to main content Physician Leader Monthly July 2022 | The Joint Commission

Physician Leader Monthly July 2022

In this issue:

  • Joint Commission Journal: An article highlights a new report from the Healthcare Association of New York State’s (HANYS) Statewide Steering Committee on Quality Initiatives, “COVID-19 Lessons Learned in New York’s Hospitals,” that used multiple performance improvement methodologies to identify risks and opportunities in current structures, processes and outcomes at New York hospitals amid the COVID-19 pandemic. 


New Joint Commission standards for 2023 to help organizations address healthcare disparities

Effective Jan. 1, 2023, new and revised requirements to reduce healthcare disparities will apply to Joint Commission-accredited hospitals, critical access hospitals, ambulatory healthcare organizations and behavioral healthcare and human services organizations.

Read the new requirements, references and resources >>


New Sentinel Event Alert on diagnostic overshadowing among groups experiencing health disparities

Diagnostic overshadowing — defined as the attribution of symptoms to an existing diagnosis rather than a potential co-morbid condition — is a risk to patient safety. A new issue of Sentinel Event Alert details this issue and includes a patient’s experience told from that patient’s point of view.

Read the Sentinel Event Alert >>


R3 Report details new, revised requirements for antibiotic stewardship

Beginning Jan. 1, 2023, new and revised antibiotic stewardship requirements will apply to all Joint Commission-accredited hospitals and critical access hospitals. The requirements are in the “Medication Management” (MM) chapter (Standard MM.09.01.01) and expand upon the current expectations for antibiotic stewardship programs in the hospital setting.

Read the R3 Report >>


New Quick Safety on managing packaged sterile supplies and devices

Managing commercially prepared sterile supplies and devices can be challenging for healthcare organizations. A new issue of Quick Safety provides guidance for managing and storing packaged sterile supplies within a facility — with the goal of keeping patients safe from infection and other potential harm caused by expired or compromised supplies and devices.

Read Quick Safety >>


Joint Commission adds pharmacist to survey team for organizations registered with NCCN

The Joint Commission has added the role of pharmacist to its survey team for healthcare organizations that are registered with the National Comprehensive Cancer Network. The announcement was made during the 2022 American Society of Health-System Pharmacists (ASHP) Summer Meetings and Exhibition earlier this month and highlighted in an article in Pharmacy Practice News.

Read the article >>


The Joint Commission joins Biden Administration pledge to decarbonize healthcare sector, make facilities resilient to climate change

The Joint Commission is joining the Biden Administration’s Health Sector Climate Pledge to reduce the carbon contributions emanating from the healthcare sector and to help make healthcare organizations more resilient to the effects of climate change. The Joint Commission plans to reduce its emissions by a minimum of 50% by 2030 and achieve net zero emissions by 2050.



Comment on proposed new, revised requirements for EM surge management plan

Comments are being accepted until July 22 on proposed changes to the Emergency Management chapter relating to the development of a crisis standards of care plan. The proposed requirements include recommendations provided by an advisory panel of experts in the field of CSC and surge planning, as well as those obtained from other sources of literature.  

Comment now >>


Dr. McKee is panelist at upcoming Social Determinants of Health Symposium

Don't miss the upcoming Social Determinants of Health Symposium on Thursday, Aug. 11, 8:30 a.m.-6 p.m. CT. Industry leaders – including The Joint Commission's Ana Pujols-McKee, Executive Vice President, Chief Medical Officer, Chief Diversity Equity and Inclusion Officer – will provide challenges and successes, best practices and strategies to effectively advance community health.  

Register >>


National Kidney Foundation and American Society of Nephrology Task Force issue report on race-free approach to diagnose kidney disease

This past September, The National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases issued a report outlining a race-free approach to diagnosing kidney disease.

It is estimated that 37 million adults in the U.S. have chronic kidney diseases, with 1 in 3 adults at risk for chronic kidney disease. Blacks or African Americans are nearly 4 times more likely than White Americans to have kidney failure. Meanwhile, Hispanics are 1.3 times more likely than non-Hispanics to have kidney failure.

Data also finds:

  • Approximately 785,000 Americans have irreversible kidney failure and need dialysis or a kidney transplant to survive.
  • More than 555,000 of these patients receive dialysis to replace kidney function, with 230,000 living with a transplant.
  • Nearly 100,000 Americans are on the waitlist for a kidney transplant — which can take, on average, up to 3 to 7 years.

The report, which incorporated input from hundreds of stakeholders, recommends:

  • The adoption of the new eGFR 2021 CKD EPI creatinine equation that estimates kidney function without a race variable.
  • Increased use of cystatin C combined with serum (blood) creatinine, as a confirmatory assessment of GFR or kidney function.

Both NKF and ASN also encourage the Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) to create or update guidelines that will make a standard, consistent process factoring in the taskforce’s recommendations. The organizations also recommend:

  • Using a blood test for creatine to diagnose kidney disease and to estimate GFR.
  • Using a urine test for albumin to calculate albumin to creatinine ratio.

The public is invited to comment on the final report at


Newly released

Refreshed Accelerate PI Dashboard Reports for primary, comprehensive stroke certified organizations

Refreshed Accelerate PI™ Dashboard Reports provide updated performance measurement data on the quality measures selected for advanced PSC and CSC certification programs. The refreshed reports contain data through the fourth quarter of 2021.


New book on updates to Emergency Management standards

A new book from Joint Commission Resources focuses on The Joint Commission’s Emergency Management standards chapter for all healthcare settings. “Emergency Management in Health Care: An All-Hazards Approach, 5th Edition” aims to help in identifying hazard vulnerabilities and preparing for any type of emergency.

Purchase the book >>


Blogs for docs

Introducing the Advancing Equity Through Quality and Safety Peer Network: Developed in conjunction with the American Medical Association and Brigham & Women’s Hospital, the network is a yearlong mentorship and networking pilot program that will equip eight participating health systems with the foundational knowledge and concrete tools to embed equity throughout their institutions’ health care delivery practices.

Meeting the Needs of the LGBTQ+ Community – Then and Now

Ambulatory Surgery Centers See a Return on Investment into Quality Improvement


In the media

New Moms Keep Dying in the Week After Birth, and the Risk Remains Highest Among Black Women | The Philadelphia Inquirer

Report Quantifies ROI on Joint Commission Accreditation | Behavioral Healthcare Executive

Medication Storage and Security Assessment is Key to Patient Medication Safety | OR Today

Cracks in the Foundation? | Repertoire


Multimedia feature

Radio Health Journal episode features Dr. McKee discussing systemic racism’s effect on low-quality healthcare

Radio Health Journal interviewed Dr. Ana Pujols McKee, Executive Vice President, Chief Medical Officer, Chief Diversity Equity and Inclusion Officer, The Joint Commission, about how systemic racism plays a role in the undertreatment of people of color. “This experience is not limited to black people, but to all people of color – and also to the LGBTQ+ community – [of] a feeling that they are being unfairly treated,” Dr. McKee said.

Listen >>