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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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:
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
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)
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))
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.
Leaders establish priorities for performance improvement Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following:
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
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)
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
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
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
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
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
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
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
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
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
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
Staffing patterns Care model Patient population Technology capabilities & configuration Architectural layout Alarm coverage model Ancillary technology Delineation of responsibility Culture
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
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
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
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
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
Standard 55%RC.01.01.01The hospital maintains complete and accurate medical records for each individual patient. 54%LS.02.01.20The hospital maintains the integrity of the means of egress. 47%IC.02.01.01The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 46%EC.02.05.01The hospital manages risks associated with its utility systems. 45%LS.02.01.10Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
Standard 44%EC.02.03.05The hospital maintains fire safety equipment and fire safety building features. 43%LS.02.01.30The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 38%LS.02.01.35The hospital provides and maintains systems for extinguishing fires. 36%EC.02.06.01The hospital establishes and maintains a safe, functional environment. 33%MM.03.01.01The hospital safely stores medications.
Standard 53%EC.02.03.05The critical access hospital maintains fire safety equipment and fire safety building features. 49%LS.02.01.10Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. 47%EC.02.05.01The critical access hospital manages risks associated with its utility systems. 43%IC.02.02.01The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 43%LS.02.01.20The critical access hospital maintains the integrity of the means of egress.
Standard 40%Ec.02.02.01The critical access hospital manages risks related to hazardous materials and waste. 40%Ls.02.01.30The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 36%LS.02.01.35The critical access hospital provides and maintains systems for extinguishing fires. 34%EC.02.05.09The critical access hospital inspects, tests, and maintains medical gas and vacuum systems. 30%MM.03.01.01The critical access hospital safely stores medications.
Standard 35%HR.02.01.04The organization permits licensed independent practitioners to provide care, treatment, and services. 23%PC.02.03.01The organization provides resident education and training based on each resident’s needs and abilities. 22%NPSG.07.01.01Comply 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.02.04.01The organization offers vaccination against influenza to licensed independent practitioners and staff. 17%WT.03.01.01Staff and licensed independent practitioners performing waived tests are competent.
Standard 15%MM.03.01.01The organization safely stores medications. 15%RC.02.01.21Clinical record documentation includes resident education. 14%MM.01.01.03The organization safely manages high-alert and hazardous medications. 14%PC.01.02.03The organization assesses and reassesses the resident and his or her condition according to defined time frames. 14%PC.01.03.01The organization plans the resident’s care.
Standard 49%HR.02.01.04The organization permits licensed independent practitioners to provide care, treatment, and services. 33%NPSG.07.01.01Comply 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.02.03.01The organization effectively manages the collection of health information. 17%IM.02.02.01The organization effectively manages the collection of health information. 16%WT.04.01.01The organization provides resident education and training based on each resident’s needs and abilities.
Standard 15%MM.01.02.01The organization addresses the safe use of look-alike/sound-alike medications. 13%IC.02.04.01The organization offers vaccination against influenza to licensed independent practitioners and staff. 12%PC.01.02.07The organization assesses and manages the resident’s pain. 12%WT.03.01.01Staff and licensed independent practitioners performing waived tests are competent. 10%HR.02.02.01The organization provides orientation to licensed independent practitioners. 10%NPSG.03.05.0 1 Reduce the likelihood of resident harm associated with the use of anticoagulant therapy.
Standard 24%HR.01.02.05The organization verifies staff qualifications. 24%PC.01.03.01The organization plans the patient’s care. 21%PI.02.01.01The organization compiles and analyzes data. 19%RC.02.01.01The patient record contains information that reflects the patient’s care, treatment, or services. 18%EM.03.01.03The organization evaluates the effectiveness of its Emergency Operations Plan. 15%LD.04.03.09Care, treatment, or services provided through contractual agreement are provided safely and effectively.
Standard 37%PC.02.01.03The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. 26%IC.02.04.01The organization offers vaccination against influenza to licensed independent practitioners and staff. 25%HR.01.06.01Staff are competent to perform their responsibilities. 25%NPSG.07.01.01Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
Standard 37%CTS.03.01.03The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served. 23%HR.02.01.03The organization assigns initial, renewed, or revised clinical responsibilities to staff who are permitted by law and the organization to practice independently. 15%CTS.02.01.05For 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.
Standard 15%HR.01.06.01Staff are competent to perform their responsibilities. 15%NPSG.15.01.01Identify individuals at risk for suicide. 14%EC.02.06.01The organization establishes and maintains a safe, functional environment. 13%HR.01.02.05The organization verifies staff qualifications. 13%MM.03.01.01The organization safely stores medications. 13%CTS.04.03.33For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products. 13%CTS.02.01.11The organization screens all individuals served for their nutritional status.
Standard 50%HR.02.01.03The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 38%MM.03.01.01The organization safely stores medications. 37%IC.02.02.01The organization reduces the risk of infections associated with medical equipment, devices, and supplies. 28%IC.01.03.01The organization identifies risks for acquiring and transmitting infections. 23%MM.01.01.03The organization safely manages high-alert and hazardous medications.
Standard 22%EC.04.01.01The organization collects information to monitor conditions in the environment. 21%MM.01.02.01The organization addresses the safe use of look-alike/sound-alike medications. 21%EC.02.02.01The organization manages risks related to hazardous materials and waste. 20%EC.02.04.03The organization inspects, tests, and maintains medical equipment. 19%WT.03.01.01Staff and licensed independent practitioners performing waived tests are competent.
Standard 71%QSA.01.01.01The laboratory participates in Centers for Medicare & Medicaid Services (CMS)–approved proficiency testing programs for all regulated analytes. 41%QSA.08.04.01The laboratory establishes workload limits for staff who perform primary cytology screening. 37%HR.01.06.01Staff are competent to perform their responsibilities. 35%QSA.02.03.01The laboratory performs calibration verification. 29%DC.02.03.01The laboratory report is complete and is in the patient’s clinical record. 27%QSA.01.02.01The laboratory maintains records of its participation in a proficiency testing program.
Standard 26%QSA.08.02.01The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. 22%TS.03.01.01The organization uses standardized procedures for managing tissues. 22%WT.05.01.01The organization maintains records for waived testing. 21%EC.02.04.03The laboratory inspects, tests, and maintains laboratory equipment.
Standard 60%HR.02.01.03The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 26%IC.02.02.01The practice reduces the risk of infections associated with medical equipment, devices, and supplies. 25%MM.01.01.03The practice safely manages high-alert and hazardous medications. 25%MM.03.01.01The practice safely stores medications. 22%NPSG.03.04.01Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
Standard 20%EC.02.05.07The practice inspects, tests, and maintains emergency power systems. 17%MM.01.02.01The practice addresses the safe use of look- alike/sound-alike medications. 15%EC.02.03.05The practice maintains fire safety equipment and fire safety building features. 15%EM.03.01.03The practice evaluates the effectiveness of its Emergency Management Plan. 15%IC.02.04.01The practice offers vaccination against influenza to licensed independent practitioners and staff. 15%WT.03.01.01Staff and licensed independent practitioners performing waived tests are competent.
Standard 28%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. 12%DSCT.5The program initiates, maintains, and makes accessible a health or medical record for every participant.
Standard 8%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.
Standard 15%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 5The HCSS firm evaluates the performance of clinical staff. 6%HSLD.5The services contracted for by the HCSS firm are provided to customers. 5%HSPM.4The HCSS firm analyzes its data. 5%HSHR.3The HCSS firm provides orientation to clinical staff regarding initial job training and information.
Standard 5%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. 5%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 independent contractors. 4%HSHR.4The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.
Standard 69%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.