At its February 29-March 1 meeting, The Joint Commission Board of Commissioners approved the continuation of the work of the Standard MS.1.20 Task Force, with a deadline of preparing its recommendations for the Board’s consideration at its May 31, 2008 meeting. At this time, the implementation of standard MS.1.20 will not be affected. In addition, the Board approved: appointing a neutral, non-Commissioner member of the public as the task force chair; amending the charge to the task force so that mitigating remedies can include revisions to the language of the standard; and including equal representation of both the medical staff and hospital leadership points of view on the task force membership.
The chair of the task force will be well-versed in issues of health care quality and safety, will have no bias toward a particular point of view regarding Standard MS.1.20, and will be a skilled facilitator. The task force is tentatively scheduled to meet in April. The task force was established in December 2007 to examine and address implementation issues related to revised hospital medical staff standard MS.1.20. 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. (Contact: Lynn Berry, lberry@jointcommission.org)
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In March 2003, The Joint Commission’s Board of Commissioners established an 18-39 month survey window (was 24-39 months) following the previous survey as part of the transition to unannounced surveys. At its February 2008 meeting, The Joint Commission’s Accreditation Committee approved the methodology for conducting these surveys. Implementation is slated for mid-2008 for all accreditation programs. Exceptions to this model include the laboratory program, which will have an 18-24 month survey window, and certification programs. The approved methodology takes into account Priority Focus Process (PFP) data across multiple quarters as well as trends in the performance of these data. Based on performance over time and trends in performance, organizations will be identified and scheduled for an earlier survey. These outliers represent circumstances where data suggest that patient safety and quality are potentially at risk. It is expected that the majority of organizations will still be surveyed in the year that their triennial survey would be due, and a minority of organizations will be surveyed earlier. For more information, see the April 2008 issue of The Joint Commission Perspectives or contact your account representative with any questions. (Contact: Carrie Mayer, cmayer@jointcommission.org)
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As part of The Joint Commission’s Standards Improvement Initiative (SII), the Board of Commissioners approved new, improved and simplified scoring and decision processes, effective January 1, 2009 for all accreditation and certification programs. The current accreditation decision process is primarily based on the volume of survey findings in relation to pre-established thresholds. The new processes:
- Are based on the “criticality” of survey findings. This means that accreditation decisions and the timing of follow-up requirements are judged in relation to the immediacy of the threat to health care quality and patient safety as the result of non-compliance with Joint Commission requirements. (See table below)
- Reflect an organization’s performance respecting compliance with Joint Commission standards and elements of performance.
Please note that the proposed changes to the scoring and decision processes are still under review by The Joint Commission. An overview of SII published this month in Update 1 is also available on The Joint Commission website. This overview includes more information about scoring and accreditation decisions, as well as sample standards that illustrate the changes being made. Final changes to the scoring and decision processes will be published by July 1, 2008 on The Joint Commission website.
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Criticality: What it means and how it will affect accreditation decisions |
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Criticality |
Definition |
Example(s) |
Result |
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Immediate Threat to Life |
Situations identified at survey that have or may potentially have a serious adverse effect on patient health and safety. |
Inoperable fire alarms
High rate of infections |
The Joint Commission President will issue an expedited Preliminary Denial of Accreditation (PDA) decision, which remains in effect until the implementation of corrective action is validated through an onsite survey. When the situation is resolved, the organization’s accreditation status would change from PDA to Conditional Accreditation, which would remain in effect until a follow-up survey is conducted in four to six months to assess the organization’s sustained implementation of appropriate corrective actions. |
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Situational Decision Rules* |
Situations in which an accreditation decision of PDA or Conditional Accreditation is recommended to the Accreditation Committee. |
Unlicensed facility
Unlicensed individual who requires a license
Failure to implement corrective action in response to identified Life Safety Code deficiencies |
The organization must demonstrate resolution through the ESC process. An onsite survey is conducted to validate implementation of corrective action. |
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Immediate Impact Requirements* |
“Implementation” based requirements |
National Patient Safety Goal 1: Two patient identifiers are used when administering medications or blood products. |
All non-compliant elements of performance must be addressed through the ESC process within 45 days. The organization’s accreditation decision is pending submission of ESC within the 45 day timeframe. Failure to resolve non-compliance would lead to progressively more adverse accreditation decisions. |
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Less Immediate Impact Requirements* |
“Planning” and “evaluation” based requirements |
“The organization sets priorities for data collection.” |
All non-compliant EPs must be addressed through the ESC process within 60 days. The organization’s accreditation decision is pending submission of ESC within the 60 day timeframe. Failure to resolve non-compliance would lead to progressively more adverse accreditation decisions. |
* Terminology may change
As requested by the field, only category A and C EPs will remain (e.g., Category A = yes/no—the Joint Commission requirement is either present or absent; Category C = multiple observations of non-compliance are required in order for the EP to be scored as partial compliance or insufficient compliance). Also being retained is the three-point element of performance scoring scale (satisfactory compliance, partial compliance, and insufficient compliance). The scoring of elements of performance will be less complex:
- Multi-bullet and multi-concept EPs will be significantly reduced.
- Category B EPs, which require the subjective assessment of compliance on the part of surveyors, have been eliminated.
- EPs associated with the National Fire Protection Association’s Life Safety Code® will be scored on the same scale as all other EPs.
Also starting in 2009, organizations will need to submit Evidence of Standards Compliance for all EPs that are scored as partial compliance or insufficient compliance. The timeline for completing the ESC will depend on the criticality of findings and immediacy of risk. Separate supplemental findings will be eliminated. The onsite survey process will not change. However, the current Accreditation Decision Report, which is left with the organization at the conclusion of the survey will be replaced with a Summary of Survey Findings, which will include the standards and associated EPs that were identified as being less than fully compliant, as well as the survey team observations. It will not contain the potential accreditation decision. For more information about the SII, including its current status, see the related article below (Standards Improvement Initiative update) or visit The Joint Commission website. (Contact: Kevin Hickey, khickey@jointcommission.org)
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The Joint Commission is engaged in the following activities as part of its Standards Improvement Initiative.
- For Phase 2 programs (behavioral health care, laboratory services, and long term care), The Joint Commission is scheduling a number of field engagement activities, including Advisory Council events, unaccredited customer focus groups, purchaser/payer surveys, and web-based surveys for gathering feedback on proposed revisions to the manual chapters. Work for Phase 2 programs is expected to continue through May 2009.
- Work continues on refining the databases for tracking revisions to the standards and elements of performance to ensure that all revisions are accurately captured. Additional databases are being developed for associating Conditions of Participation (COPs) to the revised standards and EPs.
- Based on feedback from the field, work continues on the reorganization of the manuals. Improvements include color-coded tabs, graphic icons, enhanced indexing, and hard-copy manuals for specific services. Development continues on electronic versions of the manuals—“e-ditions”—which will include all the information in the hard copy manuals plus key word searches, copy-and-paste, links, and other functions.
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 The Joint Commission website. 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 Phase 1 programs: ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.
June 2007: “Virtual” pilot testing was conducted 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.
November 2007 and January 2008: The Management of Human Resources; Management of the Environment of Care; and Medication Management chapters were approved by the Standards and Survey Procedures Committee.
February 2008: The Provision of Care, Treatment, and Services; Ethics, Rights, and Responsibilities; and Life Safety chapters were approved by the Standards and Survey Procedures Committee.
Early 2008: Work started on improvements for the Phase 2 programs: behavioral health care, laboratory services, and long term care accreditation programs.
April 2008: The Joint Commission will begin conducting mock surveys using the improved standards and manuals.
June 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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The Joint Commission seeks comment on proposed standards and elements of performance for two new Certification programs: Palliative Care and Health Care Services (this is distinct from the current Health Care Staffing Services Certification program). Comments will be solicited via an on-line survey
through April 8. (Contact: Joyce Marshall, jmarshall@jointcommission.org)
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By January 2009, The Joint Commission plans to begin using “target” measure ranges instead of national averages to reflect organization performance on measures. The bar continues to be raised for measure improvement “targets” as organizations improve their performance on the National Quality Improvement Goals. A target measure range has an upper and a lower limit. For The Joint Commission’s performance measurement reporting purposes, the lower limit will be the national average, unless the national average is greater than 95 percent, in which case the lower limit would be set to 95 percent. A performance confidence interval will be calculated for each hospital’s measure rate and a comparison of this interval to the target range would determine the rating reported on Quality Check for the National Quality Improvement Goals. Performance would still be illustrated with the star, plus, check and minus symbols:
- A star would represent 100 percent.
- A plus would represent a performance interval higher than the upper limit.
- A minus would represent a performance interval lower than the lower limit.
- A check would represent a performance interval that overlaps the area between the upper and lower limits.
The target rating methodology uses statistical principals that incorporate measure variability. An individual organization’s measure rate alone will not be used to determine its rating status. Also, for measures with overall national rates below 95 percent, the target range will be set higher than the national average to spur improvement in measure performance. New measures with fewer than 12 months of reporting experience will not receive a rating on Quality Check, but the rate will be displayed after six months of reporting experience. Once a new measure has at least 12 months of reporting experience, the measure rate and rating information will be displayed on Quality Check. The Joint Commission developed this target measure rate approach over the past year, based on feedback from the field, including state hospital associations and health plan payers, and from The Joint Commission’s Business Advisory Group, Performance Measurement Strategic Issue Work Group, Data Use Oversight Committee, and Board of Commissioners. (Contact: Stephen Schmaltz, sschmaltz@jointcommission.org)
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Health care organizations, practitioners, purchasers, oversight bodies and the public all rely on performance data to determine priority areas for quality improvement, evaluate performance, and make informed health care decisions. Yet, most performance measurement efforts operate in isolation from one another, rarely provide a consistent picture of overall quality, and represent a significant cost to the health care industry, according to a call for action released by The Joint Commission. The Joint Commission’s newest public policy white paper, “Development of a National Performance Measurement Data Strategy,” proposes a framework for creating a data infrastructure to support performance measurement activities that improve the quality of American health care. The detailed solutions, proposed by a special Joint Commission expert Roundtable, focus on creating a data infrastructure that addresses consumer expectations for data privacy, supporting a data highway that allows for data sharing and linkages, and operating under an agreed-upon set of rules and governance structure. A complete copy of the Joint Commission white paper, “Health Care at the Crossroads: Development of a National Performance Measurement Data Strategy,” is available at The Joint Commission website. The report is part of a continuing series of white papers on key public policy issues that impact patient safety and health care quality. See the entire news release. (Contact: Terri Tye, ttye@jointcommission.org)
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The Joint Commission’s CEO opinion survey of accredited organizations and programs includes questions about the benefits of Joint Commission accreditation and the accreditation process. The survey is conducted quarterly by telephone with CEOs and by mail with other representatives of organizations following their on-site survey. For the third quarter of 2007, survey questions revealed the following ratings as excellent, very good and good:
Overall survey experience—96 percent
Overall value of accreditation to the organization—96 percent
Likelihood of re-applying for accreditation—97 percent
Likelihood of recommending Joint Commission accreditation—95 percent
Engaging physicians in the survey process—87 percent
Fostering a culture of continuous operational improvement—97 percent
Providing a meaningful assessment of an organization’s strengths and weaknesses—94 percent
Reducing costs associated with survey preparation and consulting—81 percent
Relevancy of standards to providing safe, high-quality care—95 percent
Enhancing the educational benefits of an on-site survey—94 percent
Customer service—95 percent
(Contact: Chuck Mowll, cmowll@jointcommission.org)
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The Joint Commission and the National Quality Forum are accepting applications for the 2008 John M. Eisenberg Patient Safety and Quality Awards, which recognize individuals and health care organizations that are making significant contributions in improving the safety and quality of patient care. The awards honor the memory of Dr. Eisenberg, a nationally recognized leader in health care quality improvement who advocated for health care—based on a strong foundation of research—that meets the needs and perspectives of patients. The deadline for nominations is April 14, 2008. Nomination forms are available at The Joint Commission website and http://www.qualityforum.org/. (Contact: Linda Hanold, lhanold@jointcommission.org)
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