As part of The Joint Commission’s Standards Improvement Initiative (SII), the Periodic Performance Review process and availability of the on-line PPR will be affected. The PPR will be off-line from December 1, 2008 until January 1, 2009. During that time, the new standards and scoring methodology will be loaded onto the site. Therefore, the due dates for completing the PPR are being changed as follows:
- Organizations with PPR due dates from October 1, 2008 through December 31, 2008 are not required to submit a 2008 PPR.
- Organizations that wish to document Plans of Action for requirements for improvement (Full PPR or post-survey Option 2 PPR) must submit the 2008 PPR by Sunday, November 30, 2008 at 11:59 p.m. Central Time.
When the PPR is re-activated on January 1, 2009, SII Phase I programs (ambulatory care, critical access hospital, home care, hospital, and office-based surgery) will need to repopulate the Open PPR. (Note: The PPR is optional for CAHs, OBS, and Long Term Care Option 2.) The Open PPR will include a link to a data table (available throughout 2009) that provides copies of all of the organization’s data that was saved on the Open PPR. Organizations can print a variety of reports to help repopulate the PPR and they will be given ample time to do so. Automatic submission due date extensions will be granted: PPR due dates in January 2009 will be extended 90 days and PPR due dates in February and March 2009 will be extended 60 days. SII Phase II programs (behavioral health care, laboratory, and long term care) will need to re-evaluate only those standards labeled as requiring an update. In addition:
- PPR Option 2 and 3 surveys will not be scheduled in November or December 2008. PPR Option 2 or 3 surveys scheduled for 2009 will be conducted using the 2009 standards.
- For organizations with PPR due dates in January, February, or March 2009, the “Begin Submission” link will not be activated in the Open PPR during the fourth quarter of 2008; it will become available on January 1, 2009.
Service-specific tagging option in E-ditions
As part of the improvements to the standards made under The Joint Commission’s Standards Improvement Initiative (SII), the 2009 E-ditions (electronic manuals) will allow elements of performance to be “tagged” according to service or setting. This allows customers to see a customized manual. For example, sleep centers can select an option to view only the EPs applicable to that setting. Approximately 56 percent (or 610) of the 1,082 ambulatory EPs are applicable to sleep centers. Below are the percentages of elements of performance for specific services/settings for the ambulatory and home care programs. Customers have been asking for an easy way to see the EPs that are applicable to them; the new E-ditions enable this feature.
| Ambulatory Health Care Program |
Percent of EPs |
Number of EPs |
| Total number of EPs = 1,082 |
|
|
| Telehealth (non-surgical) |
42 percent |
458 |
| Telehealth (surgical) |
46 percent |
498 |
| Sleep centers |
56 percent |
610 |
| Imaging |
74 percent |
795 |
| Diagnostic/therapeutic |
80 percent |
863 |
| Medical/dental |
86 percent |
928 |
| Endoscopy |
86 percent |
928 |
| Ambulatory surgery |
96 percent |
1,039 |
| Home Care Program |
Percent of EP's |
Number of EPs |
| Total number of EPs = 1,347 |
|
|
| Supplies (mail order) |
36 percent |
478 |
| Durable medical equipment (mail order) |
36 percent |
487 |
| Personal care/support |
36 percent |
488 |
| Supplies (home) |
37 percent |
492 |
| Clinical/consultant pharmacy |
38 percent |
511 |
| Respiratory equipment |
39 percent |
529 |
| Durable medical equipment (home) |
40 percent |
532 |
| Durable medical equipment (facility) |
42 percent |
561 |
| Long term care pharmacy |
42 percent |
563 |
| Rehabilitation technology (home) |
43 percent |
574 |
| Prosthetics/orthotics (home) |
43 percent |
578 |
| Pharmacy dispensing |
44 percent |
590 |
| Prosthetics/orthotics (facility) |
46 percent |
614 |
| Rehabilitation technology (facility) |
46 percent |
614 |
| Clinical respiratory |
46 percent |
624 |
| Ambulatory infusion (pharmacy) |
56 percent |
760 |
| Hospice (patient residence) |
60 percent |
803 |
| Home health |
60 percent |
806 |
| Hospice (inpatient) |
78 percent |
1,055 |
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 following chapters for the Phase II programs: Infection Prevention and Control; Performance Improvement; and Information Management. 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)
State Hospital Association programs on 2009 changes
Some State Hospital Associations will be hosting programs on the upcoming 2009 changes. Scheduled programs are:
- September 17 Virginia Hospital and Healthcare Association, Glen Allen, Virginia
- September 25 Indiana Hospital and Health Association, Indianapolis, Indiana
- October 2 Oregon Association of Hospitals and Health Systems, Portland, Oregon
- October 16 Texas Hospital Association, Austin, Texas
- October 17 Texas Hospital Association, Houston, Texas
- October 21 California Hospital Association, Webinar
- October 24 New Mexico Hospital and Health System Association, Albuquerque, New Mexico
- November 18 Texas Hospital Association, San Antonio, Texas
- December 5 Florida Hospital Association, Ft. Lauderdale, Florida
(Contact: Mark Crafton, mcrafton@jointcommission.org)
-Top-
Each year, The Joint Commission collects data on accredited organizations’ compliance with standards and National Patient Safety Goals to identify trends and focus education on challenging requirements. The table below identifies the Joint Commission standards and NPSGs that were most frequently identified as “not compliant” from January 1, 2007 through December 31, 2007 for hospitals and critical access hospitals. Hospitals can use this information to benchmark their performance against all accredited hospitals. For more information, see the Frequently Asked Questions at http://www.jointcommission.org/Standards/FAQs.
|
|
Standards and NPSGs with Highest Non-Compliance Rates |
|
|
|
Standard
or Goal |
Summary of requirement |
Hospital |
CAH |
|
Goal 2B |
Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. |
25 percent |
-- |
|
Goal 2C |
Measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. |
36 percent |
22 percent |
|
Goal 3D |
Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. |
18 percent |
-- |
|
Goal 8A |
There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. |
19 percent |
-- |
|
UP 1C |
Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol. |
21 percent |
12 percent |
|
MM.2.20 |
Medications are properly and safely stored. |
43 percent |
20 percent |
|
MM.3.20 |
Medication orders are written clearly and transcribed accurately. |
20 percent |
-- |
|
IM.6.10 |
The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served. |
26 percent |
10 percent |
|
IM.6.50 |
Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals. |
25 percent |
-- |
|
PC.2.120 |
The critical access hospital defines in writing the time frame(s) for conducting the initial patient assessment(s). |
-- |
10 percent |
|
PC.3.20 |
An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented. |
-- |
10 percent |
|
PC.13.20 |
Operative or other procedures and/or the administration of moderate or deep sedation or anesthesia are planned. |
18 percent |
9 percent |
|
EC.5.20 |
Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®. |
29 percent |
12 percent |
|
EC.5.40 |
The hospital maintains fire-safety equipment and building features. |
18 percent |
-- |
|
HR.1.20 |
Staff qualifications are consistent with his or her job responsibilities. |
-- |
11 percent |
|
MS.4.00 |
Prior to granting of a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame. |
-- |
10 percent
|
(Contact: Standards Interpretation Group, (630) 792-5900 or online question form at http://www.jointcommission.org/Standards/OnlineQuestionForm/)
-Top-
A new grant from The Commonwealth Fund will be used by The Joint Commission to revise and develop accreditation standards for culturally competent patient-centered care in hospitals across America. This standards development initiative builds upon The Joint Commission’s ongoing “Hospitals, Language, and Culture: A Snapshot of the Nation” study that examines how hospitals in the United States respond to the diverse cultural and language needs of their patients. The Institute of Medicine’s “Crossing the Quality Chasm” report identified patient-centered and equitable care as important elements of quality. However, The Joint Commission study found that practices used to promote effective communication and cultural competence – critical elements of patient-centered and equitable care – vary widely from hospital to hospital. The Joint Commission initiative will explore how diversity, culture, language, and health literacy issues can be better incorporated into current Joint Commission standards or drafted into new requirements. The standards development process will, as is customary, include a review by interested parties in health care and the public. The Joint Commission will collaborate with The National Health Law Program (NHeLP) to develop an implementation guide to prepare Joint Commission surveyors and accredited hospitals for the release of these new standards, targeted to take effect in 2011.
(Contact: Amy Wilson-Stronks, awilson-stronks@jointcommission.org)
-Top-
Joint Commission Resources (JCR) has launched a Flu Vaccination Challenge to underscore the responsibility that hospitals have to help keep their employees and patients healthy this flu season. The Flu Vaccination Challenge is designed to increase flu vaccination rates among health care workers. According to the Centers for Disease Control and Prevention (CDC), in the 2005-2006 flu season, only 42 percent of surveyed health care workers received a flu vaccination. In past years, flu infections have been documented in health care settings and health care workers have been implicated as the potential source of these infections. JCR challenges hospitals to achieve higher vaccination rates among their staff. The Flu Vaccination Challenge begins September 1, 2008 and continues through the flu season to May 2009. Hospitals that achieve a vaccination rate of 43 percent or more will be recognized for their dedication to helping keep their employees healthy and helping to protect their patients. Hospitals can register and get more information at http://www.fluvaccinationchallenge.com/. (Contact: Gina LaMantia, glamantia@jcrinc.com)
-Top-
The Joint Commission wants to know your opinion about its Speak Up patient safety program. Since its launch in 2002, the program has grown to include 10 campaign brochures and four posters, as well as Spanish language versions of all brochures. Please take a few moments to complete the short survey, which will be open through Monday, September 29. For more information about Speak Up, visit http://www.jointcommission.org/PatientSafety/SpeakUp/.
(Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
-Top-
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)
-Top-