This portal will provide information to reduce findings of non-compliance. 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. 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. Linking and Reprinting Policy. Top 10 High & Moderate Risk Findings for 2020 If contractors are used, they need to provide service for the entire complement of devices and provide detailed reports to the organization on each item that has successfully passed its test. Not only should the top discrepancies be included, but also novel best practices seen in 2010. While strides have been made in the efforts to return to normal from the COVID-19 pandemic, recent reports have shown that COVID-19 hospitalizations have increased in 40 states over the past two weeks. Interoperability Standard Revision The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few 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. The LS and EC requirements have not changed significantly in recent years and yet hospitals continue to fall short with meeting compliance in these areas. Privacy Policy. Many organizations employ reminder files and may elect to maintain all providers on the same or rolling calendar date for renewals to stay on top of the process. 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. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Utility Systems - EC.02.05.01 - Clinical Impact, Means of Egress - LS.02.01.20 - Clinical Impact, Built Environment - EC.02.06.01 - Clinical Impact, Fire Protection - EC.02.03.05 - Clinical Impact, General Requirements - LS.02.01.10 - Clinical Impact, Protection - LS.02.01.30 - Clinical Impact, Automated Suppression - LS.02.01.35 - Clinical Impact. Learn more about the communities and organizations we serve. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. 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. Hospitals and other health care facilities are unique. This is likely due to continuing feedback from CMS. JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. New Speak Up Video 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. 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. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) . 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. We must also consider where patients receive care, and minimize risks associated with the physical environment. All Rights Reserved. Given the potential life-threatening risk that suicide poses and the fact that this is still a frequently reported sentinel event, this prioritization by surveyors makes sense. 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. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. In 2021, the most frequently reported sentinel event category was care management events with patient falls being the single largest reported harm events. Were confident that with a little guidance, compliance issues can be overcome. 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. 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. 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. 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. Ensure compliance when reprocessing reusable medical devices, including but not limited to: Following the MIFU for any devices, instruments, products, accessories or equipment used ensures they are being cleaned and disinfected or sterilized as per intended use. The new standard TJC announced in last months issue of Perspectives on interoperability has already been revised. . The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. View a larger depiction of the infographic here: Conventional, Contingency, and Crisis Care Standards: EC News has a thought-provoking article on implementing Conventional, Contingency and Crisis Care Standards that should be shared with your EM team and considered when you do revisions to your plan. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. 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. 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 EP establishes requirements for medication administration and the necessary staff verifications prior to administration. 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. Learn more about the communities and organizations we serve. So, if you are still reprocessing, you may want to take a look at this EC News article and reconsider that decision. 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. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. 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. 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. This was scored by TJC in the red, high risk category more than twice as often as in the moderate. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Get more information about cookies and how you can refuse them by clicking on the learn more button below. View them by specific areas by clicking here. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. Recommendation two in general discusses maintenance of the drug library, but there are actually six specific sub-recommendations incorporated into this section. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Top 5 most challenging requirements for 2021, Joint Commission asking healthcare staff to remain masked while interacting with surveyors, reviewers, Up in the blogosphere with The Joint Commission, Required Policies and Procedures in Suicide Prevention Program, Avoiding Unintended Retained Foreign Objects in Ambulatory Surgery Care. The basic concept here is to prevent equipment, devices and supplies (stuff) from becoming contaminated in storage. Environment of Care One of the flaws we often see with environmental risk assessments is a failure to document all observed and theoretical risks. Human Resources 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . This area has returned a top cited compliance issue after a hiatus over the last few years. During 2020, there were shortages of the previously discussed staff respirators, ventilators, and oxygen. TJC surveyors scoring of EP 5 is evenly split between high and moderate risk. This EP was scored in the moderate risk category more than twice as often as high. The last two months we provided the link to the data CMS is analyzing relative to Covid-19 test positivity in counties throughout the US. 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. It is important to ensure that only manufacturer approved products are used and that all steps of the MIFU are followed for all items undergoing reprocessing, including equipment and accessories. It requires organizations to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Next Post: Joint Commission Top 10 Findings. These tools are a great start, but remember if you find an additional item that could be a ligature hazard, you need to add it to the risk assessment tool. In addition, one potential defect in the HLD/sterilization process potentially affects many patients, not just one patient. We can help you overcome the year-of-the-pandemic and support your preparation for survey. We help you measure, assess and improve your performance. By not making a selection you will be agreeing to the use of our cookies. This total had previously peaked in 2012, when 946 sentinel events were reported. The Top 10 most frequently reported sentinel events in 2021 were: The summary data of sentinel event statistics covers 18,018 incidents reported from 1995 through Dec. 31, 2021. We noted TJC included the term ultrasound probes in their keyword section. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. Find the exact resources you need to succeed in your accreditation journey. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. 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. Learn more about the communities and organizations we serve. Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. 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. All Rights Reserved. The tenth most frequently scored EP is IC.02.02.01, EP 4 which establishes infection prevention requirements for safe storage of medical equipment, devices, and supplies. Learn about the development and implementation of standardized performance measures. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. Discretion to not enforce or discretion to enforce. 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. Utility Systems - EC.02.05.01 Means of Egress - LS.02.01.20 Built Environment - EC.02.06.01 Fire Protection - EC.02.03.05 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. The third tag addressed is A-1673 which contains the same registration in the ED or as an inpatient notice be sent but the guidance specifically refers to psychiatric hospitals. See how our expertise and rigorous standards can help organizations like yours. CMS and Joint Commission have been examining this data to determine suitability for survey. Patient Safety Topics. This caught our attention because of the hemorrhage and preeclampsia content. Joint Commission Top 10 Findings Despite the pandemic and the year we thought would never end, we're already halfway through 2021! We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. The sixth most frequently scored EP is EC.02.06.01, EP 1. They're as follows: Life Safety Requirements for Business Occupancies The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. EC.02.05.01: The hospital manages risks associated with its utility systems. contains information that reflects the patients care, treatment, or services. Your email address will not be published . View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. EP 7 in this safety goal did not make the list, but this is the PI element of performance for the safety goal, requiring organizations to monitor compliance with policies and procedures. Learn about the priorities that drive us and how we are helping propel health care forward. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. 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. As you might expect, in the hospital accreditation program the issue that is most often scored with high or moderate risk is related to suicide safety. 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Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. If clean and dirty items are managed in the same room or area, there needs to be a workflow or process in place to provide clear separation of clean and dirty items. 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. Reduce the risk for. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. The 10 most frequently reported sentinel events for 2021: Editor's note: This article was updated Feb. 23 at 6:35 p.m. CT. This portal will provide information to reduce findings of non-compliance. For example, if 30 smoke detectors were tested in the last reporting period then the expectation is that 30 devices will appear on the current report. We have reproduced that link again for your use. The 10 most frequently reported sentinel events for 2021: Fall 485 reported events Delay in treatment 97 Unintended retention of a foreign object 97 Wrong surgical site 85 Patient. We develop and implement measures for accountability and quality improvement. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. 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. The fourth most frequently scored EP is MM.06.01.01, EP 3, which somewhat surprised us. Building is shaped like the Star of Life. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing: At times we discuss the Consistent Interpretation column because it adds clarity to understanding an existing or newly published requirement, or the article speaks to a standard that is cited frequently. If you havent yet, its going to be a great resource for your continuing accreditation and compliance efforts and encourage you to do so. MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. European Commission President Ursula von der Leyen's silence about her dealings with drugmaker Pfizer leading to the EU's biggest COVID-19 vaccine contract is hurting public trust and is a . One test usually handled by staff is the monthly inspection of fire extinguishers. You should however be sure to evaluate each alert and decide which recommendations are appropriate for your organization and which are not needed. Copyright © 2023 Becker's Healthcare. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. 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. Jennifer Cowel, RN MHSA 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. 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. Copyright 2023 Becker's Healthcare. This particular issue looks to be pretty evenly split between high and moderate risk levels. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. You want to ensure that all staff using multi-patient use glucometers adhere to the IFU for cleaning and have the required cleaning agents recommended by the manufacturer. The hospital reduces the risk of infections associated with medical equipment, devices and supplies. This section of the manual describes the data elements required to calculate category assignments and measurements for The Joint Commission's National Quality Measures. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. MM.01.01.03: The practice safely manages high-alert and hazardous medications. 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.. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. We use cookies to optimize our website and our service. 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? 46% of sentinel events led to a patients death. : This latest post in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the risk for suicide will discuss the element of performance (EP) focused on written policies and procedures addressing the care and follow-up for individuals at risk for suicide, writes Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group, and Stacey Paul, MSN, PMHNP-BC, Project Director, Healthcare Standards Development. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. 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. 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. 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. Over the last several years, The Joint Commission has noticed a pattern of challenges related to certain Environment of Care and Life Safety standards. Issue looks to be pretty evenly split between high and moderate risk levels & # ;... Information, see the April issue of Perspectives or the inability to safely evacuate space... Safely manages high-alert and hazardous medications regards to patient Safety Goals ( NPSGs ) for specific programs year-of-the-pandemic support. Been examining this data to determine suitability for survey if you are still,. Helping propel Health care accreditation Program has been very active throughout the Covid-19 pandemic and necessary! Inability to safely evacuate a space during an emergency compliance issue after a hiatus over the past where the of... Care accreditation Program has been very active throughout the us the Joint Commission 's weekly newsletter is... Our cookies improve patient advocacy EP was scored by TJC in the HLD/sterilization process potentially affects patients. With medical equipment, devices and supplies but there are actually six specific sub-recommendations incorporated into section! 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Has an MRI compatible infusion pump the learn more button below past where the frequency of a. You are still reprocessing, you may want to take a look at this EC news article reconsider! At this EC news article and reconsider that decision concept here is to care.