Standards Improvement Initiative update
The Joint Commission is engaged in the following activities as part of its Standards Improvement Initiative:
- The Standards and Survey Procedures Committee reviewed the following chapters: Surveillance, Prevention and Control of Infection, Improving Organization Performance, and Management of Information. SSP members reviewed the chapters to ensure that: language is clear; the sequence of the standards and elements of performance is logical; each EP addresses only one item that can be surveyed and scored; and deletions to the standards are in fact either redundant or non-essential. The SSP Committee approved these chapters, with minor recommended changes that will be reviewed with them during a conference call in October. The SSP Committee will next review the Medication Management, Environment of Care, and Management of Human Resources chapters at its meeting in November.
- Investigating better ways to separate and improve the Life Safety Code standards, including clarifying the language and the logical flow and structure of the standards. The LSC standards currently reside in the Environment of Care chapter. Staff is recommending LSC become its own chapter, which would include the electronic statement of conditions, the requirement for life safety assessment, and the management of LSC. An additional goal is to make the scoring of the chapter consistent with the other standards and EPs. As part of the development process, The Joint Commission is working with industry experts and LSC specialists. Any changes to the LSC standards would be field reviewed, probably later this year.
- The Joint Commission is evaluating its current scoring and accreditation decision processes. While several new models have been proposed, the Joint Commission is contemplating moving away from a “threshold based” decision process and instead focusing its accreditation decision process on timely compliance with specific groups of standards. The proposed new model is being tested and reviewed with several advisory groups, including the Hospital Advisory Committee, the Surveyor Advisory Committee, the Physician Engagement Advisory Group and the Standards Improvement Initiative Accredited Customer Group.
- Posted website surveys to gather feedback on proposed changes to the Management of Human Resources, the Medication Management, and the Management of the Environment of Care chapters for the ambulatory care, critical access hospital, home care, hospital and office-based surgery program manuals. Comments and feedback will be solicited through October 22 for the HR chapter, through October 25 for the MM chapter, and through October 31 for the EC chapter.
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.
June 2007: “Virtual” pilot testing with selected surveyors and Central Office staff.
August 2007: The Surveillance, Prevention and Control of Infection, Improving Organization Performance, and Management of Information chapters were approved by the Standards and Survey Procedures Committee.
First Quarter 2008: The Joint Commission will begin conducting mock surveys using the improved standards and manuals.
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. Final revised standards will be provided to accredited organizations in the affected 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)
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The Joint Commission officially launched its certification program for hospitals that perform ventricular assist device surgery as destination therapy. A VAD is used to augment the pumping action of a weakened heart ventricle, a major pumping chamber of the heart. While VADs were originally used on a short-term basis to support failing hearts until donor hearts became available, these devices are now also used to extend the lives of end-stage heart failure patients who are not candidates for heart transplantation. The Joint Commission will immediately begin conducting on-site reviews of organizations that apply for VAD certification. Hospitals performing VAD as destination—or long-term—therapy will receive a Certificate of Distinction under The Joint Commission’s Disease-Specific Care Program for Ventricular Assist Device. The Centers for Medicare and Medicaid Services will reimburse for VAD surgery as a destination therapy when it is performed at Joint Commission certified organizations. Programs that are currently Medicare-approved must become certified by The Joint Commission no later than March 27, 2009 in order to retain their status. Facilities currently not Medicare-approved will be added to the CMS approval list following certification. The VAD standards were developed in consultation with an external task force of experts and reviewed through a public comment period. See the news release. (Contact: Liz Calderon, ecalderon@jointcommission.org)
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The National Quality Forum and The Joint Commission announced the 2007 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards. Honorees were selected in all four award categories. The honorees, by award category, are as follows:
- Individual Achievement (two recipients): Flaura Koplin Winston, M.D., Ph.D., Center for Injury Research and Prevention at The Children’s Hospital of Philadelphia and the University of Pennsylvania; Darrell A. Campbell, Jr., M.D., University of Michigan Hospitals and Health Centers
- Research: Eric J. Thomas M.D., MPH, The University of Texas Health Science Center at Houston
- Innovation in Patient Safety and Quality at the National Level: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
- Innovation in Patient Safety and Quality at the Local Level: Evanston Northwestern Healthcare, Evanston, Ill.
This year’s awards will be presented on September 27, 2007 at NQF’s Annual Policy Conference on Quality in Washington, D.C. The December 2007 issue of The Joint Commission Journal on Quality and Patient Safety will feature the achievements of each of the award recipients. The patient safety awards program, launched in 2002 by NQF and The Joint Commission, honors John M. Eisenberg, MD, MBA, former administrator of the Agency for Healthcare Research and Quality (AHRQ). Dr. Eisenberg was one of the founding leaders of the NQF and sat on its board of directors. In his roles both as AHRQ administrator and chair of the federal government’s Quality Inter-Agency Coordination Task Force, he was a passionate advocate for patient safety and health care quality and personally led AHRQ’s grant program to support patient safety research. See the entire news release. (Contact: Linda Hanold, lhanold@jointcommission.org)
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Beginning October 1, The Joint Commission’s Quality Check® website will include organizations that are not accredited by The Joint Commission as well as Joint Commission accredited organizations. Joint Commission accredited organizations are easily identified by The Joint Commission’s Gold Seal of Approval™. This is the first listing of its kind. Several thousand home care, long term care, and ambulatory care organizations will be added using publicly available lists of health care providers. After October 1, organizations not accredited by The Joint Commission can request to be added to Quality Check by accessing www.qualitycheck.org/qcdirectory. The addition of organizations that are not accredited by The Joint Commission provides consumers with more information to help them make decisions about their health care. While Quality Check will display demographic and service information for organizations not accredited by The Joint Commission on the Quality Check Search Results page, Quality Reports will only be available for organizations that are accredited by The Joint Commission. (Contact: John Cullinan, jcullinan@jointcommission.org)
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Below is an updated list of topics for the remaining 2007 free audio conferences with Joint Commission President Dennis S. O’Leary, M.D. Please disregard previous communications that had different dates and topics. Please note the new dates for a two-part call on the revised Leadership standards and Medical Staff standard 1.20. All audio conferences are one hour in length and begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Registration information is available approximately one week before each call on each accredited organization’s extranet site on The Joint Commission Connect. For more information, click here.
| October 25 |
New Leadership standards that take effect January 1, 2009, with an introduction to the revised Medical Staff standard |
| November 1 |
Continuation of the Leadership standards discussion, plus an in-depth look at the revised Medical Staff standard that takes effect July 2009 |
| December 12 |
Transplant Center Certification (Canceled) |
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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The October issue of Joint Commission Perspectives will include a question-and-answer session with Mark R. Chassin, M.D., M.P.P., M.P.H., the next President of The Joint Commission. The article is also posted on The Joint Commission website. (Contact: Cathy Hinckley, chinckley@jcrinc.com)
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Joint Commission Resources is hosting a free audio conference on “Assessing Organizational Capacity for Change: How Does Your Hospital Measure Up?” The 90-minute audio conference will be held October 12 beginning 10:30 a.m. PT/11:30 a.m. CT/12:30 p.m. ET. The audio conference will be led by Professor William Judge, Ph.D., Professor of Management and E.V. Williams Chair of Strategic Leadership, Old Dominion University, Norfolk, Virginia. For more information or to sign up, go to http://www.jcrinc.com/26652/. (Contact: Deborah Nadzam, dnadzam@jcrinc.com)
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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)
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