3 New Approaches Necessary to Improve Health Care The way health care conducts improvement is itself in need of improvementHelp health care make progress toward high reliabilityAchievement of extremely high levels of safety maintained over long periods of timeSafety comparable to that demonstrated by the commercial air travel, nuclear power, and amusement park industries
4 Improve Healthcare 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 costsExamples:Antibiotics for coldsEarly elective deliveries without a medical indication
5 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 solutionsApproach differs from long-standing efforts that emphasize evidence-based guidelines, checklists, and toolkits that typically are not customized
6 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 conditionsReporting and learning from blameless errors and unsafe conditions doesn’t eliminate need for personal responsibilityAccountability for adhering to agreed-upon safe practices is also a key component of a culture of safety
7 Focused Standards Assessment 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 2013Critical access hospitals and nursing homes are required to submit the FSA effective January 1, 2014While office-based surgery practices can still use the FSA for self-assessment, they are not required (or able) to submit an FSA
8 Changes to Accreditation Decisions Change to Contingent AccreditationModified Contingent Accreditation (CONT) CONT01Accreditation Committee will determine if the organization’s corrective action is sufficient to change the decision from Preliminary Denial of Accreditation (PDA) to Contingent AccreditationOccurs after Immediate Threat to Life (ITL) finding at survey and follow up visit verified sufficient corrective action to remove ITL
9 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 CONT05Introduced new certification decision rules due to a revised decision process in which the only two possible outcomes are Certified or Not Certified
10 Nursing Care Center Accreditation Program The Joint Commission’s reinvented Long Term Care Accreditation Program new nameNursing Care Center Accreditation ProgramReflects 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
11 Behavioral Health Home Certification Behavioral Health Home (BHH) certification accredited under the Behavioral Health Care Accreditation Program effective January 1, 2014Focuses 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 programsPeople with serious mental illness die 25 years earlier than general populationSuicide &injury account 30% to 40%60% due to medical conditions (cardiovascular, pulmonary, infectious)
12 ORYXIncreased ORYX® performance measure reporting requirements for accredited general medical/surgical hospitalsFrom a minimum of four (4) sets of core measures to at least six (6) sets of core measures for dischargesEffective January 1, 2014Additional measure set selections include both mandatory & discretionary measure sets
13 Mandatory Measure Sets 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
14 Discretionary Measure Set 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
15 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
16 Laboratory Standards Revision Revision to Quality System Assessment for Nonwaived Testing (QSA) Standard QSA (EP) 4How frequently policies/procedures of blood transfusion services are reviewed for laboratory accreditation programRevised requirement allows blood transfusion service director/technical supervisor to review blood transfusion policies/procedures every two years instead of annually
18 Emergency Management Requirements for Emergency Management Oversight Hospital effectively manages its programs, services, sites, or departmentsEP 12 Leaders identify an individual to be accountable for the following:
19 LDStaff 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 wideIdentification of & collaboration with community response partners
20 EMHospital evaluates effectiveness of its emergency management planning activitiesEP 4 The annual emergency management planning reviews are forwarded to senior hospital leadership for review (See also LD EP 25)
21 EMHospital evaluates the effectiveness of its Emergency Operations PlanEP 13Based 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))
22 EMEP 15The 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.
23 LD.04.04.01 Leaders establish priorities for performance improvement Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following:
24 LD.04.01.01 Review of the annual emergency management planning reviews Review of the evaluations of all emergency response exercises and all responses to actual emergenciesDetermination of which emergency management improvements will be prioritized for implementation
26 Patient Flow Revisions approved June 2012 Most became effective January 2013Two EPs became effective January 2014Standards impactedLD The hospital manages the flow of patients throughout the hospitalPC The hospitals accepts the patient for care, treatments, and services based on its ability to meet the patients’ needs (Perspectives, July 2012)
27 Patient Flow LD.04.03.11 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 issueSafety for boarded patientsLeadership communication with behavioral health providers and authorities to enhance coordination of care
28 Patient Flow LD.04.03.11 All EPs related to risk Patient flow throughout organization including boardingNot just Emergency DepartmentMonitoringManagingAnticipating and mitigatingObserving for trendsClear goals & accountability for improvement
29 Patient Flow PCRevision addresses safety for boarded patients with behavioral health emergencies in the following areas:Environment of care, locationStaffing and orientation/trainingAssessment, reassessment, and the care provided
30 Patient Flow PCBehavioral patients boarded for extended periods of time may not receive the safe, quality care neededStaff may not be prepared to deal with this vulnerable, challenging populationEnvironment may not be suited to the needs of the behavioral health populationPolicies and practices in the community may contribute to making this a complex issue
32 Clinical Alarms NPSG.06.01.01 Improve the safety of clinical alarms Implementation in two phasesPhase I beginning January 2014Hospitals required to establish alarms as an organization priority and identify the most important alarms to manage based on their own internal situations
33 Clinical Alarms NPSG.06.01.01 Improve the safety of clinical alarms Phase II beginning January 6Hospitals expected to develop and implement specific components of policies and proceduresEducation of those in the organization about alarm system management will also be required
34 Elements of Performance NPSG1. As of July 1, 2014, leaders establish alarm system safety as a hospital priority2. During 2014, identify the most important alarm signals to manage based on the following:Input from medical staff and clinical departmentsRisk to patients if the alarm signal is not attended to or if it malfunctions
35 Elements of Performance NPSG2. 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 fatiguePotential for patient harm based o internal incident historyPublished best practices and guidelines
36 NPSG3. 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 signalsWhen alarm signals can be disabledWhen alarm parameters can be changedWho in the organization has the authority to set alarm parametersWho in the organization has the authority to change alarm parameters
37 NPSG3. 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 signalsChecking individual alarm signals for accurate settings, proper operation, and detectability
38 Alarm Management Staffing patterns Care model Patient population Technology capabilities & configurationArchitectural layoutAlarm coverage modelAncillary technologyDelineation of responsibilityCulture
39 Preventing URFOs Sentinel Event Alert Issue 51 How to avoid leaving items (sponges, towels, instruments) in a patient’s body after surgeryUnintended 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 years95% additional care and/or extended stay$200,000 in medical and liability payments each
40 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 drainsNeedles and other sharpsInstruments, most commonly malleable retractors
42 Most Frequently Reported Sentinel Events January – June 2013 Wrong-patient, wrong-site, or wrong- procedure—60Unintended retention of a foreign object—56Delay in treatment—56Falls—48Other unanticipated events—40Operative/postoperative complication—37Suicide—35Criminal event (assault/rape/homicide)—26Medication error—20Perinatal death/injury—15
43 Most Frequently Identified Root Causes January – June 2013 Human factors (such as fatigue or distraction)—314Communication (such as among staff, across disciplines, or with patients)—292Leadership (regarding lack of performance improvement infrastructure or community relations)—276Assessment (such as patient observation processes or its documentation)—246Information management (such as patient identification of confidentiality)—101
44 Most Frequently Identified Root Causes January – June 2013 Physical environment (such as emergency management or hazardous materials)—70Care planning (planning and/or interdisciplinary collaboration)—49Continuum of care (includes transfer and/or discharge of patient)—48Medication use (such as storage/control or labeling)—48Operative care (such as blood use or patient monitoring)—45
45 Hospitals Standard 55% RC.01.01.01 The hospital maintains complete and accurate medical records for each individual patient.54%LSThe hospital maintains the integrity of the means of egress.47%ICThe hospital reduces the risk of infections associated with medical equipment, devices, and supplies.46%ECThe hospital manages risks associated with its utility systems.45%LSBuilding and fire protection features are designed and maintained to minimize the effects of fire, smoke,and heat.
46 Hospitals Standard 44% EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.43%LSThe hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.38%LSThe hospital provides and maintains systems for extinguishing fires.36%ECThe hospital establishes and maintains a safe, functional environment.33%MMThe hospital safely stores medications.
47 Critical Access Hospitals Standard53%ECThe critical access hospital maintains fire safety equipment and fire safety building features.49%LSBuilding and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.47%ECThe critical access hospital manages risks associated with its utility systems.43%ICThe critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.LSThe critical access hospital maintains the integrity of the means of egress.
48 Critical Access Hospitals Standard40%EcThe critical access hospital manages risks related to hazardous materials and waste.LsThe critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.36%LSThe critical access hospital provides and maintains systems for extinguishing fires.34%ECThe critical access hospital inspects, tests, and maintains medical gas and vacuum systems.30%MMThe critical access hospital safely stores medications.
49 Nursing & Rehabilitation Centers Standard35%HRThe organization permits licensed independent practitioners to provide care, treatment, and services.23%PCThe organization provides resident education and training based on each resident’s needs and abilities.22%NPSGComply 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%ICThe organization offers vaccination against influenza to licensed independent practitioners and staff.WTStaff and licensed independent practitioners performing waived tests are competent.
50 Nursing & Rehabilitation Centers Standard15%MMThe organization safely stores medications.RCClinical record documentation includes resident education.14%MMThe organization safely manages high-alert and hazardous medications.PCThe organization assesses and reassesses the resident and his or her condition according todefined time frames.PCThe organization plans the resident’s care.
51 Medicare/Medicaid Certification-Based Long Term Care Standard49%HRThe organization permits licensed independent practitioners to provide care, treatment, and services.33%NPSGComply 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%PCThe organization effectively manages the collection of health information.IM16%WTThe organization provides resident education and training based on each resident’s needs and abilities.
52 Medicare/Medicaid Certification-Based Long Term Care Standard15%MMThe organization addresses the safe use of look-alike/sound-alike medications.13%ICThe organization offers vaccination against influenza to licensed independent practitioners and staff.12%PCThe organization assesses and manages the resident’s pain.WTStaff and licensed independent practitioners performing waived tests are competent.10%HRThe organization provides orientation to licensed independent practitioners.NPSGReduce the likelihood of resident harm associated with the use of anticoagulant therapy.
53 Home CareStandard24%HRThe organization verifies staff qualifications.PCThe organization plans the patient’s care.21%PIThe organization compiles and analyzes data.19%RCThe patient record contains information that reflects the patient’s care, treatment, or services.18%EMThe organization evaluates the effectiveness of its Emergency Operations Plan.15%LDCare, treatment, or services provided through contractual agreement are provided safely and effectively.
54 Home CareStandard37%PCThe organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation.26%ICThe organization offers vaccination against influenza to licensed independent practitioners and staff.25%HRStaff are competent to perform their responsibilities.NPSGComply with either the current Centers for Disease Control and Prevention (CDC) hand hygieneguidelines or the current World Health Organization (WHO) hand hygiene guidelines.
55 Behavioral Health 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%HRThe organization assigns initial, renewed, or revised clinical responsibilities to staff who are permitted by law and the organization to practice independently.15%CTSFor 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.
56 Behavioral Health Standard 15% HR.01.06.01 Staff are competent to perform their responsibilities.NPSGIdentify individuals at risk for suicide.14%ECThe organization establishes and maintains a safe, functional environment.13%HRThe organization verifies staff qualifications.MMThe organization safely stores medications.CTSFor organizations providing food services: The organization has a process for preparing and/ordistributing food and nutrition products.CTSThe organization screens all individuals served for their nutritional status.
57 Ambulatory Care 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%MMThe organization safely stores medications.37%ICThe organization reduces the risk of infections associated with medical equipment, devices, and supplies.28%ICThe organization identifies risks for acquiring and transmitting infections.23%MMThe organization safely manages high-alert and hazardous medications.
58 Ambulatory Care Standard 22% EC.04.01.01 The organization collects information to monitor conditions in the environment.21%MMThe organization addresses the safe use of look-alike/sound-alike medications.ECThe organization manages risks related to hazardous materials and waste.20%ECThe organization inspects, tests, and maintains medical equipment.19%WTStaff and licensed independent practitioners performing waived tests are competent.
59 Laboratory and Point of Care Testing Standard71%QSAThe laboratory participates in Centers for Medicare & Medicaid Services (CMS)–approved proficiency testing programs for all regulated analytes.41%QSAThe laboratory establishes workload limits for staff who perform primary cytology screening.37%HRStaff are competent to perform their responsibilities.35%QSAThe laboratory performs calibration verification.29%DCThe laboratory report is complete and is in the patient’s clinical record.27%QSAThe laboratory maintains records of its participation in a proficiency testing program.
60 Laboratory and Point of Care Testing Standard26%QSAThe laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations.22%TSThe organization uses standardized procedures for managing tissues.WTThe organization maintains records for waived testing.21%ECThe laboratory inspects, tests, and maintains laboratory equipment.
61 Office Based Surgery Practices Standard60%HRThe practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.26%ICThe practice reduces the risk of infections associated with medical equipment, devices, and supplies.25%MMThe practice safely manages high-alert and hazardous medications.MMThe practice safely stores medications.22%NPSGLabel all medications, medication containers, and other solutions on and off the sterile field inperioperative and other procedural settings.
62 Office Based Surgery Practices Standard20%ECThe practice inspects, tests, and maintains emergency power systems.17%MMThe practice addresses the safe use of look-alike/sound-alike medications.15%ECThe practice maintains fire safety equipment and fire safety building features.EMThe practice evaluates the effectiveness of its Emergency Management Plan.ICThe practice offers vaccination against influenza to licensed independent practitioners and staff.WTStaff and licensed independent practitioners performing waived tests are competent.
63 Disease Specific Care Certification Standard28%DSDF.2The 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.3The program is designed to meet the participant’s needs.13%DSSE.3The program addresses participants’ education needs.12%DSDF.1Practitioners are qualified and competent.DSCT.5The program initiates, maintains, and makes accessible a health or medical record for every participant.
64 Disease Specific Care Certification Standard8%DSPR.1The program defines its leadership roles.7%DSPM.6The program evaluates participant perception of the quality of care.6%DSPM.1The program has an organized, comprehensive approach to performance improvement.5%DSPR.8The program communicates to participants the scope and level of care, treatment, and services it provides.3%DSSE.1The program involves participants in making decisions about managing their disease or condition.
65 Health Care Staffing Services Certification Standard15%HSHR.1The HCSS firm confirms that a person’s qualifications are consistent with his or her assignment(s).10%HSLD.9The HCSS firm addresses emergency management.7%HSHR.6The HCSS firm evaluates the performance of clinical staff.6%CPR 5HSLD.5The services contracted for by the HCSS firm are provided to customers.5%HSPM.4The HCSS firm analyzes its data.HSHR.3The HCSS firm provides orientation to clinical staff regarding initial job training and information.
66 Health Care Staffing Services Certification Standard5%CPR 11Any 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.CPR 6The 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.4The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.
67 Advanced Certification for Palliative Care Standard69%PCPC.4The interdisciplinary program team assesses and reassesses the patient’s needs.31%PCPM.7The 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.3The program tailors care, treatment, and services to meet the patient’s lifestyle, needs, and values.19%PCPI.2The program collects data to monitor its performance.13%PCPM.6Program leaders are responsible for selecting, orienting, educating, retaining, and providing incentives for staff.6%PCIM.2The program maintains complete and accurate medical records.