As part of the U.S. Centers for Medicare and Medicaid Services’ (CMS) review of The Joint Commission’s hospital deeming renewal application, The Joint Commission has made several editorial changes to its elements of performance (EPs) that will take effect on July 1, 2022, to reflect CMS regulatory language more closely. The revisions are applicable to hospitals and critical access hospitals with rehabilitation and psychiatric distinct part units.
View the prepublication standards.
New Accelerate PI™ Dashboard Reports are available for primary stroke centers (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 second quarter of 2021.
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.
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the United States. Delayed treatment of PPH, including due to the lack of proximity of essential supplies and medications, can lead to significant blood loss and increased morbidity and mortality.
A new study in the February 2022 issue of The Joint Commission Journal on Quality and Patient Safety — “Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit,” by Benjamin K. Kogutt, MD, and coauthors — details how a labor and delivery (L&D) unit implemented these two interventions to reduce the time and distance traveled to obtain materials necessary to treat PPH.
The researchers created a simulation dictating the collection of a prespecified list of supplies commonly used in response to PPH. Baseline data were collected, and then Lean Six Sigma tools were used to construct a process map, including recording times and cumulative distance traveled to collect each item.
The simulation was repeated after developing, creating and deploying two interventions:
- Intervention 1: A cart containing the supplies most used in response to PPH.
- Intervention 2: A medication kit with a refrigerated box of all medications typically administered during PPH.
The average time to collect a prespecified list of supplies and medication in response to a PPH scenario was 11 minutes 5 seconds, with an average cumulative distance traveled of 4,092 feet. Following Intervention 1, the time decreased to 4 minutes with 918 feet traveled; and following Intervention 2, the time further decreased to 2 minutes 14 seconds with 462 feet traveled. This represents a 79.8% reduction in time and an 88.7% reduction in distance from baseline to postintervention – optimizing the ability to efficiently treat PPH.
Also, to address maternal health, The Joint Commission implemented 13 new elements of performance to improve the quality and safety of care of women during all stages of pregnancy and postpartum. The Joint Commission also began publicly reporting hospital performance on two perinatal care measures last year.
Also featured in the February issue:
- Harnessing Event Report Data to Identify Diagnostic Error During the COVID-19 Pandemic (Brigham and Women’s Hospital, Boston)
- Improving Diagnostic Error Detection and Analysis: The First Step on a Long Path to Diagnostic Error Prevention (editorial)
- A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU (Northwestern University Feinberg School of Medicine, Chicago)
- Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients (NYU Langone Health, New York)
- ICU Volunteer “Transition Guides”: A Prospective Study on Improving the Patient Transfer Experience (Beth Israel Deaconess Medical Center, Boston)
- Conversion of a Skilled Nursing and Rehabilitation Facility into a Satellite Hospital in Response to a COVID-19 Surge (Maimonides Medical Center, New York)
- Building a Targeted Automatic e-Consult (TACo) Program (University of California, San Francisco)
Access the Journal.
A new, free on-demand webinar is available from The Joint Commission that addresses the annual updates for Joint Commission-only electronic perinatal care (ePC) measures. The webinar addresses the electronic clinical quality measures (eCQM) of ePC-01, ePC-02 and ePC-06.
The objectives of the on-demand webinar are to:
- Apply concepts learned about the logic and intent for the ePC-01, ePC-02 and ePC-06.
- Prepare to implement the eCQMs for the 2022 eCQM reporting period.
- Identify common issues and questions.
Common questions from JIRA and other sources also will be addressed.
The webinar offers 1.0 Continuing Education (CE) credit for those who:
- Individually register for the webinar.
- Complete the on-demand webinar in its entirety by March 14. Only those completing the educational activity will be able to receive credit.
- Complete a post-program evaluation/attestation that you completed the educational activity.
An outcome-based electronic clinical quality measure (eCQM) to address maternal morbidity in the hospital inpatient acute care setting has been developed by The Joint Commission in collaboration with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) and under contract with the Centers for Medicare and Medicaid Services (CMS).
The new perinatal care (PC) measure, ePC-07 (Severe Obstetric Complications), is now available as an optional measure to meet Joint Commission ORYX eCQM reporting requirements. Measure specifications, measure flow diagram and value set information are now available.
Learn more and save the date for a live educational webinar on the new ePC-07 measure scheduled for March 8. Registration information will be coming soon.
- Improvement Insights — Prone Positioning in Awake Patients: Lessons From the Pandemic: While efforts were underway to develop prone positioning teams for intubated patients, we launched a multidisciplinary initiative to increase prone positioning among patients with respiratory failure, but who did not yet need intubation or ICU level care. Our initiative, detailed in the article, “Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety, consisted of four separate interventions, writes Jonah Zaretsky, MD.
- Improvement Insights — 5 Effective Care Transition Strategies Reduce Burden on Patients, Families and Caregivers: In the study, “Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety, we collected data on nearly 8,000 patients across 42 participating hospitals to evaluate the association of different combinations of TC strategies with patient-reported and post-discharge outcomes, writes Mark V. Williams, MD, and Jing Li, MD, DrPH, MS.
- Leading Hospital Improvement — Addressing Transgender Health Inequity: Case Example #6 – Part 1: Call Me By My Name: A Case of Transgender Health Inequity” is the latest in a Joint Commission series offering examples of real-life issues in health care. In this instance, a transgender individual who was assigned male at birth and whose legal sex is female presented at an emergency department for abdominal pain. Her experience illustrates some of the most common problems encountered by transgender individuals, writes Christina Cordero, PhD, MPH, Project Director, Technical.