Certification Matters - Issue 2, 2023
News about certification programs, including Disease-Specific Care.
June 29, 2023
The Joint Commission has developed a new Health Care Equity (HCE) Certification program that will be available July 1, 2023. This advanced certification program will recognize accredited hospitals and critical access hospitals that strive for excellence in their efforts to provide equitable care, treatment, and services.
The HCE Certification also will be available for non-Joint Commission-accredited hospitals and critical access hospitals that comply with applicable federal laws, including U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs).
Improving health care equity is a quality and safety priority. The HCE Certification builds on The Joint Commission’s longstanding accreditation requirements that support health care equity and the new requirements to reduce health care disparities. The new certification requirements emphasize the structures and processes that health care organizations need to decrease health care disparities in their patient populations; promote diversity, equity, and inclusion for their staff; and address the following topics:
- Data collection
- Provision of care
- Performance improvement
Additionally, to help organizations pursuing the new certification, The Joint Commission has launched the HCE Certification Resource Center to provide practical strategies for meeting the program’s standards and elements of performance (EPs).
View the HCE Certification prepublication standards. Questions may be directed to the Department of Standards and Survey Methods.
June 29, 2023
Effective Jan. 1, 2024, The Joint Commission has approved new and revised requirements for the Advanced Disease-Specific Care Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Thrombectomy-Capable Stroke Center (TSC), and Comprehensive Stroke Center (CSC) certification programs. These changes will apply to hospitals that are seeking initial certification or recertification in the stroke programs.
The new and revised requirements are designed to help certified hospitals improve safety and the quality of care for individuals diagnosed with stroke. The Joint Commission reviewed its existing stroke programs and updated the requirements to:
- Include current guidelines.
- Clarify the intent of the requirements.
- Align requirements across programs.
The requirements reflect the American Heart Association/American Stroke Association national guidelines for stroke care and program implementation, as well as current evidence-based practices, research, and scientific statements. The Joint Commission also obtained feedback from subject matter experts and customers that have a stroke program certification.
View the prepublication standards.
June 29, 2023The Joint Commission and the American Heart Association have revised requirements for the Advanced Certification in Heart Failure program to align with the latest clinical practice guidelines for heart failure. The revised requirements will be effective Jan. 1, 2024.
The Advanced Certification in Heart Failure addresses care, treatment, and services for all types of heart failure, including new onset heart failure, acute-on-chronic heart failure, and decompensated heart failure, across the continuum of care provided by a robust interdisciplinary team. The requirements for the interdisciplinary team members have been expanded to include emergency room physicians, advanced practice providers (if used by the organization), hospitalists, pharmacists, and cardiologists/heart failure specialists. The revised requirements include more specificity for developing certified organizations’ written protocols, such as utilizing the new heart failure definitions and criteria for assessing, diagnosing, classifying, and staging heart failure through the continuum of care.
The revised requirements also emphasize how using a variety of assessments, such as patient-reported outcomes and assessing health-related social needs, aligns the individualized plan of care with the patient’s goals and supports healthy lifestyle changes.
View the prepublication standards.
June 29, 2023Refreshed Accelerate PI™ Dashboard Reports are available for primary (PSCs) and comprehensive stroke centers (CSCs) to 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 2022.
The dashboards provide performance measurement data on all the measures that PSCs and CSCs report using the Certification Measure Information Process (CMIP). The reports are intended to be a springboard for conversations on performance measures and quality improvement during the certification process, as well as a guide to support an organization’s quality journey.
Reports are located under the “Resources and Tools” menu below the DASH heading in Joint Commission Connect®. Users must select “Certification” on the home screen prior to accessing the menu.
June 29, 2023Stroke volume (STK-VOL) performance measure STK-VOL-1 is being renamed to Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy, removing the word “eligible” from the title.
This change relates to user feedback and distinguishes ischemic stroke patients who receive mechanical endovascular reperfusion therapy at a primary stroke center (that is, STK-VOL-1) from therapy-eligible ischemic stroke patients who are transferred to a higher-level stroke center for possible neuro-intervention and reported in stroke outpatient (STK-OP) performance measure STK-OP-1: Door to Transfer to Another Hospital.
These changes will be effective for discharges on and after Jan. 1, 2024.
June 29, 2023The Joint Commission is asking for comments on specifications for three draft candidate performance measures, which will be used to enhance performance measurement requirements for the Advanced Certification in Heart Failure program.
These candidate measures address major aspects of heart failure care. Comments will be accepted through midnight July 25.
June 29, 2023Beginning with calendar year (CY) 2024, the Centers for Medicare and Medicaid Services (CMS) is removing the Perinatal Care (PC) electronic clinical quality measure (eCQM) ePC-05 from the Inpatient Quality Reporting Program. However, The Joint Commission supports exclusive breast milk feeding for the first six months of neonatal life, which has been a long-term goal of the World Health Organization (WHO), U.S. Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG).
To support this goal, The Joint Commission will maintain both the PC-05 chart-abstracted measure and ePC-05 for optional use in ORYX® reporting. Keeping the measure as an optional measure will allow Joint Commission-accredited critical access hospitals and hospitals to use the measure for data collection, monitoring, and quality improvement efforts. This change will be effective Jan. 1, 2024. The PC-05 chart-abstracted measure will continue to be required for Advanced Certification in Perinatal Care (ACPC).
Additionally, The Joint Commission will update the verbiage in performance measure PC-05 to reflect more inclusive language. The measure name and references to breastfeeding will be updated to Human Milk Feeding to be inclusive of donor milk and chest feeding.
June 29, 2023
Effective Jan. 1, 2024, The Joint Commission and the American Heart Association (AHA) have revised two performance measure labels and the ejection fraction rate for its Advanced Certification in Heart Failure (ACHF) and Comprehensive Cardiac Center (CCC) certification programs to align with the most recent clinical practice guidelines for heart failure from the AHA, the American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA)—2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure refers to the drug class aldosterone receptor antagonists as mineralocorticoid receptor antagonists. To remain consistent and align with these guidelines, the performance measures affected by this language change will be updated in the v2024A Specifications Manual. All data elements previously labeled aldosterone receptor antagonists will be revised to mineralocorticoid receptor antagonists. The following are the updated measure labels:
- Advanced Certification Heart Failure – Outpatient (ACHFOP)—ACHFOP-03: Hospital Outpatient Mineralocorticoid Receptor Antagonists (MRA)
- Comprehensive Cardiac Center – Inpatient (CCCIP)—CCCIP-02: Mineralocorticoid Receptor Antagonist (MRA) Prescribed at Discharge
The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure recommends prescribing MRA antagonists for patients with heart failure with reduced ejection fraction (HFrEF) and New York Heart Association (NYHA) Class II to IV symptoms. This updated guidance will affect two Joint Commission performance measures that were updated to align with these guidelines — ACHFOP-03 and CCCIP-02.
To adhere with current clinical practice guidelines and align with the AHA’s Get With The Guidelines® – Heart Failure registry to reduce abstractor burden, the denominator population for ACHFOP-03 and CCCIP-02 will change from heart failure patients with a documented ejection fraction of ≤ 35% to heart failure patients with an ejection fraction of ≤ 40%. This change will occur in the v2024A Specifications Manual and will affect discharges beginning on Jan. 1, 2024. (Contact: Danielle Hermosillo, firstname.lastname@example.org)
June 29, 2023
The Joint Commission has released its Sentinel Event Data 2022 Annual Review on serious adverse events from Jan. 1 through Dec. 31, 2022. A sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.
The Joint Commission reviewed 1,441 sentinel events in 2022. The most prevalent sentinel event types were:
- Falls (42%)
- Delay in treatment (6%)
- Unintended retention of foreign object (6%)
- Wrong surgery (6%)
- Suicide (5%)
Failures in communication, teamwork and consistently following polices were the leading causes for reported sentinel events. Most reported sentinel events occurred in a hospital (88%). Of all the sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care/extended stay.
“COVID-19 continued to present challenges to health care organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” said Haytham Kaafarani, MD, MPH, FACS, Chief Patient Safety Officer and Medical Director, The Joint Commission. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted health care organization to identify underlying causes and improvement strategies. Our goal is to help prevent these types of adverse events from occurring again.”
Most sentinel events (90%) were voluntarily self-reported to The Joint Commission by an accredited or certified health care organization. The remaining sentinel events were reported either by patients or their families, or employees of a health care organization. Reporting of sentinel events to The Joint Commission is a voluntary process, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.
Read the full sentinel event data summary.