The submission of The Joint Commission’s hospital deeming application to the Centers for Medicare and Medicaid Services (CMS) is on target for January 30, 2009. Currently, open issues related to the application are being addressed by Joint Commission staff and a steering committee. Staff also is conducting informal conversations with CMS representatives. The application process has already been fruitful in helping to clarify standing orders for hospitals (see the related article below). For background information, see the August 2008 issue of Joint Commission Online. (Contact: Patricia Kurtz, pkurtz@jointcommission.org and Kevin Hickey, khickey@jointcommission.org)
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On October 24, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum that clarifies the use of standing orders in hospitals. This clarification was sought by The Joint Commission and brings CMS’ interpretation of standing orders into alignment with The Joint Commission’s view on how to facilitate the timely treatment of certain patients, particularly those who need medications, not previously ordered, to be administered within brief timeframes. The Joint Commission identified the issue through concerns raised by the field and brought it to the attention of CMS. The Joint Commission has been working with CMS on this issue for some time, advocating on behalf of Joint Commission accredited hospitals. Subsequently, other organizations and hospitals voiced support for this CMS change.
The new memorandum clarifies an earlier CMS memo issued in February 2008, and removes a requirement to obtain patient-specific practitioner approval for standing orders that meet the CMS’ criteria prior to treatment. With this new memo, timely treatment can be provided to patients and the order can be signed by the physician at a later time. The Joint Commission believes this approach provides the safest, most expeditious way to provide timely care and treatment to patients. CMS’ previous interpretation of its Conditions of Participation on this issue raised serious questions about whether common safety practices in the care of newborns, patients with asthma and other acute conditions, and deteriorating patients would be permitted to continue.
The clarification issued in CMS’ Survey and Certification Group memo states: The use of standing orders must be documented as an order in the patient’s medical record and signed by the practitioner responsible for the care of the patient, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances.
In the memo, CMS notes its intention to work with the professional community to develop an understanding of best practices and definitions for standing orders, pre-printed order sets, and effective methods to promote evidence-based medicine. The Joint Commission will continue to work with CMS and other stakeholders on these issues. The CMS memorandum can be found at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage. Questions should be sent to The Joint Commission’s Standards Interpretation Group at (630) 792-5900 or via the online submission form at http://www.jointcommission.org/Standards/OnlineQuestionForm. (Contact: Margaret VanAmringe, mvanamringe@jointcommission.org)
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Beginning January 1, 2009, under new Joint Commission policy, laboratory accreditation decisions will no longer immediately impact hospital accreditation decisions. This policy establishes comparability in the way that a laboratory with an adverse accreditation decision rendered by The Joint Commission or one of its cooperative partners, College of American Pathologists (CAP) or COLA, impacts the hospital with which the laboratory is affiliated. Currently, a laboratory’s accreditation has a direct impact on the accreditation status of its affiliated hospital. Under the new policy, the accreditation of laboratories and hospitals accreditation will continue to be linked, due to the critical importance of laboratory services to the delivery of hospital care. The new Joint Commission policy establishes a “related impact requirement” for the laboratory and the hospital. By “related impact requirement,” The Joint Commission means that any adverse laboratory accreditation decision—whether a result of a Joint Commission, CAP or COLA survey—will be integrated into the Priority Focus Process (PFP). An adverse laboratory accreditation decision will serve as an information point in the PFP, along with other data, to prioritize and customize the hospital’s next survey, which, as a result, could occur earlier in the 18 – 39 month survey window.
“The new approach meets the needs of Joint Commission customers and reinforces the importance of the laboratory in the delivery of patient care,” says Ann Scott Blouin, Ph.D., R.N., executive vice president, Accreditation and Certification Operations. The Joint Commission has been evaluating and accrediting hospital laboratory services since 1979 and freestanding laboratories since 1995. Today, The Joint Commission accredits nearly 2,000 organizations providing laboratory services, representing almost 3,000 CLIA-certified labs, including freestanding labs. The Centers for Medicare & Medicaid Services (CMS) officially recognizes the Joint Commission Laboratory Accreditation Program as meeting the requirements of CLIA ’88. (Contact: Ann Scott Blouin, ablouin@jointcommission.org)
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This year, in response to feedback heard from accredited organizations regarding their desire for an electronic, searchable version of the manual, and as an integral component of the Standards Improvement Initiative (SII), The Joint Commission and Joint Commission Resources announced that an E-dition version of the 2009 standards has been developed and will soon launch. All organizations will receive one complimentary single-user license E-dition for each of their accredited programs. This single-user license will allow anyone in the organization to access E-dition on a one person at-a-time basis. E-dition may be upgraded by purchasing a multi-use site license or additional single-user licenses.
Between November 14 and 21, accredited organizations will receive an e-mail from JCR containing a password with a link for accessing E-dition. The e-mail will be sent to the organization’s primary accreditation and Periodic Performance Review (PPR) contacts. Additionally, a link to the E-dition will be posted on every organization’s Joint Commission Connect extranet Web site. This link will be a single-user guest link specific to each organization and will provide staff with the convenience of accessing E-dition without providing a login and password. The official publisher of The Joint Commission, Joint Commission Resources, publishes the accreditation standards manuals. Each organization should have received its complimentary print copy of the manual in October. In addition to the standards, the 2009 E-dition contains many new features and navigational tools such as:
- Always current. E-dition provides access to the same changes published in Perspectives.
- Relevant standards. E-dition helps users focus on the EPs relevant to the organization by tailoring displays to show only those standards applicable to the setting.*
- History tracking. E-dition tracks the changes in standards that occur from year to year, and will give a side-by-side comparison of how individual EPs changed between 2008 to 2009.*
- Search ability. E-dition provides powerful keyword search across all standards, rationales, and EPs to help users quickly find what they’re looking for.
- Three clicks to most standards. E-dition puts The Joint Commission standards and National Patient Safety Goals at user’s fingertips, with every standard and EP only a few clicks away.
- Related links. E-dition links Joint Commission FAQs, sentinel event communications, and other valuable information to related chapters of standards.
* Introduced in 2009 for ambulatory care, critical access hospitals, home care, hospital and office based surgery. Available in 2010 for behavioral health care, laboratory and long term care.
For more information visit the JCR website at www.jcrinc.com/e-dition, or contact a JCR customer service representative at (877) 223-6866. (Contact: Jean Courtney, jcourtney@jcrinc.com)
SII background and current online surveys
SII is limited to changes of current standards; it is not designed to introduce new requirements. Changes have been made to clarify the language of the standards, delete duplicative requirements, renumber and reorganize the standards, and improve the scoring and decision processes. Work continues on Phase II programs: behavioral health care, laboratory, and long term care. Phase II implementation is planned for January 2010; however, the revised scoring and decision methods will be effective January 1, 2009 for all accreditation and certification programs (including Phase I and Phase II programs). Feedback is currently being sought on the Environment of Care, Human Resources and Waived Testing chapters for the Phase II programs. Feedback is also being sought on the Transplant Safety chapter for the laboratory program. To participate in the online surveys, or for more information about SII, visit http://www.jointcommission.org/Standards/SII. (Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
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This summer, The Joint Commission conducted an online survey about its Speak Up patient safety program. Of the more than 1,900 organizations that responded, nearly 85 percent reported that campaigns like Speak Up bring value to the accreditation and certification process; more than 80 percent rated the Speak up program as excellent or good; and more than 60 percent would use a free Speak Up video series if it was available. They also reported that the program has promoted and increased communication with both patients and staff about safety. Organizations are using Speak Up materials and information in a variety of ways:
- Nearly 75 percent reported that they have reproduced or downloaded Speak Up brochures or posters and more than 32 percent have purchased Speak Up materials from Joint Commission Resources. The most reproduced and purchased brochures are the original Speak Up, Five Things You Can Do to Prevent Infection, Know Your Rights, and Help Avoid Mistakes With Your Medicines.
- More than 67 percent have used Speak Up information in advertisements or billboards and nearly 30 percent have used it in closed circuit patient education television.
- More than 60 percent have reprinted the information in the Speak Up brochures in their patient handbook or education materials.
Heath care organizations have reported printing Speak Up materials for patient rooms; sponsoring local public service announcements; including Speak Up content in patient information materials, websites and community newsletters; distributing material at health fairs; sharing it on closed circuit patient education television; using it for staff education and orientation; and distributing it on bedside tent cards. Since its launch in 2002, the Speak Up program has grown to include 11 campaign brochures and four posters, as well as Spanish language versions of all brochures. For more information about Speak Up, visit http://www.jointcommission.org/PatientSafety/SpeakUp/. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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Physicians have played an integral role in The Joint Commission since its inception in 1951. A presentation is now available on The Joint Commission Web site is a presentation highlighting the role of physicians as partners with The Joint Commission. The four-part document is titled Physicians and The Joint Commission: The Patient Safety Partnership and includes:
- Te role of the physician in The Joint Commission
- Focus on patient safety, the accreditation process, standards and performance measurement
- Patient safety initiatives
- Enhancing physician involvement in quality and safety improvement initiatives
The document is available at http://www.jointcommission.org/Physicians/md_tjc.htm. (Contact: William Jacott, wjacott@jointcommission.org)
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In an effort to help improve the rate of health care worker influenza immunization, The Joint Commission will produce a new monograph that includes examples of successful strategies and tools that have been used to improve immunization rates. The monograph, with funding from Sanofi Pasteur, will be produced in partnership with leaders in the fields of infection prevention and infectious disease from the Association for Professionals in Infection Control and Epidemiology, the Centers for Disease Control and Prevention, the Society for Healthcare Epidemiology of America, and the National Foundation for Infectious Diseases.
According to the CDC, vaccination coverage of health care personnel remains low despite the documented benefits on patient outcomes, staff absenteeism and reducing infections among staff. In addition, increased vaccination rates can reduce costs within health care organizations. Health care personnel can acquire influenza from patients and can also spread the disease to vulnerable patients or other staff. In 2007, The Joint Commission implemented a new standard for the hospitals and long term care facilities it accredits requiring that influenza vaccinations be offered to staff and practitioners.
The Joint Commission will use funding derived, in part, from an educational grant from Sanofi Pasteur, to gather and review real-world examples of successful initiatives for implementing influenza immunization programs for health care personnel. The free, educational monograph is planned for publication in mid-2009. Health care organizations are encouraged to submit examples of immunization programs that have successfully increased immunization rates among health care personnel. Submissions can be made online at http://www.jointcommission.org/PatientSafety/InfectionControl/. (Contact: Linda Kusek, lkusek@jointcommission.org)
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The Joint Commission named the 2008 recipients of the 12th Annual Ernest Amory Codman Award, which recognizes excellence in the use of outcomes measurement to achieve improvements in the quality and safety of health care. Awards are given for organization and individual achievement. The award recipients in the following categories are:
- Hospital: Carolinas Medical Center, Charlotte, North Carolina; Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and Mission Hospital, Mission Viejo, California.
- Multiple Organization: Novant Health, Winston-Salem, North Carolina.
- Individual: the late Shukri F. Khuri, M.D.
Established in 1996, the award is named for the physician regarded in health care as the “father of outcomes measurement,” and is the first national award to recognize excellence in outcomes measurement. The Joint Commission recognizes an individual and organizations that have played significant leadership roles in promoting the use of performance measures to improve health care services, or have made major contributions to the development and testing of performance measures or the science and art of quality improvement. A panel of national experts in quality measurement and improvement selected the five recipients of the 2008 Awards. The awards will be presented on November 19 during The Joint Commission and Joint Commission Resources’ Annual Conference on Quality and Safety in Chicago. For more about the achievements of the 2008 Codman Award winners, see the news release at http://www.jointcommission.org/NewsRoom/NewsReleases/nr_08_codman_awards.htm, or visit http://www.jointcommissioncodman.org/. (Contact: Teena Wilson, twilson@jointcommission.org)
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The American Case Management Association announced the availability of the 2009 Franklin Award of Distinction application. This national award of excellence recognizes those practices demonstrating commitment to collaboration, care coordination along the continuum, and the application of interdependency across disciplines in achieving patient outcomes. The Franklin Award of Distinction has been awarded annually since 2003 by ACMA and The Joint Commission. Just as this award is designed to promote the advancement of hospital case management practice on a national level, the application process is an excellent way to promote the advancement and recognition of case management within an organization. The application is due by November 28, 2008. Questions should be e-mailed to franklinaward@acmaweb.org. The application and information about the award are available at http://www.acmaweb.org/section.asp?sID=20. (Contact: Laure Dudley, ldudley@jointcommission.org)
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