The Board of Commissioners of The Joint Commission announced the appointment of Mark R. Chassin, M.D., M.P.P., M.P.H., to lead The Joint Commission as its next president. The appointment is effective January 1, 2008. Dr. Chassin is the Edmond A. Guggenheim Professor of Health Policy and chairman of the Department of Health Policy at Mount Sinai School of Medicine, New York, and executive vice president for Excellence in Patient Care at The Mount Sinai Medical Center. Prior to joining Mount Sinai, Dr. Chassin served as commissioner of the New York State Department of Health. He is a board-certified internist and practiced emergency medicine for 12 years. His background also includes service in the federal government and many years of health services and health policy research. He is a member of the Institute of Medicine of the National Academy of Sciences and co-chaired its National Roundtable on Health Care Quality.
While at The Mount Sinai Medical Center, Dr. Chassin built a nationally recognized quality improvement program which focuses on achieving substantial gains in all aspects of quality of care, encompassing safety, clinical outcomes, the experiences of patients and families, and the working environment of caregivers. In addition, Dr Chassin has led successful efforts to introduce Six Sigma quality improvement methods in Mount Sinai’s hospital and medical school, using them to enhance both patient safety and the efficiency of operations. His research during his 12 years at Mount Sinai has focused on developing health care quality measures; using those measures in quality improvement; and understanding the relationship of quality measurement and improvement to health policy. More recently, he has expanded his research program to include a number of intervention trials that concentrate on reducing racial and ethnic disparities in health and health care.
In 2001, Dr. Chassin was recognized for his contributions to the fields of quality measurement and improvement with several honors. He was selected in the first group of honorees as a lifetime member of the National Associates of the National Academies, a new program of the National Academy of Sciences recognizing career contributions to the National Academies. He also received the Founders Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability. Dr. O’Leary, who has led The Joint Commission for the past 21 years, will become president emeritus of The Joint Commission on January 1, 2008. See the full news release. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
-Top-
Effective January 1, 2008, The Joint Commission’s Public Information Policy has been revised to address the public release of complaint information. The revised Policy specifies that any individual, including the complainant, who inquires about a specific complaint at an accredited organization, will be provided information about the specific standards that were the subject of the complaint investigation. The current Policy states that only the relevant standard areas would be released. Concerns about the safety or quality of care at an accredited organization may be shared with The Joint Commission Office of Quality Monitoring at complaint@jointcommission.org or (800) 994-6610. For more information, see the fact sheet about the Public Information Policy. (Contact: Gail Weinberger, gweinberger@jointcommission.org)
-Top-
Each year, The Joint Commission collects data on accredited organizations’ compliance with its standards and National Patient Safety Goals to identify trends and focus education on challenging requirements. The table below identifies the Joint Commission standards and NPSGs that were most frequently identified as “not compliant” from January 1, 2006, through December 31, 2006 for hospitals and critical access hospitals. Hospitals can use this information to benchmark their performance against all accredited hospitals and to investigate their performance to determine if their processes meet requirements. For more information, see the Frequently Asked Questions.
|
Standard or Goal |
Summary of requirement |
Hospital |
CAH |
|
Goal 2 |
Improve the effectiveness of communication among caregivers. |
58 percent |
29 percent |
|
Goal 3 |
Improve the safety of using medications. |
17 percent |
7 percent |
|
Goal 8 |
Accurately and completely reconcile medications across the continuum of care. |
46 percent |
23 percent |
|
UP 1 |
The organization fulfills the expectations set forth in the Universal Protocol. |
30 percent |
12 percent |
|
MM.2.20 |
Medications are properly and safely stored. |
44 percent |
34 percent |
|
MM.3.20 |
Medication orders are written clearly and transcribed accurately. |
26 percent |
9 percent |
|
IM.6.10 |
The hospital/CAH has a complete and accurate medical record for patients assessed, cared for, treated, or served. |
18 percent |
10 percent |
|
PC.8.10 |
Pain is assessed in all patients. |
19 percent |
-- |
|
EC.1.10 |
The hospital manages safety risks. |
17 percent |
-- |
|
EC.5.20 |
Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®. |
26 percent |
-- |
|
PC.13.20 |
Operative or other procedures and/or the administration of moderate or deep sedation or anesthesia are planned. |
-- |
12 percent |
|
MM.4.10 |
The CAH collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege. |
-- |
7 percent |
|
MS.4.20 |
The medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege. |
-- |
14 percent |
(Contact: Standards Interpretation Group, (630) 792-5900 or online question form)
-Top-
The Joint Commission launched its Strategic Surveillance System (S3) on July 30. The S3 is an exclusive benefit provided to accredited hospitals (excluding critical access hospitals) and is provided at no additional cost. It is not a requirement for accreditation and does not require data input from hospitals. The data included in the S3 tool is confidential and will not be released publicly. The first tool within S3 is the Performance Risk Assessment which provides a series of risk assessments and comparative reports to help hospitals improve their care processes and prioritize actions to take for improvement. A free audio conference on S3 for accredited hospitals was conducted on August 16; playback information and a transcript of the call are available online . Perspectives has published a number of articles about S3: September 2006, March 2007, May 2007 and June 2007. Questions about S3 should be directed to the organization’s account representative or to Carrie Mayer, (630) 792-5712. (Contact: Carrie Mayer, cmayer@jointcommission.org)
-Top-
The Joint Commission is engaged in the following activities as part of its Standards Improvement Initiative:
- Completed review of the Management of Human Resources, Management of the Environment of Care, and Medication Management chapters. Proposed revisions to these chapters will be posted to the Joint Commission website for field review and comment later this summer.
- Started reviewing the Provision of Care, Treatment, and Services and the Ethics, Rights, and Responsibilities chapters.
- Developing a new database that would link corresponding Medicare Conditions of Participation with the revised standards and elements of performance.
- Reviewed standards manuals from other organizations and designing potential prototypes of the new manual.
- Developed a pilot testing plan that will assess surveyor’s ability to apply the revised standards and elements of performance in the survey process. Testing will include both “virtual” and mock testing.
SII is part of a continuous effort to eliminate non-essential standards and to ensure that the remaining standards are understandable and relevant to the care setting to which they apply. The initiative is limited to changes of current standards; it is not designed to introduce new requirements. The redesign of the manuals will result in the renumbering of the standards. Questions and suggestions can be sent to standardsimprovement@jointcommission.org.
SII Timeline
October 2006: The Standards Improvement Initiative was launched. The Joint Commission began seeking feedback through an on-line opinion survey and public comment on standards for the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.
August 2007: The Surveillance, Prevention and Control of Infection Control (IC), Improving Organization Performance (PI) and Management of Information (IM) chapters will be presented to the Standards and Survey Procedures Committee for approval.
June and November 2007: “Virtual” pilot testing will take place with selected surveyors and Central Office staff.
First Quarter 2008: The Joint Commission will begin conducting mock surveys using the improved standards and manuals, and will make the revised standards available to all affected accredited organizations.
Mid 2008: Target date for completing improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals. The Joint Commission will begin seeking feedback through an on-line opinion survey and public comment on standards for the behavioral health care, laboratory and long term care accreditation programs.
January 2009: Improvements to the standards are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs.
(Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
-Top-
The Joint Commission’s Accreditation Committee approved the 2008 accreditation decision rules for all programs. Effective January 1, 2008, two new decision rules were added to the Denial of Accreditation category: 1) the health care organization fails to resolve a Conditional Accreditation status prior to withdrawing from the accreditation process; and 2) the health care organization fails to submit payment for survey fees or annual fees. Currently, Denial of Accreditation results when a health care organization does not permit the performance of any survey by The Joint Commission, or the organization fails to meet requirements for the timely submission of data and information to The Joint Commission within 91 days of the due date(s). See more information about 2008 accreditation decisions. (Contact: Keith Winfrey, kwinfrey@jointcommission.org)
-Top-
Although abbreviations in health care may be efficient, their use comes at the expense of patient safety, according to a new study published in the September 2007 issue of The Joint Commission Journal on Quality and Patient Safety. The findings of this study provide further support for The Joint Commission’s “Do Not Use” list of abbreviations that is part of its National Patient Safety Goals. The study also suggests the need to consider additions to the “Do Not Use” list. Although abbreviations are known causes of medication errors, the study—The Impact of Abbreviations on Patient Safety—is the first to examine the exact characterization and impact of these errors. The study collected and analyzed data through a retrospective review of errors resulting from abbreviations as reported to the United States Pharmacopeia’s MEDMARX®, a national database for medication errors, from 2004 through 2006. The study found that nearly 5 percent of all errors reported to MEDMARX® during this time period were attributable to abbreviations. This analysis of nearly 30,000 medication error reports involving abbreviations suggests that health care organizations should consider additions to the “Do Not Use” list. The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources, features peer-reviewed research and case studies on improving quality and safety in health care organizations. See the news release. (Contact: Steve Berman, sberman@jcrinc.com)
-Top-
Effective January 1, 2008, all Joint Commission certified Primary Stroke Centers will be required to collect and report data on all 10 measures of the following standardized set of performance measures:
- Deep Vein Thrombosis (DVT) Prophylaxis
- Discharged on Antithrombotics
- Patients with Atrial Fibrillation Receiving Anticoagulation Therapy
- Thrombolytic Therapy Administered
- Antithrombotic Therapy by End of Hospital Day Two
- Discharged on Cholesterol Reducing Medication
- Dysphagia Screening
- Stroke Education
- Smoking Cessation/Advice/Counseling
- Assessed for Rehabilitation
Currently, certified Primary Stroke Centers are required to collect data on the first four measures of this set. Identified by The Joint Commission’s Stroke Technical Advisory Panel, these measures were derived from the draft standardized stroke measures that were implemented and pilot tested in 2004-2005. Following the pilot test, the measures were revised and harmonized with similar measures used by the American Heart Association/American Stroke Association and the Paul Coverdell stroke registry that is administered by the Centers for Disease Control and Prevention. Complete measure specifications will be included in the revised Stroke Performance Measure Implementation Guide, to be published on the Joint Commission website. (Contact: Ann Watt, awatt@jointcommission.org)
-Top-
Effective January 1, 2008, all Joint Commission certified Health Care Staffing Services and any staffing firm interested in undergoing an initial review will be required to collect data on the following standardized set of performance measures:
- Do Not Return—Clinical
- Do Not Return—Professional
- Completeness of Personnel File
Currently, all health care staffing firms and certified Health Care Staffing firms collect data on one non-standardized measure. The new standardized measure set was identified by The Joint Commission Health Care Staffing Services Performance Measure Technical Advisory Panel and was pilot tested in 2006-2007. Complete specifications for the standardized measure set are published in the HCSS Performance Measure Implementation Guide, 2nd Edition, available on The Joint Commission website.
(Contact: Ann Watt, awatt@jointcommission.org)
-Top-
Beginning October 1, The Joint Commission’s Quality Check® website will include health care organizations that are not accredited by The Joint Commission. The addition of non-Joint Commission accredited organizations provides health care consumers with more information and highlights the value of accreditation. In addition, Quality Check users can locate health care providers by the types of services they provide, for example, hospice or dementia care. The new Search by Service feature is in addition to the existing search by name and type of provider. The inventory of services on the Application for Survey has been expanded to support the Search by Service feature. An organization can update their inventory of services at any time by accessing The Joint Commission Extranet. (Contact: John Cullinan, jcullinan@jointcommission.org)
-Top-
The Joint Commission has been awarded a contract by the World Health Organization to oversee global field testing of the long-planned International Classification for Patient Safety (ICPS). The project has been sponsored by the WHO World Alliance for Patient Safety and is overseen by a panel of international experts. The Joint Commission was first approached by WHO in 2005 to coordinate the development of the ICPS in collaboration with a panel of experts. The goal of the project has been to create a classification system that optimizes the comparability of patient safety data and information across international borders. The field testing effort will determine the extent to which the ICPS reflects the realities and scope of patient safety worldwide, is feasible to implement across disparate health care settings, and produces valid and reliable results which can be used to enhance patient safety globally. The ICPS methodology is consistent with the WHO – Family of International Classifications guidelines and previous field testing undertaken by the WHO for the International Classification of Diseases (ICD). The official version of the ICPS is expected to be available for global implementation in late 2008. See the news release. (Contact: Heather Sherman, hsherman@jointcommission.org)
-Top-
Health care organizations across the country are faced with the challenge of staying competitive while continuously improving all aspects of their organizations. Meeting these challenges and moving from good to greatness is the focus of The Joint Commission and Joint Commission Resources’ 21st Annual Conference on Quality and Safety. This year’s annual conference, “Organizational Greatness: Actions for Health Care Excellence,” set for November 12-14 at the Hilton Chicago, will highlight strategies to help leadership instill in practitioners a passion for patient safety and quality that extends system wide, and take the steps necessary to get there. An important change to this year’s event is the addition of two simultaneous tracks— one on quality and the other on safety. The quality track concentrates on the measurement and continuous improvement aspects of organizational greatness. The safety track explores evidence-based practice and implementation methodologies that have helped health care providers achieve a culture of patient safety.
Two optional pre-conference workshops will be offered on the morning of November 12. The first workshop will provide an overview of The Joint Commission’s Annual Quality Report and interpretation of the 2006 findings. The report details how America’s hospitals are performing against evidence-based measures. The second workshop will examine The Joint Commission’s 2008 National Patient Safety Goals and related Requirements. The focus of this session will be on current expectations in meeting these Requirements and the major challenges that health care organizations face in overcoming identified barriers to success. Strategies for implementing both the current and the 2008 Goals and Requirements will be presented. To register, call the Joint Commission’s Customer Service Center at 1 (877) 223-6866 or visit http://www.jcrinc.com/. See the news release. (Contact: Anna Hanuszewicz, ahanuszewicz@jcrinc.com)
-Top-
The Joint Commission is conducting free monthly one-hour audio conferences on topics of interest. All audio conferences begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Information is sent to accredited organizations via list-serve approximately one week prior to each call. To sign up to receive registration information on upcoming audio conferences, accredited organizations can go to their extranet site on The Joint Commission Connect. Below is the schedule of upcoming audio conferences:
| September 13 |
National Patient Safety Goals |
| October 25 |
New Leadership standards that take effect January 1, 2009, with an introduction to the revised Medical Staff standard (Note new date and topic) |
| November 1 |
Continuation of the Leadership standards discussion, plus an in-depth look at the revised Medical Staff standard that takes effect July 2009 (Note new date and topic) |
| December 12 |
Transplant Center Certification (Canceled) |
Note: The October 25 and November 1 conferences will be conducted as a two-part call. By participating in both calls, listeners will:
- Understand the revisions to the Leadership chapter and the rationale for those changes
- Recognize the connection between Standard MS.1.20 and the revised Leadership standards
- Learn the details of the application of MS.1.20
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
-Top-
The Joint Commission is seeking comments on the organization of the Standards Frequently Asked Questions (FAQs) section of its website. This section lists common questions that come from the field via the online question form. Please take a few minutes to complete this short survey to help The Joint Commission review and improve this information. Click here to access the survey. (Contact: Frank Barancyk, fbarancyk@jointcommission.org)
-Top-
The Joint Commission is interested in your thoughts about This Month and how it can be improved. A short online readership survey is available through October 15. (Contact: Caron Wong, cwong@jointcommission.org)
-Top-