The Joint Commission announced the 2009 National Patient Safety Goals and related requirements for each of its accreditation programs and its Disease-Specific Care Certification Program. The NPSGs promote specific improvements in patient safety by focusing on system wide solutions and apply to the more than 15,000 Joint Commission accredited and certified health care organizations and programs. Major changes include three new hospital and critical access hospital requirements related to preventing deadly health care-associated infections due to multiple drug-resistant organisms (MDROs), central line-associated bloodstream infections and surgical site infections. These additions build on an existing Goal to reduce the risk of health care-associated infections, and recognize that patients continue to acquire preventable infections at an alarming rate within hospitals. The new requirements have a one-year, phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.
The existing medication reconciliation Goal was revised after feedback was received from a Medication Reconciliation Summit convened in late 2007. The revision is included in the 2009 update. Other changes to the NPSGs include a requirement to eliminate transfusion errors related to patient misidentification, as well as requirements for engaging patients in their care regarding infection control, prevention of surgical adverse events, and the patient identification process. Requirements to the existing Universal Protocol, initiated to help prevent errors in surgical and non-surgical invasive procedures, were also clarified for 2009. These changes, which address the topics of procedure verification, marking the procedure site, and conducting a time out immediately prior to staring procedures, were based on feedback received at the Wrong Site Surgery Summit in 2007. See
National Patient Safety Goals, updated Universal Protocol; and the news release.
(Contact: Peter Angood, pangood@jointcommission.org)
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The Joint Commission’s Board of Commissioners approved the continued engagement of the Implementation Task Force on the revision of medical staff standard MS.1.20. The Board also suspended the July 2009 date for implementation of the revised standard, approved by the Board in June 2007. It is anticipated that the Task Force will be prepared to present its recommendations for revising MS.1.20 at the Board’s August 1-2 meeting. The Board will be asked at that time to authorize a field review of the recommended modified standard MS.1.20. Depending on the feedback received during the field review, which will be conducted in August and September, the Board will be requested to approve changes to the standard at its November 14-15 meeting. During that meeting, the Board will be requested to establish a new effective implementation date. At its June 2007 meeting, the Board of Commissioners approved revisions to the hospital standard MS.1.20 related to medical staff bylaws and associated rules and regulations and policies. Due to concerns regarding the implementation of this standard, the Board convened a 19-member Implementation Task Force to analyze the potential impact of implementing the revised standard. The Task Force is charged with addressing the standard’s prescriptiveness regarding the level of associated details related to the requirements that must be in the medical staff bylaws. The Task Force will consider whether these associated details should be in the medical staff bylaws or can reside in rules and regulations or policies. (Chuck Mowll, cmowll@jointcommission.org)
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Accreditation Participation Requirement 17 has been revised to specify that any individual who provides care, treatment, or services in a hospital can report concerns about safety to The Joint Commission. The revised APR, effective January 1, 2009, states: The hospital/critical access hospital educates its staff and medical staff that any employee, physician, or any other individual who provides, care, treatment, or services who has concerns about the safety or quality of care provided in the hospital may report these concerns to The Joint Commission. The intent of the APR is to encourage employees of accredited organizations to report their concerns about safety or quality of care to The Joint Commission on a routine basis without fear of retaliatory disciplinary action by the organization. Before the implementation of unannounced surveys, employees could schedule a meeting with the survey team to express these types of concerns; now, employees do not receive any advance notice of an unannounced survey. (Contact: Gail Weinberger, gweinberger@jointcommission.org)
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In further development of the new, improved and simplified scoring and decision processes approved by the Board of Commissioners in March, The Joint Commission recently defined and identified “Direct Impact” requirements. The definition is: A requirement has a “Direct Impact” if non-compliance is likely to create an immediate risk to patient safety or quality of care. The difference between Direct Impact and other requirements is that there are no or few processes—or no or few protective defenses—intervening between non-compliance and the impact on the safety or quality of a patient’s care.
While identifying Direct Impact requirements, any “on the fence” requirements were tagged as Indirect Impact. All Direct Impact requirements will be tagged in the 2009 print manuals that will be available in September 2008 and the E-ditions (electronic manuals) that will be available in November 2008. Direct Impact requirements will be reviewed and modified as appropriate annually. In July 2008, the complete set of the revised 2009 standards for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs will be provided on The Joint Commission website. An extensive history tracking document will also be posted with the standards to help with the transition to the new numbering system. The standards will be available on the website until the print manuals are published in September 2008.
The improved, simplified scoring and decision processes are a result of the Standards Improvement Initiative (SII). Effective January 1, 2009 for all accreditation and certification programs, the new scoring and decision processes are based on the criticality of the standards and other requirements regarding their relationship to the quality and safety of patient care. [See Scoring and Accreditation Decision Model below.] The current accreditation decision process is primarily based on the volume of survey findings in relation to pre-established thresholds. Please note that the proposed changes to the scoring and decision processes are still under review by The Joint Commission. Final changes to the scoring and decision processes will be published in July 2008 on The Joint Commission website.
As a reminder, SII is limited to changes of current standards; it is not designed to introduce new requirements. In addition to the improved scoring and decision processes highlighted in this article, changes have been made to clarify the language of the standards, delete duplicative requirements, and renumber and reorganize the standards. (Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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Effective with October 1, 2008 discharges, accredited hospitals that provide acute inpatient psychiatric services will be able to use The Joint Commission’s Hospital-Based Inpatient Psychiatric Services (HBIPS) measure set to meet current Joint Commission ORYX performance measurement requirements. In conjunction with the HBIPS measures, The Joint Commission also will implement an important modification to existing ORYX performance measurement requirements by offering free-standing psychiatric hospitals the option of collecting and submitting data on either the seven measures included in the final HBIPS measure set or nine non-core measures. Additionally, general medical/surgical hospitals that provide acute inpatient psychiatric services will be able to select the HBIPS measure set as one of their four sets of core measures needed to meet ORYX requirements for 2008. Detailed specifications for the seven HBIPS measures are available on The Joint Commission’s website. The Joint Commission will publicly report hospital performance on the measure set through Quality Check once the measure set has received National Quality Forum endorsement and Hospital Quality Alliance approval. The data will not be included in The Joint Commission’s Priority Focus Process or its Strategic Surveillance System until that time. (Contact: Frank Zibrat, fzibrat@jointcommission.org)
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Free, one-hour audio conferences about changes related to the Standards Improvement Initiative are being conducted in July. All audio conferences begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Registration information is sent to accredited organizations via list-serve approximately one week prior to each call. Each audio conference includes an opportunity to ask questions related to the call topic. Below is the schedule of upcoming audio conferences:
- Thursday, July 24: SII overview for home care organizations
- Monday, July 28: SII overview for hospitals and critical access hospitals
- Thursday, July 31: SII overview for ambulatory organizations and office-based surgery practices
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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The Joint Commission and Joint Commission Resources’ 22nd Annual Conference on Quality and Safety will be held Wednesday, Nov. 19, through Friday, Nov. 21, 2008 in Chicago. The theme of the conference is “Driving Sustained Improvements” and focuses on organizational greatness and decisions and actions for health care executives who seek to improve quality, reduce errors, contain costs, increase productivity, improve execution, and build leaders. For more information, visit http://www.jcrinc.com/; to register, call JCR’s Customer Service at (877) 233-6866. (Contact: Leslie LaBelle, llabelle@jcrinc.com)
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