Joint Commission Online - Aug. 30, 2023
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
August 30, 2023
Effective Jan. 1, 2024, The Joint Commission has revised its hospital requirements to better align with critical access hospitals revisions and the U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs).
This comes after CMS reviewed The Joint Commission’s critical access hospital deeming renewal application, and The Joint Commission made several changes to its elements of performance (EPs) for critical access hospitals to better align with the CMS CoPs. Those revised requirements went into effect on Aug. 27.
The hospital changes include:
- New EPs to address the expectation for compliance with the National Fire Protection Association’s (NFPA) Life Safety Code® (NFPA 101-2012) and the Health Care Facilities Code (NFPA 99-2012).
- Environment of Care (EC) chapter revisions to remove references to alternative equipment maintenance (AEM) programs and manufacturer’s recommendations from the requirements for equipment maintenance.
The AEM and manufacturer’s recommendations language was removed from the EPs to clarify that medical and utilities equipment must be maintained, but it is up to the hospital to determine how it will perform that maintenance, whether it be through manufacturer-recommended maintenance activities and schedules or an AEM program.
View the prepublication standards. Questions may be directed to the Department of Standards and Survey Methods.
August 30, 2023Those attending NAHQ Next will have the opportunity to hear from experts on The Joint Commission’s Health Care Equity standards and Cook County Health’s experience with social risk factors regarding assessments, coding, and interventions.
NAHQ Next — a multi-day virtual event that addresses the most urgent and important issues facing healthcare today — is scheduled for Sept. 11-13. Registration allows users access to content live during the event and on-demand viewing through Dec. 31.
Christina L. Cordero, PhD, MPH, Senior Project Director, Healthcare Standards Development, The Joint Commission, and William Trick, MD, Co-Director of the Center for Health Equity & Innovation, Cook County Health, will present “Putting Joint Commission Accreditation Requirements into Practice: Implementing Processes to Drive Change and Advance Health Care Equity.”
August 30, 2023
Traditional, in-person multidisciplinary rounds (MDRs) in patient care units are shown to reduce length of stay (LOS) and improve throughput. A new study in the September 2023 issue of The Joint Commission Journal on Quality and Patient Safety sought to determine whether virtual MDRs could also reduce LOS and improve throughput, as well as promote accountability and reduce provider variation.
Researchers at Yuma Regional Medical Center, Arizona, designed and implemented virtual multidisciplinary rounds via phone conference calls with key stakeholders, including hospitalists, case managers, the clinical documentation improvement team, physical and occupational therapy, and nursing leaders.
To track progress in real time, dashboards were created using data from electronic medical records. After several months, unit-based discharge huddles were added to supplement the process and sustain the improvement.
The interventions led to more than 60% of discharges below geometric mean LOS after starting the initiative, compared to approximately 52% before the initiative. Mean observation hours went from 44 hours to 31.9 hours, and the change was sustained for more than a year. A total of 3,813 excess days were reduced in 10 months, resulting in a combined savings of $6.7 million. Additionally, a decrease in hospitalist provider variation was noted.
The researchers determined that virtual MDRs combined with other interventions can effectively reduce LOS and observation hours. Decreased variation among hospitalists and improved key stakeholder engagement can also be achieved with virtual MDRs.
Also featured in the September issue are:
- Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014 (Agency for Healthcare Research and Quality, Rockville, Maryland)
- The Positive Predictive Value of Hospital Discharge Data for Identifying Severe Maternal Morbidity with and Without Blood Transfusion (University of Southern California Medical Center, Los Angeles)
- Optimizing PROM Implementation in Orthopedic Clinics for Longitudinal Outcome Monitoring: Lessons from a Multisite Study (12 U.S. orthopedic practices)
- Sociotechnical Work System Approach to Occupational Fatigue (University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin)
- A Novel Web-Based and Mobile Application to Measure Q1 Real-Time Moral Distress: An Initial Pilot and Feasibility Study (University of Virginia, Charlottesville, Virginia)
- Preventing Light Source–Related Burns from Laparoscopy and Arthroscopy (The Joint Commission, Oakbrook Terrace, Illinois)
- 2022 John M. Eisenberg Patient Safety and Quality Award recipients:
- An Interview with Jason S. Adelman, MD, MS
- Anesthesia Risk Alert Program: A Proactive Safety Initiative
Access the Journal.
August 30, 2023
Registration is now open for an Expert to Expert series webinar on the 2024 annual updates to Perinatal Care (PC) electronic clinical quality measures (eCQMs) PC-02 and PC-07. The 75-minute webinar is scheduled for Sept. 26, starting at 9 a.m. PT/10 a.m. MT/11 a.m. CT/noon ET.
This series provides a deep-dive into measure intent, logic, and other clinical/technical aspects of eCQMs to assist hospitals to improve data use for quality improvement and incorporates content from The Joint Commission, Centers for Medicare & Medicaid Services, and Mathematica. Common questions from JIRA and other sources will be addressed. Additionally, participants will be invited to ask questions during a live Q&A segment.
The learning objectives of the webinar are to:
- Navigate the eCQI Resource Center website to locate measure specifications, value sets, measure flow diagrams and technical release notes.
- Apply concepts learned about the logic and intent for the PC-02 and PC-07 eCQMs.
- Prepare to implement the PC-02 and PC-07 eCQMs for the 2024 eCQM reporting period.
- Identify common issues and questions regarding the PC-02 and PC-07 eCQMs.
This webinar is approved for 1.0 Continuing Education Credit. To claim credit, you must:
- Individually register for the webinar.
- Attend the entire live broadcast.
- Complete a post-program evaluation/attestation. The program evaluation/attestation link will be sent to your registered email after the webinar.