During the past year, The Joint Commission has made many changes, innovations and revisions to the standards and certification process. You can read about some of these transformations in the article below.
I’m encouraged by these improvements and The Joint Commission’s new vision, “To collaborate with health care organizations to lead the transformation of health care into a high reliability industry.”
We’re making this vision a reality through a number of critical activities. Led by our new president, Mark Chassin, M.D., The Joint Commission has internally launched Robust Process Improvement™, an integrated Lean Six Sigma approach. So far, we have trained 20 Green Belts and 20 Change Agents who are working along with employees throughout the enterprise to improve customer satisfaction, standards development and communication. In the future, The Joint Commission will begin a large-scale redesign of all aspects of the accreditation and certification processes with the goals of simplification, standardization, consistency and transparency to the health care organizations we serve.
The results of these efforts should be improved customer service and ultimately, better care delivered to patients. I welcome your suggestions in response to these ideas or any other thoughts about how The Joint Commission can strengthen its certification process to serve you better. You can contact me at jrange@jointcommission.org or (630) 792-5256. I look forward to hearing from you.
Jean Range, R.N., M.S., C.P.H.Q.
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As part of its Standards Improvement Initiative (SII), The Joint Commission has revised its scoring and decision processes, effective January 1, 2009. The new processes focus on how critical an issue is to patient care or safety, as identified by noncompliant standards. The more critical the issue, the shorter the time frame that an organization has to address it.
Scoring
The standards fall into one of the following four levels of criticality:
- Indirect Impact requirements (Tier 4): Typically applied to planning and evaluation of care processes, the risk to patient safety increases if these requirements are not resolved over time.
- Direct Impact requirements (Tier 3): Based on the implementation of care processes that are likely to create an immediate risk to patient safety or quality of care if these requirements are not adhered to.
- Situational Decision Rules (Tier 2): Based on specific situations at the time of an on-site review, some issues will generate a recommendation to the Board of Commissioners for Conditional or Preliminary Denial of Certification.
- An Immediate Threat to Health and Safety (Tier 1): Identified during an on-site review will continue to drive an expedited decision of Preliminary Denial of Certification.
Decisions
- Decisions of Conditional Certification and Preliminary Denial of Certification will be driven by those standards that have the most Direct Impact on patient care or safety.
- There is no longer a supplemental section in the Certification Report. All findings of less than full compliance require resolution via submission of Evidence of Standards Compliance.
- The use of “thresholds” to determine Conditional Certification and Preliminary Denial of Certification will no longer occur. Instead, they will be used as “screens” for identifying organizations whose survey findings require more extensive review by Joint Commission Central Office staff.
- The screens are based on the number of Direct Impact standards (see icon key) that are noncompliant. Reviews that generate five or more requirements for improvement will be screened.
New icons
Icons will be used to identify the scoring category, measure of success designation, whether documentation is needed, and the criticality of certain elements of performance (EPs). The icons that will be used in the manuals and their meanings are defined below. An icon key is provided at the bottom of each requirement page. EPs that do not have a “2” or “3” icon are considered Indirect Impact requirements (level 4). No EP is tagged as an Immediate Threat to Life requirement; instead, an Immediate Threat to Life situation is usually the result of noncompliance with a combination of EPs at any or all of the Situational Decision Rules, Direct Impact and Indirect Impact levels.
For a complete description of the changes, see the December 2008 edition of Joint Commission Perspectives or the introduction to the 2009 Disease-Specific Care Certification Manual.
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A number of changes have been made to the stroke measure set due to feedback received from primary stroke centers and other stakeholders during the past year. Most of the revisions will become effective with discharges on or after January 1, 2009 with the exception of changes to Stroke-6. Stroke-6 revisions will become effective for discharges occurring in the fourth quarter 2009. However, data collection for the current Stroke-6 measure specifications should continue until then.
Key revisions include:
- Expansion of the data element definition for Admitted for Elective Carotid Endarterectomy. The revised definition, Elective Carotid Intervention, details exclusions for percutaneous insertion of carotid artery stents and other elective procedures involving the carotid artery. This change applies to all 10 performance measures.
- Stroke-5: Antithrombotic Therapy by End of Hospital Day Two was modified, and a new decision point was added to the measure calculation to exclude patients who received intravenous or intra-arterial thrombolytic therapy within the past 24 hours.
- Stroke-6: Discharged on Cholesterol Reducing Medications was changed to Discharged on Statin Medication. Significant revisions were made to this measure, including data definitions and medication table changes. The changes clarify that this measure applies only to ischemic stroke patients with evidence of atherosclerosis who are discharged on a statin medication.
The changes are published in the Stroke Performance Measurement Implementation Guide, 2nd Edition, Version 2.a, available on The Joint Commission’s Web site. To download, visit www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters and click the link under the “October 2008 Update” in the “Resources” column.
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Better Outcomes for Older adults through Safe Transitions (BOOST) is a project to improve the care of patients as they transition from the hospital to home. Research shows one in five patients discharged from the hospital suffer an adverse event, which often leads to re-hospitalization.
“The hospital discharge process can be confusing and stressful for anyone, particularly the elderly,” says Jean Range, executive director, Disease-Specific Care Certification Program. “Project BOOST, launched by the Society of Hospital Medicine, provides a clear plan of action for hospitals that want to improve the discharge process for their older patients. Utilizing the free resources that BOOST provides will result in decreased re-hospitalization and better patient outcomes ― a win-win situation for all involved.”
Project BOOST has a complete online toolkit for health care professionals. The resources are designed to:
- Reduce the 30-day readmission rate for general medicine patients (with particular focus on older adults)
- Improve patient satisfaction scores
- Improve information flow between sending and receiving physicians
- Ensure high-risk patients receive follow-up calls within 72 hours of discharge
- Improve patient and family education practices to encourage use of the teach-back process around risk-specific issues
“We’re delighted with the enthusiastic response from our six pilot sites in the mentoring program located across the U.S. from Hawaii to Vermont and from Wisconsin to Georgia,” says Mark V. Williams, M.D., F.A.C.P., principal investigator, Project BOOST, who is also professor and chief of the Division of Hospital Medicine, Northwestern University Feinberg School of Medicine. “Given Project BOOST’s initial success, we are seeking an additional 24 sites to enroll in our next cohort of mentoring sites. Interested hospitals must apply before December 31, 2008 at our Web site, www.hospitalmedicine.org/BOOST.”
Project BOOST is advised by a board of recognized leaders in hospital medicine, care transition, payers and regulatory agencies. The board, chaired by Eric Coleman, M.D., includes representatives from the Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS), The Joint Commission, American Society of Health-System Pharmacists, American Geriatrics Society, Case Management Society of America, Society of General Internal Medicine, Institute for Healthcare Improvement, Blue Cross and Blue Shield Association; National Consumers League (SOS Rx), the Society of Hospital Medicine, and others. To start using the online resources, go to www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.
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The Joint Commission is asking for your comments on proposed revisions to the National Patient Safety Goals. To comment through December 24, go to www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/fe_npsg.htm.
DSC program staff members attend conventions and speak throughout the year. In 2009 we’ll be at:
- American Heart Association, Chicago, Ill., January 7
- International Stroke Conference, San Diego, Calif., February 18-20
- American Case Management Association, Boston, Mass., April 18-22
- American Thoracic Society, San Diego, Calif., May 17-19
DSC Update, the free quarterly newsletter, is chock full of the latest news and information from the Disease-Specific Care Certification Program. Be the first on the block to receive the newsletter by signing up to receive it automatically at www.jointcommission.org/Library/Newsletters/list_serve.htm.
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Publications
2008 Disease-Specific Care Certification Manual Update
This update provides all the new information for 2009 including the improved scoring categories and certification process, revised certification decision rules, and revisions to the recently renumbered and revised 2009 National Patient Safety Goals. The handy table that accompanies your package summarizes the changes and serves as a guide for replacing the affected pages.
Order code: DSCC08S, $50
2009 Disease-Specific Care Certification Manual
New to this edition is the introduction of improved scoring categories made as a result of The Joint Commission's sweeping Standards Improvement Initiative, as well as updates of the National Patient Safety Goals and the certification process chapters. Also included in this package are all six setting-specific modules, allowing you to focus on the standards most applicable to your setting.
Order code: DSCC09, $125
Clinical Improvement Action Guide
In microsystem thinking, the quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. This book explains how to integrate clinical microsystems and practice-based learning into your own organization.
Order code: AG200, $75
For information or to order products from Joint Commission Resources, Inc., go to http://store.jcrinc.com or call (877) 223-6866.
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DSC Certification (630) 792-5291
Standards Interpretation Group (630) 792-5900
DSC Account Representative (630) 792-3007
Customer Service (630) 792-5800
Pricing Unit (630) 792-5115
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