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Myth Vs. Fact: The Joint Commission’s Response to COVID-19


By Mark Pelletier, MS, RN, chief operating officer and chief nursing officer and Robert Campbell, PharmD, director, clinical standards interpretation for hospital/ambulatory programs

Since The Joint Commission began providing guidance and resources on issues  related to the COVID-19 pandemic in mid-March, public reaction has been intense.

We wouldn’t have it any other way. While our social media audience is not always in agreement with all our initiatives, the most important thing is that we are all engaging in new ways to work through this crisis.  

As we shift past the “panic” stage of the COVID-19 outbreak and start thinking of managing the virus in the longer term, we wanted to take some time to clarify our intents and address misperceptions.

What Accreditors Can—And Can’t—Do
A good deal of frustration has been directed at The Joint Commission and why we are not mandating hospitals to take certain actions during COVID-19. It’s fair enough to think we have some responsibility for helping our accredited organizations mitigate this crisis. We accredit 77% of the nation’s hospitals and are the oldest accreditation body in the United States.

However, it’s important to note that we are a private accreditor. We are NOT a public or regulatory agency that has the power to make mandates of health care organizations or to close or fine them. Our mission has always been to help organizations identify deficiencies in care and correct them as quickly and sustainably as possible.

Why The Joint Commission Isn’t Surveying   
On March 16, The Joint Commission made the decision to stop surveying for the first time in our history to protect our surveyors and to allow healthcare organizations to implement their emergency management plans.

Many of our surveyors are doctors, nurses and life safety code specialists who work for health care organizations and part-time for The Joint Commission. These employees are needed on the front line now more than ever. (Read this blog post about our associate director of Standards Interpretation on the front lines in a Chicago emergency department.) 

We continue our efforts to provide resources in partnership with CMS, CDC and the FDA to our customers. We’ve developed a COVID-19 portal which includes numerous FAQs, blogs and webinars, which is updated on a daily basis. Our account executives are specially trained to connect accredited organizations with the right resources to get their questions answered. Furthermore, the Standards Interpretation Department is answering questions that are coming through the online submission form at record pace. 

Stance on Expired PPE and Other Supplies
There’s also been a great deal of confusion about our role in asking organizations to throw away expired PPE and other supplies in advance of a survey.
Expiration dates are determined by the manufacturer and then evaluated in an approval process by the approving government agency. In most cases with health care, this agency is the U.S. Food and Drug Administration (FDA). The Joint Commission has no role in this.

Since items are only considered appropriate for use until their expiration date, a process is required to remove expired items from inventory. The Joint Commission requires organizations to follow manufacturer instructions. If an item, device or medication has labeling with an expiration date, then organizations are required to remove the expired items. Not all devices or products have expiration dates, including many medical supplies like most gowns, sterile gloves, and some gauze. 

The only standard The Joint Commission has that directly requires removing expired items is located within the Medication Management chapter. It requires organizations to remove all expired, damaged and/or contaminated medications. The Joint Commission does not consider nearly expired items to be non-compliant, nor do we encourage organizations to incur waste and increase cost. Law and regulation and manufacturer guidelines should further define a hospital’s approach to medication storage. 

We partner with organizations to assist with enhancing their processes to limit patient care risks. We also know these are unprecedented times and recognize the need for hospitals to modify their infection control and emergency management plans based on guidance from government agencies and/or regulatory bodies.  

Use of Expired N95 Masks
We are following the guidance from the Centers for Disease Control and Prevention (CDC) on patient care issues, especially with respect to N95 face masks. The CDC issued a statement supporting use of face mask respirators with expiration dates beyond the manufacturer-designated shelf life as a possible alternative during a pandemic.

The Joint Commission has never issued patient care directives on any subject so it was never in consideration to come out with a statement on expired equipment before agencies like the CDC.

Resuming Survey Activity
All Survey activity has been are canceled for now  but we are in the process of developing a recovery plan which we will share with you in the near future. We know all health care professionals are 100% consumed with COVID-19 right now and promise not to abruptly surprise anyone with news that we’ll be back surveying at your site within days. We’re asking our accredited organizations NOT to worry about us right now and concentrate on your patients. We’ll reach out when we plan on resuming surveying activities. We sincerely appreciate everything health care workers are doing in taking care of patients across the country.

Robert Campbell, PharmD, is director, clinical standards interpretation hospital/ambulatory Programs and director, medication management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.

Mark G. Pelletier, RN, MS is the chief operating officer, Accreditation and Certification Operations, and chief nursing executive for The Joint Commission. Prior to his current position, Pelletier served as the executive director for the Hospital Accreditation Program and was also responsible for business development in the Hospital, Critical Access Hospital and Laboratory accreditation programs. Mr. Pelletier has more than 30 years of experience in hospital operations, performance and quality improvement, process redesign, and program development. Previously, he was the senior vice president and chief operating officer of Condell Medical Center, Libertyville, Illinois. He has also served in executive positions for several hospitals in the Chicago area including Resurrection Health Care, Northwestern Memorial Hospital, Children’s Memorial Medical Center and Mercy Hospital Medical Center.