serious mental illness die 25 years earlier than general population

Suicide &injury account 30% to 40% 60% due to medical conditions (cardiovascular,

pulmonary, infectious)

Behavioral Health Home Certification

Increased ORYX® performance measure reporting requirements for accredited general medical/surgical hospitals

From a minimum of four (4) sets of core measures to at least six (6) sets of core measures for discharges

Effective January 1, 2014 Additional measure set selections include

both mandatory & discretionary measure sets

ORYX

Acute myocardial infarction (AMI) Heart failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP)

Perinatal care (PC)—for hospitals with 1,100 or more live births per year

Mandatory Measure Sets

Discretionary sixth measure set (Or fifth and sixth measure sets, for hospitals with fewer than 1,100 births per year)

Can be chosen from among the remaining complement of core measure sets

Discretionary Measure Set

Children’s asthma care (CAC) Hospital-based inpatient psychiatric services

(HBIPS) Hospital outpatient (OP) Immunization (IMM) Emergency department (ED) Venous thromboembolism (VTE) Stroke (STK) Tobacco treatment (TOB) Substance use (SUB) Perinatal care (PC)—for hospitals with fewer than

1,100 live births per year

Discretionary Measure Set

Revision to Quality System Assessment for Nonwaived Testing (QSA) Standard QSA.05.01.01 (EP) 4

How frequently policies/procedures of blood transfusion services are reviewed for laboratory accreditation program

Revised requirement allows blood transfusion service director/technical supervisor to review blood transfusion policies/procedures every two years instead of annually

Laboratory Standards Revision

Requirements for Emergency Management Oversight

Hospital effectively manages its programs, services, sites, or departments

EP 12 Leaders identify an individual to be accountable for the following:

Emergency Management

Staff implementation of 4 phases of emergency management (mitigation, preparedness, response, & recovery)

Staff implementation of emergency management across 6 critical areas (communications, resources & assets, safety & security, staff responsibilities, utilities, and patient clinical & support activities)

Collaboration across clinical & operational areas to implement emergency management hospital wide

Identification of & collaboration with community response partners

LD.04.01.05

Hospital evaluates effectiveness of its emergency management planning activities

EP 4 The annual emergency management planning reviews are forwarded to senior hospital leadership for review (See also LD.04.01.01 EP 25)

EM.03.01.01

Hospital evaluates the effectiveness of its Emergency Operations Plan

EP 13 Based on all monitoring activities &

observations, including relevant input from all levels of staff affected, hospital evaluates all emergency responses exercises and all responses to actual emergencies using a multidisciplinary process (which includes Licensed Independent Practitioners (LIPs))

EM.03.01.03

EP 15 The deficiencies & opportunities for

improvement identified in the evaluation of all emergency response exercises and all responses to actual emergencies, are communicated to the improvement team responsible for monitoring environment of care issues and to senior hospital leadership.

EM.03.01.03

Leaders establish priorities for performance improvement

Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following:

LD.04.04.01

Review of the annual emergency management planning reviews

Review of the evaluations of all emergency response exercises and all responses to actual emergencies

Determination of which emergency management improvements will be prioritized for implementation

LD.04.01.01

Revisions approved June 2012 Most became effective January 2013 Two EPs became effective January 2014 Standards impacted LD.04.03.11 The hospital manages the flow

of patients throughout the hospital PC.01.01.01 The hospitals accepts the

patient for care, treatments, and services based on its ability to meet the patients’ needs (Perspectives, July 2012)

Patient Flow

Revisions address the following: Leadership use of data and measures to

identify, mitigate, and manage issues affecting patient flow throughout the hospital (effective January 2014)

Management of the Emergency Department throughput as a system-wide issue

Safety for boarded patients Leadership communication with behavioral

health providers and authorities to enhance coordination of care

Patient Flow LD.04.03.11

All EPs related to risk Patient flow throughout organization

including boarding Not just Emergency Department Monitoring Managing Anticipating and mitigating Observing for trends Clear goals & accountability for

improvement

Patient Flow LD.04.03.11

Revision addresses safety for boarded patients with behavioral health emergencies in the following areas:

Environment of care, location Staffing and orientation/training Assessment, reassessment, and the care

provided

Patient Flow PC.01.01.01

Behavioral patients boarded for extended periods of time may not receive the safe, quality care needed

Staff may not be prepared to deal with this vulnerable, challenging population

Environment may not be suited to the needs of the behavioral health population

Policies and practices in the community may contribute to making this a complex issue

Patient Flow PC.01.01.01

NPSG.06.01.01 Improve the safety of clinical alarms

Implementation in two phases Phase I beginning January 2014 Hospitals required to establish alarms as an

organization priority and identify the most important alarms to manage based on their own internal situations

Clinical Alarms

NPSG.06.01.01 Improve the safety of clinical alarms

Phase II beginning January 6 Hospitals expected to develop and

implement specific components of policies and procedures

Education of those in the organization about alarm system management will also be required

Clinical Alarms

NPSG.06.01.01 1. As of July 1, 2014, leaders establish

alarm system safety as a hospital priority 2. During 2014, identify the most important

alarm signals to manage based on the following:

Input from medical staff and clinical departments

Risk to patients if the alarm signal is not attended to or if it malfunctions

Elements of Performance

NPSG.06.01.01 2. During 2014, identify the most important

alarm signals to manage based on the following:

Whether specific alarm signals are needed or unnecessarily contribute to alarm noise & alarm fatigue

Potential for patient harm based o internal incident history

Published best practices and guidelines

Elements of Performance

3. As of January 1, 2016, establish policies/ procedures for managing alarms identified in EP 2 that at a minimum address the following:

Clinically appropriate settings for alarm signals

When alarm signals can be disabled When alarm parameters can be changed Who in the organization has the authority to

set alarm parameters Who in the organization has the authority to

change alarm parameters

NPSG.06.01.01

3. As of January 1, 2016, establish policies/ procedures for managing alarms identified in EP 2 that at a minimum address the following:

Who in the organization has the authority to set alarm parameters to “off”

Monitoring and responding to alarm signals Checking individual alarm signals for

accurate settings, proper operation, and detectability

NPSG.06.01.01

Staffing patterns Care model Patient population Technology capabilities & configuration Architectural layout Alarm coverage model Ancillary technology Delineation of responsibility Culture

Alarm Management

Sentinel Event Alert Issue 51 How to avoid leaving items (sponges, towels,

instruments) in a patient’s body after surgery Unintended retention of foreign objects (URFOs)

or retained surgical items (RSIs) serious patient safety issue may cause death or physical and emotional harm

>770 voluntary reports of URFOs, 16 resulting in death during past 7 years

95% additional care and/or extended stay $200,000 in medical and liability payments each

Preventing URFOs

Soft goods (sponges and towels) Small miscellaneous items, including

unretrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains

Needles and other sharps Instruments, most commonly malleable

retractors

URFOs

Wrong-patient, wrong-site, or wrong-procedure—60

Unintended retention of a foreign object—56 Delay in treatment—56 Falls—48 Other unanticipated events—40 Operative/postoperative complication—37 Suicide—35 Criminal event (assault/rape/homicide)—26 Medication error—20 Perinatal death/injury—15

Most Frequently Reported Sentinel Events January – June 2013

Human factors (such as fatigue or distraction)—314

Communication (such as among staff, across disciplines, or with patients)—292

Leadership (regarding lack of performance improvement infrastructure or community relations)—276

Assessment (such as patient observation processes or its documentation)—246

Information management (such as patient identification of confidentiality)—101

Most Frequently Identified Root Causes January – June 2013

Physical environment (such as emergency management or hazardous materials)—70

Care planning (planning and/or interdisciplinary collaboration)—49

Continuum of care (includes transfer and/or discharge of patient)—48

Medication use (such as storage/control or labeling)—48

Operative care (such as blood use or patient monitoring)—45

Most Frequently Identified Root Causes January – June 2013

Standard

55% RC.01.01.01 The hospital maintains complete and accurate medical records for each individual patient.

54% LS.02.01.20 The hospital maintains the integrity of the means of egress.

47% IC.02.01.01 The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

46% EC.02.05.01 The hospital manages risks associated with its utility systems.

45% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke,and heat.

Hospitals

Standard

44%

EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.

43%

LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

38%

LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.

36%

EC.02.06.01 The hospital establishes and maintains a safe, functional environment.

33%

MM.03.01.01 The hospital safely stores medications.

Hospitals

Standard

53%

EC.02.03.05 The critical access hospital maintains fire safety equipment and fire safety building features.

49%

LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

47%

EC.02.05.01 The critical access hospital manages risks associated with its utility systems.

43%

IC.02.02.01 The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

43%

LS.02.01.20 The critical access hospital maintains the integrity of the means of egress.

Critical Access Hospitals

Standard

40%

Ec.02.02.01 The critical access hospital manages risks related to hazardous materials and waste.

40%

Ls.02.01.30 The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

36%

LS.02.01.35 The critical access hospital provides and maintains systems for extinguishing fires.

34%

EC.02.05.09 The critical access hospital inspects, tests, and maintains medical gas and vacuum systems.

30%

MM.03.01.01 The critical access hospital safely stores medications.

Critical Access Hospitals

Standard

35%

HR.02.01.04 The organization permits licensed independent practitioners to provide care, treatment, and services.

23%

PC.02.03.01 The organization provides resident education and training based on each resident’s needs and abilities.

22%

NPSG.07.01.01

Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

17%

IC.02.04.01 The organization offers vaccination against influenza to licensed independent practitioners and staff.

17%

WT.03.01.01 Staff and licensed independent practitioners performing waived tests are competent.

Nursing & Rehabilitation Centers

Standard

15%

MM.03.01.01 The organization safely stores medications.

15%

RC.02.01.21 Clinical record documentation includes resident education.

14%

MM.01.01.03 The organization safely manages high-alert and hazardous medications.

14%

PC.01.02.03 The organization assesses and reassesses the resident and his or her condition according todefined time frames.

14%

PC.01.03.01 The organization plans the resident’s care.

Nursing & Rehabilitation Centers

Standard

49% HR.02.01.04 The organization permits licensed independent practitioners to provide care, treatment, and services.

33% NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

17% PC.02.03.01 The organization effectively manages the collection of health information.

17% IM.02.02.01 The organization effectively manages the collection of health information.

16% WT.04.01.01 The organization provides resident education and training based on each resident’s needs and abilities.

Medicare/Medicaid Certification-Based Long Term Care

Standard

15%

MM.01.02.01 The organization addresses the safe use of look-alike/sound-alike medications.

13%

IC.02.04.01 The organization offers vaccination against influenza to licensed independent practitioners and staff.

12%

PC.01.02.07 The organization assesses and manages the resident’s pain.

12%

WT.03.01.01 Staff and licensed independent practitioners performing waived tests are competent.

10%

HR.02.02.01 The organization provides orientation to licensed independent practitioners.

10%

NPSG.03.05.01

Reduce the likelihood of resident harm associated with the use of anticoagulant therapy.

Medicare/Medicaid Certification-Based Long Term Care

Standard

24% HR.01.02.05 The organization verifies staff qualifications.

24% PC.01.03.01 The organization plans the patient’s care.

21% PI.02.01.01 The organization compiles and analyzes data.

19% RC.02.01.01 The patient record contains information that reflects the patient’s care, treatment, or services.

18% EM.03.01.03 The organization evaluates the effectiveness of its Emergency Operations Plan.

15% LD.04.03.09 Care, treatment, or services provided through contractual agreement are provided safely and effectively.

Home Care

Standard

37% PC.02.01.03 The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation.

26% IC.02.04.01 The organization offers vaccination against influenza to licensed independent practitioners and staff.

25% HR.01.06.01 Staff are competent to perform their responsibilities.

25% NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygieneguidelines or the current World Health Organization (WHO) hand hygiene guidelines.

Home Care

Standard

37%

CTS.03.01.03 The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.

23%

HR.02.01.03 The organization assigns initial, renewed, or revised clinical responsibilities to staff who are permitted by law and the organization to practice independently.

15%

CTS.02.01.05 For organizations providing care, treatment, or services in non–24-hour settings: The organization implements a written process requiring a physical health screening to determine the individual’s need for a medical history and physical examination.

Behavioral Health

Standard

15%

HR.01.06.01 Staff are competent to perform their responsibilities.

15%

NPSG.15.01.01 Identify individuals at risk for suicide.

14%

EC.02.06.01 The organization establishes and maintains a safe, functional environment.

13%

HR.01.02.05 The organization verifies staff qualifications.

13%

MM.03.01.01 The organization safely stores medications.

13%

CTS.04.03.33 For organizations providing food services: The organization has a process for preparing and/ordistributing food and nutrition products.

13%

CTS.02.01.11 The organization screens all individuals served for their nutritional status.

Behavioral Health

Standard

50%

HR.02.01.03 The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.

38%

MM.03.01.01 The organization safely stores medications.

37%

IC.02.02.01 The organization reduces the risk of infections associated with medical equipment, devices, and supplies.

28%

IC.01.03.01 The organization identifies risks for acquiring and transmitting infections.

23%

MM.01.01.03 The organization safely manages high-alert and hazardous medications.

Ambulatory Care

Standard

22%

EC.04.01.01 The organization collects information to monitor conditions in the environment.

21%

MM.01.02.01 The organization addresses the safe use of look-alike/sound-alike medications.

21%

EC.02.02.01 The organization manages risks related to hazardous materials and waste.

20%

EC.02.04.03 The organization inspects, tests, and maintains medical equipment.

19%

WT.03.01.01 Staff and licensed independent practitioners performing waived tests are competent.

Ambulatory Care

Standard

71% QSA.01.01.01 The laboratory participates in Centers for Medicare & Medicaid Services (CMS)–approved proficiency testing programs for all regulated analytes.

41% QSA.08.04.01 The laboratory establishes workload limits for staff who perform primary cytology screening.

37% HR.01.06.01 Staff are competent to perform their responsibilities.

35% QSA.02.03.01 The laboratory performs calibration verification.

29% DC.02.03.01 The laboratory report is complete and is in the patient’s clinical record.

27% QSA.01.02.01 The laboratory maintains records of its participation in a proficiency testing program.

Laboratory and Point of Care Testing

Standard

26%

QSA.08.02.01 The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations.

22%

TS.03.01.01 The organization uses standardized procedures for managing tissues.

22%

WT.05.01.01 The organization maintains records for waived testing.

21%

EC.02.04.03 The laboratory inspects, tests, and maintains laboratory equipment.

Laboratory and Point of Care Testing

Standard

60%

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.

26%

IC.02.02.01 The practice reduces the risk of infections associated with medical equipment, devices, and supplies.

25%

MM.01.01.03 The practice safely manages high-alert and hazardous medications.

25%

MM.03.01.01 The practice safely stores medications.

22%

NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field inperioperative and other procedural settings.

Office Based Surgery Practices

Standard

20%

EC.02.05.07 The practice inspects, tests, and maintains emergency power systems.

17%

MM.01.02.01 The practice addresses the safe use of look-alike/sound-alike medications.

15%

EC.02.03.05 The practice maintains fire safety equipment and fire safety building features.

15%

EM.03.01.03 The practice evaluates the effectiveness of its Emergency Management Plan.

15%

IC.02.04.01 The practice offers vaccination against influenza to licensed independent practitioners and staff.

15%

WT.03.01.01 Staff and licensed independent practitioners performing waived tests are competent.

Office Based Surgery Practices

Standard

28% DSDF.2 The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence based practice to deliver or facilitate the delivery of clinical care.

16% DSDF.3 The program is designed to meet the participant’s needs.

13% DSSE.3 The program addresses participants’ education needs.

12% DSDF.1 Practitioners are qualified and competent.

12% DSCT.5 The program initiates, maintains, and makes accessible a health or medical record for every participant.

Disease Specific Care Certification

Standard

8% DSPR.1 The program defines its leadership roles.

7% DSPM.6 The program evaluates participant perception of the quality of care.

6% DSPM.1 The program has an organized, comprehensive approach to performance improvement.

5% DSPR.8 The program communicates to participants the scope and level of care, treatment, and services it provides.

3% DSSE.1 The program involves participants in making decisions about managing their disease or condition.

Disease Specific Care Certification

Standard

15%

HSHR.1 The HCSS firm confirms that a person’s qualifications are consistent with his or her assignment(s).

10%

HSLD.9 The HCSS firm addresses emergency management.

7% HSHR.6 The HCSS firm evaluates the performance of clinical staff.

6% CPR 5 The HCSS firm evaluates the performance of clinical staff.

6% HSLD.5 The services contracted for by the HCSS firm are provided to customers.

5% HSPM.4 The HCSS firm analyzes its data.

5% HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information.

Health Care Staffing Services Certification

Standard

5% CPR 11 Any staffing firm employee or independent contractor who has concerns about the quality and safety of patient care provided by the staffing firm’s employees or independent contractors can report these concerns to The Joint Commission without retaliatory action from the staffing firm.

5% CPR 6 The staffing firm notifies the public it serves about how to contact the firm’s management and The Joint Commission to report concerns about the quality and safety of patient care provided by the staffing firm’s employees or independentcontractors.

4% HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.

Health Care Staffing Services Certification

Standard

69% PCPC.4 The interdisciplinary program team assesses and reassesses the patient’s needs.

31% PCPM.7 The program has an interdisciplinary team that includes individuals with expertise in and/or knowledge about the program’s specialized care, treatment, and services.

25% PCPC.3 The program tailors care, treatment, and services to meet the patient’s lifestyle, needs, and values.

19% PCPI.2 The program collects data to monitor its performance.

13% PCPM.6 Program leaders are responsible for selecting, orienting, educating, retaining, and providing incentives for staff.

6% PCIM.2 The program maintains complete and accurate medical records.

Advanced Certification for Palliative Care