The Joint Commission collects data on organizations’ compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements.
The following were identified as the Top 5 Joint Commission requirements cited most frequently as “not compliant” during surveys and reviews from Jan. 1 through Dec. 31, 2021. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement.
EC.02.02.01: The organization manages risks related to hazardous materials and waste.
- EP 5: The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.
HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services.
- EP 1: Before permitting licensed independent practitioners new to the organization to provide care, treatment, and services, the organization does the following:
- Documents current licensure and any disciplinary actions against the license available through the primary source.
- Verifies the identity of the individual by viewing a valid state or federal government-issued picture identification (for example, a driver’s license or passport).
- Obtains and documents information from the National Practitioner Data Bank (NPDB). The medical director evaluates this information.
- Determines and documents that the practitioner is currently privileged at a Joint Commission-accredited organization; this determination is verified through the accredited organization. If the organization cannot verify that the practitioner is currently privileged at a Joint Commission-accredited organization, the medical director oversees the monitoring of the practitioner’s performance and reviews the results of the monitoring. This monitoring continues until it is determined that the practitioner is able to provide the care, treatment, and services that he or she is being permitted to provide.
HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services.
- EP 5: At least every two years, before permitting licensed independent practitioners to continue to provide care, treatment, and services, the organization does the following:
- Documents current licensure and any disciplinary actions against the license available through the primary source.
- Obtains and documents information from the National Practitioner Data Bank (NPDB). The medical director evaluates this information.
- Reviews any clinical performance in the organization that is outside acceptable standards. The medical director evaluates this information.
- Reviews information from any of the organization’s performance improvement activities pertaining to professional performance, judgment, and clinical or technical skills. The medical director evaluates this information.
- Confirms the licensed independent practitioner’s adherence to organization policies, procedures, rules, and regulations.
IC.02.01.01: The organization implements its infection prevention and control plan.
- EP 1: The organization implements its infection prevention and control activities, including surveillance, to reduce and/or minimize the risk of infection.
WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent.
- EP 5: Competency for waived testing is assessed using at least two of the following methods per person per test:
- Performance of a test on a blind specimen.
- Periodic observation of routine work by the supervisor or qualified designee.
- Monitoring of each user’s quality control performance.
- Use of a written test specific to the test assessed.
For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. (Contact: Standards Interpretation Group, 630-792-5900 or online question form)
Beginning Jan. 1, 2023, four new and 14 revised requirements will take effect for The Joint Commission’s Assisted Living Community Accreditation Program. The modified standards span multiple chapters and address:
- Infection control
- Dementia care
- Staffing
- Staff wellness
- Resident well-being
The changes reflect current scientific evidence and evidence-based practices, including lessons learned from the COVID-19 pandemic. They also align with recommendations and practice guidelines from the Alzheimer’s Association and U.S. Centers for Disease Control and Prevention. The Joint Commission also sought feedback and expert guidance from:
- A Standards Review Panel (SRP) field review
- A public field review that included administrators with experience in the assisted living care setting.
View the prepublication standards.
The Joint Commission’s Assisted Living Community (ALC) Accreditation Program is approved and recognized by Iowa and Georgia as meeting requirements for initial and renewal certification surveys for assisted living programs.
Assisted living programs in Iowa and Georgia can use their Assisted Living Community Accreditation to meet licensing or certification requirements. These states determined that The Joint Commission’s accreditation requirements for assisted living communities meet or exceed its state certification and recertification or licensing requirements.
“We are pleased that Iowa and Georgia have joined the growing list of states that recognize and accept The Joint Commission’s Assisted Living Community Accreditation Program as meeting state certification requirements,” said Gina Zimmermann, executive director, Nursing Care Center and Assisted Living Community Services, The Joint Commission. “We look forward to offering our accreditation program to Iowa and Georgia assisted living providers — helping them provide a safe living environment for their residents.”
In addition to streamlining the path to state certification, Joint Commission accreditation offers ALCs:
- Resident-focused standards to help establish a consistent approach to care.
- A collaborative and solutions-driven survey process that shares best practices and learning opportunities.
- Business intelligence dashboards to help identify trends in performance and to prioritize improvement efforts.
- Support and educational resources.
Learn more about the ALC Accreditation Program and view the current list of ALC state/payor recognitions.
Refreshed Accelerate PI™ Dashboard Reports are available for Joint Commission-accredited Nursing Care Centers (NCCs) to provide performance measurement data on a select subset of quality measures. The updated NCC reports contain data through the fourth quarter of 2021.
Data in the reports comes from the Centers for Medicare & Medicaid Service (CMS) Compare website. The reports are intended to be a springboard for conversations on performance measures and quality improvement during the survey process, as well as a guide to support an organization’s quality journey.
Reports are located under the Resources and Tools tab below the DASH heading in Joint Commission Connect®.
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. The Joint Commission also is committed to working with the U.S. Department of Health and Human Services and other health sector organizations to support their efforts to reduce the industry’s carbon footprint.
Jonathan B. Perlin, MD, PhD, The Joint Commission’s new president and CEO, targeted climate change as a top strategic priority.
“Decarbonization and sustainability are critical to a health agenda, especially because climate change is having a direct and inequitable impact on the health and well-being of people globally,” Dr. Perlin said. “Our mission is to continuously improve healthcare for the public, and we cannot fulfill that without addressing climate change. As the largest standards-setting and accrediting body in healthcare, it is vital that we take a leadership role and work with healthcare organizations nationally and internationally to reduce the carbon footprint.”
Recently, The Joint Commission convened a group of healthcare organizations to learn about the steps they took to address their impact on the climate. Moving forward, The Joint Commission plans to identify and curate resources for organizations to help them take steps to reduce their own carbon emissions, and to make those resources readily available.
The webpage provides links to materials developed by The Joint Commission and key healthcare-related organizations, such as the National Academy of Medicine and government agencies (including the Office of the Surgeon General and the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health). The content focuses on organization and system-level resources.
The Joint Commission hopes healthcare workers find the information useful and welcomes suggestions for improvement.
A pilot study focusing on the extent to which nursing homes’ organizational culture supports workplace safety for healthcare staff is being launched by the Agency for Healthcare Research and Quality (AHRQ). Nursing homes that are determined to be eligible to participate in the study also may be eligible for an incentive payment.
Nursing homes that participate in “Workplace Safety Supplemental Items for the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey” will receive:
- Free survey administration of the SOPS Nursing Home Survey with the SOPS Workplace Safety Supplemental Items to nursing home staff in July/August 2022.
- Feedback reports comparing their results to other pilot sites.
- The option to have findings included in the next SOPS Nursing Home Database.
Interested organizations may email WorkplaceSafety@westat.com or call 855-390-2448.
An online toolkit from The Joint Commission — the Readiness Roadmap — will help Nursing Care Centers and Assisted Living Communities better locate available resources for survey based on where they are in the accreditation process.
The toolkit is accessible on The Joint Commission’s Connect extranet site under the Resources and Tools tab. It features resources sorted by categories, including:
- Checklists
- Crosswalks
- Webinars
- Videos
For more information or questions, organizations should reach out to their designated account executive.
A new book available from Joint Commission Resources (JCR) focuses on The Joint Commission’s Emergency Management (EM) standards for all healthcare settings, including nursing care centers and assisted living communities. “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.
Highlights of the book include:
- Focused information and resources for nursing care centers.
- More than 30 customizable, downloadable tools to assist with emergency preparedness and compliance with the EM standards.
- Lessons learned from the COVID-19 pandemic.
- EM education and training, as well as testing and evaluating the components of an organization’s EM program, such as:
- Hazard vulnerability analysis (HVA)
- Continuity of operations plan (COOP)
- Emergency exercises or responses to real emergencies
Purchase the book.