Standard PC.12.90, which addresses the requirement for in-person evaluation of a patient when restraint or seclusion is initiated, has been revised to align with the Centers for Medicare & Medicaid Services’ Final Rule for Patient Rights. Issued in December 2006, the rule allows a registered nurse or physician assistant to evaluate a patient within one hour of the initiation of restraint or seclusion, provided that such practitioner has been trained in accordance with CMS requirements and that this practitioner consults with the attending physician or a licensed independent practitioner as soon thereafter as possible. The revised standard is effective immediately. (Contact: Mary Brockway, mbrockway@jointcommission.org)
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Standard LD.3.110 Element of Performance 12 has been revised to clarify its requirements respecting the procurement and donation of organs and other tissues. EP 12 requires hospitals to have a policy that addresses opportunities for asystolic recovery (often known as “donation after cardiac death”). While the EP does not require hospitals to provide for asystolic recovery, it does require that the policy be mutually agreed upon by the hospital, its medical staff, and its Organ Procurement Organization (OPO). There have been instances in which a hospital and its medical staff agree that they will not provide for asystolic recoveries. Reasons for this decision vary from a lack of resources to support asystolic recovery to concerns about ethics or quality of end-of-life care. An Organ Procurement Organization may not agree with these decisions. While the revised standard is not effective until January 1, 2008, in the interim, a hospital that cannot reach an agreement with its OPO will not be cited. Surveyors will continue to survey for the presence of a policy on asystolic recovery, evidence that the hospital and its medical staff are in agreement about the policy, and that the hospital involved its OPO in its discussion about asystolic recovery. The EP has been revised to include the following: When the hospital and its medical staff agree not to provide for asystolic recovery and cannot achieve agreement with the designated OPO, the hospital documents its efforts to reach an agreement with its OPO, and the donation policy addresses the hospital’s justification for not providing for asystolic recovery. (Contact: Kelly Fugate, kfugate@jointcommission.org)
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Effective January 1, 2008, standard PC.2.120, which addresses the timeframes for taking histories and physicals, has been revised to align with the Centers for Medicare & Medicaid Services’ final rule regarding these timeframes. The Joint Commission’s revised standard requires that a medical history and physical examination be completed no more than 30 days prior to or within 24 hours after inpatient admission. For a medical history and physical examination that was completed within 30 days prior to inpatient admission, an update documenting any changes in the patient’s condition is to be completed within 24 hours after inpatient admission or prior to surgery. The proposed standard underwent field review and 875 responses were received. There was no consensus among respondents as to an acceptable timeframe for completing histories and physicals that would not require an update at the time of admission. (Contact: Mary Brockway, mbrockway@jointcommission.org)
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Effective January 1, 2008, the emergency management standards (EC.4.10 and EC.4.20) for hospitals, critical access hospitals and long term care facilities have been revised to reflect an “all-hazards” approach to emergency preparedness that permits appropriately flexible and effective responses. The revised standards emphasize a “scalable” approach that can help manage the variety, intensity and duration of the disasters that can affect a single organization, multiple organizations or an entire community. They also stress the importance of planning and testing response plans for emergencies during conditions when the local community cannot support the health care organization. The proposed revisions were vetted for field comment in January; responses were received from 397 hospitals, 66 critical access hospitals and 18 long term care organizations. In addition, interviews were conducted with selected organizations in order to fully understand the impact that the proposed requirements would have on them. Based on this input, changes were made to the proposed revised standards, specifically in relation to concerns about organizations’ ability to comply with some requirements. In addition, some expectations were clarified and some redundant and overly-prescriptive expectations were eliminated.
Over the past five years, The Joint Commission has studied a variety of disasters that impacted health care organizations, including floods, widespread electrical utility outages, the terrorist attacks of September 11, the four back-to-back Florida hurricanes of 2004, and the Katrina and Rita hurricanes that struck the Gulf Coast in 2005. In formulating these standards changes, The Joint Commission was debriefed by health care organizations affected by these disasters, engaged emergency management experts, served on national emergency management panels, and reviewed the current literature on emergency management. From these studies, The Joint Commission concluded that it is not sufficient to require that health care organizations plan for a single event; they should be able to demonstrate sufficient flexibility to respond effectively to combinations of escalating events. (Contact: John Fishbeck, jfishbeck@jointcommission.org)
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The Joint Commission is conducting the following field assessment: Advanced Disease-Specific Care Certification for the Management of Patients with Chronic Obstructive Pulmonary Disease (COPD); the deadline for comments is June 5, 2007. (Contact: Lisa Vidovic, lvidovic@jointcommission.org)
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An upcoming field review will cover a proposed new standard that will address health care industry representatives who provide training and guidance regarding medications, medical equipment, devices, supplies and procedures in the presence of patients. When available, the field review will be posted on The Joint Commission website and notification of the field review will be sent via list-serv to organizations in The Joint Commission’s hospital, critical access hospital, ambulatory and office-based surgery accreditation programs. In order to better understand how organizations utilize HCIRs, The Joint Commission has:
- Reviewed the American College of Surgeons position statement on HCIRs and the Association of periOperative Registered Nurses position statement and guidelines on HCIRs.
- Engaged in discussion with Joint Commission advisory councils and committees.
- Interviewed vendors, vendor member organizations, accredited organizations and professional organizations.
- Reviewed the results from two surveys conducted by the Voluntary Hospitals of America on the use of HCIRs in their hospitals.
(Contact: Laura Smith, lsmith@jointcommission.org)
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As part of the Standards Improvement Initiative, The Joint Commission recently held conference calls with newly organized panels of experts; these panels represented the ambulatory health care, home care and hospital fields. The panels are charged with providing input on the relevance of the current medication management standards to their setting; input on setting-specific patient safety issues regarding medication management; and ideas for future standards development in the area of medication management. Also, on Wednesday, May 2, look for a posting on the Joint Commission website of the recommended changes to the standards related to the Surveillance, Prevention and Control of Infection (IC) chapter. These proposed standards changes apply to the ambulatory care, critical access hospital, home care, hospital and office-based surgery programs. Comments and feedback through a web-based survey will be solicited from April 30 through June 8, 2007 online.
The Standards Improvement Initiative 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. This initiative involves extensive communication and interaction with health care organizations to gain their perspectives and advice on how to improve the content and organization of the standards. Feedback is being sought from both accredited and non-accredited health care organizations, The Joint Commission advisory groups, payers, purchasers, consumers, governmental agencies and The Joint Commission surveyors. Questions can be sent to standardsimprovement@jointcommission.org.
Standards Improvement Initiative 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.
January-March 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.
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; standards improvements for the behavioral health care, laboratory and long term care accreditation programs will follow.
(Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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Nine solutions to prevent health care errors that harm millions of people daily throughout the world were unveiled today by the World Health Organization’s Collaborating Centre for Patient Safety Solutions. The nine Patient Safety Solutions are available for use by WHO Member States. The Patient Safety Solutions address the issues of look-alike, sound-alike medication names; correct patient identification; hand-over communications; correct procedure at the correct body site; control of concentrated electrolyte solutions; medication accuracy; catheter and tubing misconnections; needle reuse and injection device safety; and hand hygiene. The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients. In 2005, WHO designated The Joint Commission and Joint Commission International as its Collaborating Centre on Patient Safety Solutions. The Joint Commission International Center for Patient Safety operationalized this effort by identifying widespread problems and challenges to safe care, identifying promising solutions, and vetting them through an extensive field review process that garnered feedback from health care providers, practitioners, and other experts from more than 100 countries. See the news release. For more information or to view the complete Patient Safety Solutions, visit www.jointcommissioninternational.org/solutions. (Contact: Peter Angood, pangood@jointcommission.org)
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A new Joint Commission report recommends targeted strategies to address language and cultural issues that increasingly pose challenges to hospitals seeking to deliver safe, effective care to diverse American populations. The recommendations in “Hospitals, Language, and Culture: A Snapshot of the Nation, Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings” result from a study of how 60 hospitals across the country are providing health care to culturally and linguistically diverse patient populations. This report, the first in a series, provides details of the challenges of providing care and services to populations that may not speak the same language or share the same customs and how hospitals are addressing these challenges. Subsequent reports and papers will investigate the data further to report how one hypothetical patient’s language and communication needs were met; better understand what drives some hospital CEOs to embrace the provision of linguistic and cultural services as “the right thing to do;” and report on identified practices that are employed by hospitals in this study and appear to be promising. Copies of the report are available at no cost. See the news release. (Contact: Amy Wilson-Stronks, awilson-stronks@jointcommission.org)
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The Joint Commission and the American Case Management Association recently named Morton Plant Mease Health Care in Clearwater, Florida, the winner of the 2007 Franklin Award of Distinction. Morton Plant Mease demonstrated collaborative practice between nursing and social work while maintaining awareness and application of their unique professional standards of practice by reinforcing these through education initiatives, and for social work, through a specific council. Morton Plant Mease developed an internship for professionals who are interested, yet inexperienced, in case management.
Evaluation criteria for the award included the organization’s ability to demonstrate their commitment to a collaborative philosophy and an interdisciplinary process for case management. The award is named for Benjamin Franklin, the co-founder of the first organized hospital in the United States. His personal character, integrity and credibility, as well as his reputation as an entrepreneur and inventor, represent the type of leadership and forward thinking that distinguish the hospitals or health systems recognized as Franklin Award recipients. The ACMA and The Joint Commission formally presented the Franklin Award to Morton Plant Mease on April 23 at the 14th annual NICM Clinical Case Management Conference and 8th annual ACMA meeting in Miami, Florida. See the news release. (Contact: Jean Range, jrange@jointcommission.org)
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The Joint Commission is currently redesigning The Joint Commission Connect extranet site, which is the Joint Commission’s main electronic communication link with its customers. The Joint Commission Connect will have a number of new features which will be available in the third quarter of 2007, including:
- Enhanced security controls to enable organizations to apply security settings for individuals. An organization will be able to allow certain individuals to have access to all of the accreditation tools on the site or limit access to other tools, for example, access only to the application for accreditation. In a customer satisfaction survey conducted in 2006, 92 percent of accredited organizations said that it would be helpful to limit user access within the extranet.
- A “What’s Due” section that provides an at-a-glance display of accreditation tasks, such as Evidence of Standards Compliance, Measures of Success, the Periodic Performance Review and the application for accreditation.
- A “New Reports” section that provides an at-a-glance display of recently posted organization reports, such as the accreditation report.
- For corporate and multi-organization systems, a drop down menu list will enable the user to switch from one organization site to another.
- A “Disease Certification” tab for organizations that are both accredited and disease-specific care certified.
- A “Quicklink” to update extranet contacts and apply security settings.
(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 begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Information is sent to accredited hospitals 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:
| May 9 |
Standards Improvement Initiative (Ambulatory Care and Home Health providers) |
| May 17 |
Standards Improvement Initiative (Hospitals) |
| June 21 |
Wrong Site Surgery |
(Contact: Cathy Barry-Ipema, cipema@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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The 16th Annual State Hospital Association Forum will take place on Friday, June 8, 2007, at The Joint Commission’s Central Office in Oakbrook Terrace, Illinois. (Contact: Karen Eberspacher, keberspacher@jointcommission.org)
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