The Joint Commission has announced the 2008 National Patient Safety Goals and related Requirements for each of its accreditation programs and its Disease-Specific Care Certification Program. The Goals and Requirements, recently approved by the Joint Commission’s Board of Commissioners, apply to more than 15,000 Joint Commission-accredited and certified health care organizations. Major changes in this sixth annual issuance of NPSGs include:
- A new Requirement to take specific actions to reduce the risks of patient harm associated with the use of anticoagulant therapy. This Requirement addresses a widely-acknowledged patient safety problem and becomes a key element of the Goal: Improve the safety of using medications. It is applicable to hospitals, critical access hospitals, ambulatory care and office-based surgery settings, and home care and long term care organizations.
- A new Goal and Requirement that address the recognition of and response to unexpected deteriorating in a patient’s condition. This new Goal and Requirement will ask hospitals and critical access hospitals to select a suitable method for enabling care-givers to directly request and obtain assistance from a specially-trained individual(s) if and when a patient’s condition worsens.
Each of the foregoing new Requirements has a one-year phase-in period that includes defined milestones. Full implementation is targeted for January 2009. In addition:
- An existing Requirement to assure the timely reporting of critical test results has been extended to the long term care program.
- For all programs, the Requirement that addresses hand hygiene also has been expanded to permit use of the World Health Organization Hand Hygiene Guidelines as an alternative to the Centers for Disease Control and Prevention hand hygiene guidelines.
- The Requirement to limit and standardize drug concentrations that is part of the Goal to improve the safety of using medications will be retired as a NPSG, but organization compliance will continue to be evaluated as part of the Medication Management standards.
The full text of the 2008 Goals and Requirements is posted online. See the news release. (Contact: Peter Angood, pangood@jointcommission.org)
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Effective April 6, 2007, the interim action was suspended for Standard MM 4.10 Element of Performance 1 that required a retrospective review of all medication orders in the Emergency Department (ED) by a pharmacist when a prospective review was not conducted. The interim action was implemented on January 1, 2007 for EDs in hospitals and critical access hospitals. The decision to suspend the interim action was based on several concerns cited by the field, including the lack of prior hospital pharmacist involvement in the ED setting, the costs to hospitals of providing additional pharmacist manpower to support medication review of any type in the ED, and the frequent unavailability of pharmacists because of the long-standing pharmacist shortage.
With the suspension of the interim action, the requirement for Standard MM 4.10 EP 1 will be reinstated as written in the 2007 accreditation manual, which states: “Before dispensing, (CAH: when on-site pharmacy services are available,) removal from floor stock, or removal from an automated storage and distribution device, a pharmacist reviews all prescription or medication orders unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the [patient], including situations in which the [patient] experiences a sudden change in clinical status (for example, new onset of nausea).”
However, The Joint Commission will now permit organizations to implement the two exceptions in Standard MM 4.10 EP 1 more broadly in order to minimize treatment delays and patient back-up. To clarify this position, each exception is addressed below emphasizing its implementation in the ED:
- Exception 1: “…unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication.”
Implementation: When using this exception, medications ordered by a licensed independent practitioner in the ED can be processed, including administration of the medication, by a registered nurse or other licensed staff with medication administration responsibilities (e.g. respiratory therapist) in accordance with law and regulation. A licensed independent practitioner will not be required to remain at the bedside when the medication is administered. However, the licensed independent practitioner must remain available to provide immediate intervention should a patient experience an adverse medication event.
- Exception 2: “…in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.”
Implementation: When using this exception, urgent care situations will be defined by the licensed independent practitioner who is providing care to the patient.
The broad implementation of the two exceptions to Standard MM 4.10 EP 1 will remain in effect for EDs while this standard is under revision and further tested in the field. Organizations that have successfully implemented prospective medication order review by a pharmacist are encouraged to continue doing so whenever possible.
Two further actions are underway by The Joint Commission to resolve the issue pertaining to MM 4.10 in the ED:
- The Joint Commission is convening an interdisciplinary Task Force to review the recommendations from stakeholders and the 2006 field review of Standard MM 4.10 EP 1 in the ED, and to develop a proposal for revisions to this standard.
- An additional field review is planned to obtain field input on proposed strategies to revise Standard MM 4.10 EP 1.
Please direct questions to the Standards Interpretation Group at 630-792-5900, option 6, or through the online submission form. (Contact: Kelly Podgorny, kpodgorny@jointcommission.org)
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Effective January 1, 2009, a revised Leadership chapter will be introduced for all accreditation programs. This chapter encompasses expectations regarding creation of a culture of safety; leadership accountabilities of the leadership groups, which in hospitals may include the governing body, senior managers, management, and the leaders of the medical staff; management of disruptive behavior in those who work in the organization; and conflict management. The extended implementation period allows organizations to fully evaluate the standards and gives them more time to implement changes, if necessary. Portions of the standards have been in development for several years, including those addressing leadership accountabilities, the culture of safety and quality, and performance of organization-wide systems. The proposed changes for the chapter underwent two field reviews and multiple conversations with key stakeholders. Changes include:
- New standards derived from the work of the Leadership Accountabilities Task Force, such as those addressing shared leadership accountabilities, skills required of leaders, and communication among leaders.
- A new hospital standard that addresses conflict management. The intent of the standard is to help organizations manage conflict among leaders regardless of the cause of the conflict. The standard requires that leaders work together to manage conflict while still recognizing the authority of governance to make decisions.
- A new culture of safety and quality standard that addresses disruptive behavior for those who work in the organization.
- An increased emphasis on standards addressing the performance of important systems in the organization.
- A more explicit description of the roles of the leaders of the medical staff in addressing organization-wide issues.
- The introductory statements and relevant rationales emphasize the ultimate responsibility of governance.
The chapter was reorganized into four sections covering Leadership Structure, Leadership Relationships, Organization Culture and System Performance Expectations, and Operations. Substantial edits were made to existing requirements. The pre-publication standards for the revised Leadership chapter are available on The Joint Commission website. (Contact: Maureen Carr, mcarr@jointcommission.org)
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The Joint Commission recently conducted the following activities as part of the Standards Improvement Initiative:
- Held two audio conferences on SII; the first audio conference was held on May 9 for the Ambulatory, Office-Based Surgery, and Home Care accreditation programs, and the second was on May 17 for the Hospital and Critical Access Hospital accreditation programs. Callers provided suggestions as to potential changes that could help improve their use of the manuals.
- Held a conference call with the Joint Commission’s Business Advisory Group to review the proposed changes to the standards and get the purchaser’s perspective.
- Conducted an electronic survey to get the payer’s perspective on the proposed changes and received an excellent response.
- Met with the Accredited Customer Groups that represent hospitals, critical access hospitals, ambulatory facilities, office-based surgery practices, and home care organizations. These groups discussed the refinements being made to the Medication Management (MM) and Environment of Care (EC) chapters, and to the overall organization and content of the manual.
- Completing a cost-benefit analysis of making the content of accreditation manuals available electronically and developing a prototype
- Developed potential scoring models and planning for feasibility testing.
- Posted a website survey to gather feedback on recommended changes to the Management of Information (IM) chapter for the ambulatory care, critical access hospital, home care, hospital and office-based surgery program manuals. Comments and feedback will be solicited through July 1.
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. For more information, click here. 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.
May 2008: 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.
June 2008: Target date for completing improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals. Begin standards improvements 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)
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The Joint Commission launched a national campaign to help Americans understand their rights when receiving medical care. “Know Your Rights” is part of The Joint Commission’s award-winning Speak Up™ program that urges people to take an active role in their own health care. Patients who ask questions and are aware of their rights have a greater chance of getting the care that they need when they need it. “Know Your Rights” provides tips to help people become more involved in their treatment, thus improving the safety and quality of care received. The campaign advises patients that they have a right to be informed about the care they will receive; get information about care in their preferred language; know the names of their caregivers; receive treatment for pain; receive an up-to-date list of current medications; expect that they will be heard; and be treated with courtesy and respect.
“Knowing your rights regarding treatment and care is the foundation for all interactions with your caregivers at health care facilities. Candid conversations between patients and their caregivers will help facilitate the delivery of safe, high quality care and ultimately, enhance recovery,” says Paul Schyve, M.D., senior vice president, The Joint Commission. Consumers can download the free Speak Up brochure from The Joint Commission website. All of the Speak Up brochures are being redesigned in an easy-to-read format and will also be available in Spanish. To sign up to receive future issues of Speak Up via e-mail, please join the Speak Up list serve. See the news release. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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New compliance data for the National Patient Safety Goals for the first quarter of 2007 is available online. The data was derived from surveys conducted at 1,231 health care organizations from January 1 to March 31, 2007. (Contact: Pat Adamski, padamski@jointcommission.org)
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The Joint Commission will begin a first-of-its kind study of smoke-free hospital campuses in June 2007. The project, which will seek input from nearly all of America’s hospitals, is being funded by a grant from the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program. Although many studies have examined the development, adoption and effects of indoor smoke-free policies in health care settings, the Joint Commission study represents the first systematic evaluation of the challenges to implementing, or the impact of transitioning to, a smoke-free hospital campus. The study recognizes a new trend emerging on hospital campuses in which smoking is prohibited outdoors, at entranceways, on grounds and in parking areas. The electronic survey will be distributed to more than 4,200 Joint Commission-accredited hospitals in the United States. The survey will explore hospital smoking policies, gathering data on the experiences of hospitals that have successfully implemented smoke-free campus policies, as well as the experiences and perceptions of hospitals that have not yet adopted such policies. Survey responses will be analyzed with respect to hospital demographic characteristics and hospital performance on The Joint Commission’s smoking cessation counseling core measures. See the news release. (Contact: Scott Williams, swilliams@jointcommission.org)
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Beginning third quarter 2007, The Joint Commission will launch its redesigned Connect extranet site, the main electronic communication link with Joint Commission customers. Customers can log-in as usual or go to www.jointcommissionconnect.org. The new site will include Frequently Asked Questions about the new site, a PowerPoint presentation about the new security features, and a survey form for comments about the new site. A preview of the new features is available on the current extranet site under “What’s New.” Questions about the new Connect site should be directed to the organization’s Account Representative. If the organization’s Account Representative is not known, call (630) 792-3007 and the call will be automatically routed to the appropriate Account Representative. (Contact: Teena Wilson, twilson@jointcommission.org)
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The Joint Commission is conducting free monthly one-hour audio conferences on topics of interest. All audio conferences (except the July 18 one) 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, go to your organization’s extranet site on The Joint Commission Connect. Below is the schedule of upcoming audio conferences:
| July 18 |
Standard MM 4.10: Review of Medication Orders in the ED [Note different time for this audio conference: 9:30 a.m. PT/10:30 MT/11:30 p.m. CT/12:30 p.m. ET] |
| August 16 |
Strategic Surveillance System—Understanding Reports |
| September 13 |
National Patient Safety Goals |
| October 24 |
Inpatient Diabetes Certification |
| November 8 |
Hospital Leadership: Administration, Governance and Medical Staff Working Together |
| December 12 |
Transplant Center Certification |
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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The Joint Commission’s first quarter 2007 CEO opinion survey of all accredited organizations and programs included questions about the benefits of Joint Commission accreditation and the new accreditation process. Survey questions about the new accreditation process revealed the following ratings as excellent, very good or good:
Overall survey experience—98 percent
Overall value of accreditation to the organization—95 percent
Likelihood of re-applying for accreditation—97 percent
Likelihood of recommending Joint Commission accreditation—94 percent
Engaging physicians in the survey process—86 percent
Fostering a culture of continuous operational improvement—97 percent
Providing a meaningful assessment of an organization’s strengths and weaknesses—93 percent
Reducing costs associated with survey preparation and consulting—78 percent
Relevancy of standards to safe, high-quality care—94 percent
Enhancing the educational benefits of an on-site survey—92 percent
Customer service—95 percent
This survey is conducted quarterly by telephone with CEOs and by mail with other representatives of organizations surveyed by the Joint Commission. (Contact: Chuck Mowll, cmowll@jointcommission.org)
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The 15th Annual Liaison Network Forum will take place July 10 – 11, 2007, at The Joint Commission’s Central Office in Oakbrook Terrace, Illinois. Individuals interested in receiving the agenda and registration materials should provide an e-mail address to which these materials may be sent. Questions and comments can be sent to dbcameeting@jointcommission.org. (Contact: Christina Wichmann, cwichmann@jointcommission.org)
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