We can make a difference on your journey to provide consistently excellent care for each and every patient. 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. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. The first recommended action is to assign responsibility to a project team or department, such as your pharmacy and therapeutics committee, for smart infusion pump interoperability, developing and maintaining the DERS, changes to infusion protocols, and pump maintenance. 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. Environment of Care EC.02.05.01: The hospital manages risks associated with its utility systems. Learn about the priorities that drive us and how we are helping propel health care forward. The Joint Commission is a registered trademark of the Joint Commission enterprise. This is a point of confusion as the requirements TJC or CMS apply differ based on the gas supply system present and the types and amount of gases stored. One of the keywords they have included from this element of performance is titration rates. As we have all seen for maybe the last five years, medication titration adjustments and documentation have been one of the more frequently scored issues on survey. The second most common issue falls into the maintenance of provider files, including issues related to licensure verification prior to the expiration date and renewal of privileges prior to when the current privileges expire. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. 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. These events affected a total of 14,731 patients (as multiple patients may be affected by a single event): An estimated fewer than 2% of all sentinel events are reported to The Joint Commission. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. 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. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. Many settings still dont have a meter, an alarm or even a ball in the wall device to identify the correct air pressure relationship. 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. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) . Rank Incidence of High Harm Percent High Harm Clinical or Environmental Association with ITL Clinical High-level disinfection and sterilization IC.02.02.01 EP02 2000 2 790 40% Clinical 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. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. Top 10 High & Moderate Risk Findings for 2020: This month we will not be breaking our discussion into high or lower priorities since Perspectives has some good information about scoring practices experienced in 2020. The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. We can make a difference on your journey to provide consistently excellent care for each and every patient. So, if your patient has a PCP and a cardiologist or other specialist the patient identifies as primarily responsible for their care, you would want to ensure that both providers receive the aftercare notice. If so, we have important feedback about current high focus areas we're seeing in 2021 surveys. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. 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.. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. All Rights Reserved. We hope that you have all gotten a chance to check out our NEW WEBSITE to view all the new and reformatted tools available to you! CMS also makes it clear in their guidance that emergency room notice must be sent regardless of the decision to admit or not. This applies to the cleanliness of the area in which items are directly stored (e.g., drawers or shelves). Accordingly, The Joint Commissions surveyors and reviewers will remain masked while onsite at an organization, adhere to social distancing and follow other guidelines as recommended by the Centers for Disease Control and Prevention. LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services. The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. : 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. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. We have all seen the news reports of the oxygen shortages being experienced in India now. The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. contains information that reflects the patients care, treatment, or services. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. We develop and implement measures for accountability and quality improvement. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. EC.02.06.01: The hospital establishes and maintains a safe, functional environment. When this is the case, organizations must ensure they set up maintenance intervals that align with National Fire Protection Association (NFPA) code requirements, be it quarterly, semi-annually or annually. This is scored about twice as often in the red, high risk category rather than the moderate orange category. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. . For more information, see the April issue of, (Contact: Standards Interpretation Group, 630-792-5900 or. 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. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. Crisis care planning is not yet a requirement of the standards, but we have read that TJC will be revising the standards in the near future. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. 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. Your email address will not be published . We sometimes see these, and at times there is no awareness that radiology has a unique infusion pump that is not part of the hospital wide update process. 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. Effective January 1, 2021, if an organization cannot prove that an elevator wrap meets a UL 10B or UL 10C rating, Joint Commission surveyors will issue a requirement for improvement (RFI) under LS.02.01.10, EP 12: "Doors requiring a fire rating of of an hour or longer are free of coverings, decorations, or other This likely will be the subject of discussion among hospital attorneys prior to the effective date at the end of June. JenCowel@PattonHC.com, John Rosing, MHA We do have a preference for printed materials that a patient can refer to, but this video might be a valuable component of your patient education initiative. This portal will provide information to reduce findings of non-compliance. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. These are searchable keywords surveyors can use to help them find where to score a particular issue. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. We suggest that their flow chart be discussed and analyzed at an environment of care meeting and used during EC or Quality rounds to verify that you have the correct signage present. The number of serious patient safety incidents reported to The Joint Commission jumped in 2021, reaching the highest annual level seen since the accrediting body started publicly reporting them in 2007, according to a report shared with Becker's Feb. 22. Drive performance improvement using our new business intelligence tools. You certainly would not want to be in a position of stating you have not seen the alert or have not considered the recommendations. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. 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. This is likely due to continuing feedback from CMS. Reduce the risk for. Doing thorough PI on these processes is really the key to preventing TJC surveyors from identifying gaps in adherence to safety measures designed to protect patients at risk for suicide. Linking and Reprinting Policy. Linking and Reprinting Policy. Interoperability Standard Revisions. Learn about the priorities that drive us and how we are helping propel health care forward. NPSG.15.01.01: Reduce the risk for suicide. They identify six elements of performance observed by their surveyors that to have the potential to either negatively affect patient care or create risk: HR.01.05.03, EP 1; HR.01.06. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. 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