After January 1, 2008, on-site surveys will include a new consideration that will benefit organizations that submit the full Periodic Performance Review or PPR Option 2. If the surveyor identifies a Requirement for Improvement (RFI) that the organization has already identified as a compliance issue in its Plan of Action (POA)—and the POA completion date is not yet passed—the Joint Commission will take that into consideration and the RFI would not count toward the organization’s accreditation decision. Only those organizations that submit full PPR and PPR Option 2 are eligible for this consideration, as they include the submission of actual compliance issues along with POA and Measures of Success (MOS). PPR Option 1 and PPR Option 3 do not submit identified compliance issues or POA and MOS.
The organization will have their accreditation report and PPR reviewed by the Joint Commission’s Standards Interpretation Group (SIG). The RFI will not count toward the accreditation decision as long as the RFI and the compliance issue identified in the POA and MOS are identical and the POA implementation has not yet passed (or if the PPR is not yet approved by SIG and everything is acceptable). The RFI will remain in the accreditation report but it will not count toward the accreditation decision. For example, if a small hospital has 15 RFIs (the threshold is 14 for Preliminary Denial of Accreditation) and it has self-identified in its PPR three of the issues identified in the accreditation report (and they meet the criteria noted above) the RFIs would remain in the report. However, only 12 of the RFIs would count toward the accreditation decision, making the organization eligible for Conditional Accreditation.
This change acknowledges the organization’s assessment while ensuring that all identified compliance issues are corrected within the time frames required for corrective Evidence of Standards Compliance (ESC). The Joint Commission wants to avoid penalizing an organization that is already working to address compliance issues through its POA and MOS. Depending on the POA timeframe, the RFI will not count toward the organization’s accreditation decision. However, if the POA time frame has expired and the compliance issue has not been addressed, the RFI would count toward the accreditation decision.
The Periodic Performance Review is a compliance assessment tool designed to help organizations with their continuous monitoring of performance and performance improvement activities. The PPR provides the framework for continuous standards compliance and focuses on the critical systems and processes that affect patient care and safety. The Joint Commission provides four options for meeting the PPR requirement: the full PPR or Options 1, 2 and 3. Through the PPR, the organization self-evaluates its compliance with all Accreditation Participation Requirements, National Patient Safety Goals, applicable standards and Elements of Performance, and develops a Plan of Action for all areas of performance identified as needing improvement. (Contact: Pat Adamski, padamski@jointcommission.org)
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Effective January 1, 2008, The Joint Commission will discontinue track record requirements for organizations undergoing initial surveys or reviews. These organizations will not need to demonstrate a four-month track record of compliance with the standards at the time of the initial survey or review. However, initial hospitals that provide surgical or pediatric services must undergo a follow-up on-site survey one year after becoming accredited (with the exception of critical access hospitals that are certified by the Centers for Medicare & Medicaid Services and have had their one-year follow-up survey by CMS). The Joint Commission’s follow-up survey is limited in scope, focusing on only those areas that are most important to the provision of patient care in each of the identified high risk services (e.g., medication management, infection control). For hospitals and critical access hospitals, the current track record requirements for re-surveys or re-reviews are: 12 months with a score of 2 (satisfactory compliance); 6 to 11 months with a score of 1 (partial compliance); and fewer than 6 months with a score of 0 (insufficient compliance). Please note that track record requirements remain in place for organizations undergoing re-surveys or re-reviews. For more information, see the September issue of The Joint Commission Perspectives.
Also effective January 1, 2008 and related to this action is the elimination of Early Survey Policy—Option 2 for all programs (except the laboratory program). This option permitted the conduct of two full surveys at an organization, the first to assess compliance with all applicable standards at the time of survey, and the second to assess the organization’s ability to demonstrate sustained compliance over a four-month period. (Contact: Gail Weinberger, gweinberger@jointcommission.org)
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The Joint Commission announced the establishment of a special fact-finding task force that will examine implementation issues related to revised hospital medical staff standard MS.1.20 and address issues of concern that have been raised. The revised standard MS.1.20 was approved by The Joint Commission’s Board of Commissioners in June 2007 and will become effective in July 2009. This 15-member task force will analyze the potential impact of implementing the revised standard MS.1.20 through the examination of case examples and factual information and will suggest mitigating remedies that will support achievement of the objectives of the standard revision. The intent of the revised standard was to support and reinforce a productive working relationship between the organized medical staff and the governing body while minimizing disruptions to the hospital, including its medical staff. The revised standard calls for the medical staff and the governing body to work together, reflecting clearly recognized roles, responsibilities and accountabilities, to enhance the quality and safety of care provided to patients.
The MS.1.20 Implementation Task Force will focus on gaining a better understanding of the practical implementation issues related to hospital compliance with the four concepts contained within the revised standard: 1) the flexibility allowed the organized medical staff and the governing body on the placement of documents in or outside of the medical staff by-laws, 2) the expectation that the decisions of the Medical Executive Committee reflect the wishes of the organized medical staff, 3) the expectation that organizations with productive working relationships among leadership will find the voting requirements of the organized medical staff reasonable to implement, and 4) the method to limit items requiring joint approval, thus not burdening the hospital. Organizations proceeding with any medical staff by-laws revisions are advised that The Joint Commission will act as expeditiously as possible on recommendations from the task force. The Joint Commission anticipates receiving the task force’s report at the meeting of the Board of Commissioners on February 29-March 1, 2008. (Contact: Robert Wise, rwise@jointcommission.org)
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The Joint Commission seeks comment on the proposed Life Safety (LS) chapter for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, office-based surgery, and long term care programs. All of the standards included in the proposed LS chapter are currently located in the Environment of Care (EC) chapter and reflect requirements consistent with those issued by the Centers for Medicare & Medicaid Services, and those published in the National Fire Protection Agency’s Life Safety Code (101-2000). Comments and feedback will be solicited through January 22 at http://www.jointcommission.org/Standards/FieldReviews/lsc_field_review.htm. (Contact: Jeff Conway, jconway@jointcommission.org)
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The Joint Commission is engaged in the following activities as part of its Standards Improvement Initiative:
- At its November meeting, the SSP Committee reviewed proposed changes to the Medication Management, Environment of Care, and Management of Human Resources chapters.
- Posted website survey to gather feedback on proposed changes to the Provision of Care, Treatment and Services and Patient Rights and Responsibilities chapters for the ambulatory care, critical access hospital, home care, hospital and office-based surgery program manuals. Comments and feedback will be solicited for the first half of the Provision of Care, Treatment and Service chapter through January 17 and for the Patient Rights and Responsibilities chapter through December 31 at http://www.jointcommission.org/Standards/SII/.
The Infection Prevention and Control, Management of Information, and Improving Organization Performance chapters have been completed through the Standards Improvement Initiative process and were approved by the Standards and Survey Procedures Committee at its August and October meetings. The SII process includes two field reviews of each chapter: the first to gather feedback on the current chapters and the second to gather feedback on the proposed revised chapters. Below is a summary of the findings from the surveys of these first three chapters.
- Infection Prevention and Control: Respondents believe that the revised chapter is an improvement over the current chapter. Respondents indicated that the revised chapter is clearer and easier to understand. However, few changes occurred between the first and second surveys in terms of views on specific applicability and reasonableness. Many of the suggestions from the field relate to the need for additional standards in certain areas, which is outside the scope of SII. These suggestions will be researched to determine their potential for future standards development.
- Management of Information: Respondents had a number of questions about the terminology used in the chapter. The terminology was made more congruent with federal regulations. The field also noted that there is a need to expand requirements regarding electronic health records and the use of health information technology. They provided a number of good suggestions; The Joint Commission will consider developing standards in these areas in the future.
- Improving Organization Performance: Respondents believe that the revised chapter is improved, including: what is required, how to meet the requirements, applicability, association to quality care, and amount of effort required. Additionally, the chapter has been reorganized to reflect the three phases of performance improvement: collect data, analyze data, use results of analysis to improve performance. Respondents describe the chapter as clearer, with improved understanding of the survey process.
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. For more information, visit Standards Improvement Initiative. 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 and October 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.
Early 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. 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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American hospitals are making measurable strides in the quality of care provided for patients with heart attacks, heart failure, pneumonia and surgical conditions, according to the Joint Commission’s second annual report on health care quality and patient safety in the nation’s hospitals. The detailed report portrays the aggregate performance of accredited hospitals against the Joint Commission’s standardized national performance measures and its National Patient Safety Goals. Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2007 also shows, however, that whether or not patients receive proven treatments for these common reasons for hospitalization often depends on where they live. For example, statewide performance of hospitals on the measure of providing discharge instructions to patients with heart failure ranges from 49 percent to 91 percent.
The Joint Commission issues this annual report as part of its on-going efforts to emphasize the importance of accountability and continuous improvement for hospitals, and to empower consumers with information that will make them more active participants in their health care. This report examines how America’s accredited hospitals performed against quality-related performance measures and safety goals during 2006 and in previous years.
Among the specific findings in the 2007 report, accredited hospitals continue to show measurable improvements in performance. The magnitude of improvement from 2002 to 2006 ranges from 3.6 percent to 52.2 percent. Some improvements over the five-year period of data collection—such as in providing smoking cessation advice—have been dramatic. Hospitals provided this advice to 89.4 percent of patients admitted with pneumonia in 2006 compared with only 37.2 percent of such patients in 2002. Hospitals also demonstrated 90 percent or higher compliance with 10 of 16 National Patient Safety Goal requirements that address issues such as medication safety, caregiver communication and preventing patient falls. The report is available at http://www.jointcommissionreport.org/. See the complete news release. (Contact: Jerod Loeb, jloeb@jointcommission.org)
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Quality Check®—at http://www.qualitycheck.org/ now includes reports on how often pneumonia patients were given a flu shot before leaving the hospital during the 2006-2007 flu season. The Seasonal Influenza Vaccination measure was added to the pneumonia care measure set for National Quality Improvement Goals (NQIG) for hospitals. Due to the shortage of influenza vaccine in October and November 2006, reports cover the timeframe of December 2006 to February 2007. Hospitals were required to have all three months of data in order to be able to display a comparative symbol (checkmark, plus sign or minus sign) on Quality Check. Hospitals that reported less than three months of data have their rates displayed without the comparative symbol. (Contact: Dawn Allbee, dallbee@jointcommission.org)
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In January 2008, The Joint Commission will post on Quality Check™ (http://www.qualitycheck.org/) performance results of the Centers for Medicare & Medicaid Services 30-day mortality measures for heart attack and heart failure. The measures are currently posted for pre-review by accredited hospitals on The Joint Commission Connect extranet site. These same measures were first posted by CMS in June 2007 on its Hospital Compare website. CMS displayed this information after developing and testing the measures last year. The Joint Commission’s posting of the data coincides with the release of the current performance measure results for the third quarter of 2007. The CMS 30-day mortality measure data reporting period includes discharges from July 2005 through June 2006. CMS last updated its data file on September 13, 2007. The Joint Commission will continue to update its National Quality Improvement Goals data quarterly, which will include the most recently available CMS mortality data file.
Patient mortality is one of the most important outcomes of care. Incorporating this information into Quality Check supports consumer health care decision making and the transparency of reporting efforts. Derived from CMS reports, the mortality measures are from more than 4,500 hospitals across the country. They are risk-adjusted and take into account previous health problems to help “level the playing field” among hospitals. Developed over five years by a team of experts from Yale and Harvard Universities, the measures are endorsed by the National Quality Forum, a voluntary standard-setting, consensus building organization representing providers, consumers, purchasers, and researchers. Contact: Dawn Allbee, dallbee@jointcommission.org)
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The Joint Commission’s 2008 Ernest Amory Codman Award application is now available. This year, the innovation criterion has been elevated and now garners 20 percent of the weight of the application scoring. This criterion is intended to encourage new thinking and new approaches to improving the safety and quality of care delivery. The Codman Award is the first national health care award that was designed to recognize excellence in performance measurement. Award recipients receive a specially designed award, national recognition and the opportunity to share their achievements at The Joint Commission’s Annual Conference in Chicago in Spring 2009. Visit the new Codman Award website, http://www.jointcommissioncodman.org/, to find out more information, to sign up for the Codman list-serv, and to get the 2008 Ernest Amory Codman Award Program application. The application is also available by calling the Joint Commission's Customer Service Center at (630) 792-5800. The deadline for applications is February 15, 2008. (Contact: Teena Wilson, twilson@jointcommission.org)
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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 December 28. (Contact: Caron Wong, cwong@jointcommission.org)
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