Joint Commission Online - Feb. 24, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
February 24, 2021
Effective July 1, 2021, The Joint Commission will offer Advanced Certification for Spine Surgery (ACSS) in collaboration with the American Academy of Orthopaedic Surgeons (AAOS). This new program will be available to hospitals, critical access hospitals and ambulatory surgery centers that perform spine procedures, including those organizations that are Joint Commission-accredited, accredited by another accrediting organization, or non-accredited.
The Joint Commission currently certifies over 100 spine health care organizations through its foundational Disease-Specific Care Certification Program. The new Advanced Certification for Spine Surgery goes beyond the core Disease-Specific Care standards to provide a more in-depth assessment of an organization’s spine surgery program. Components of the new ACSS program include the following:
- On-site intraoperative observations by Joint Commission reviewers
- Consistent communication and effective collaboration between all health care providers involved in the care of the patient from the initial spine surgery consultation through the follow-up visit with the spine surgeon after discharge
- Demonstrated application of and compliance with clinical practice guidelines, which may include the guidelines and recommendations published by the AAOS, American Society of Anesthesiologists (ASA), National Association of Orthopaedic Nurses (NAON), and North American Spine Society (NASS)
- Data collection for clinical performance measures through the American Spine Registry (ASR), a collaborative effort of the American Association of Neurological Surgeons (AANS) and AAOS.
The ACSS program was developed with the help of a spine surgery technical advisory panel composed of clinical experts with specific knowledge of this type of care, including clinical leadership from the ASR, a collaborative effort of the AANS and the AAOS. ACSS standards incorporate the latest research, best practices, and federal regulations to improve quality and safety for spine surgery patients. This new program will address the various domains related to spine surgery, such as:
- Program structure
- Delivery of care
- Care coordination
- Performance measurement
The Joint Commission adopted four standardized measures from the ASR. Data collection for these measures must commence four months prior to the initial certification review for organizations seeking certification. Data collection is then ongoing thereafter for all ACSS-certified organizations. The measures are:
- ACSS-01: Surgical Site Infection Rates
- ACSS-02: New Neurological Deficits
- ACSS-03: Unplanned Return Visit to the OR
- ACSS-04: Preoperative and Postoperative Patient Reported Outcomes (PROs)
More information about the performance measures will come later, but questions regarding the measures or participating in ASR may be sent to info@AmericanSpineRegistry.org.
February 24, 2021
Effective immediately but not appearing in E-dition or the hard copy accreditation manuals until the spring updates, The Joint Commission is revising its Medical Staff (MS) requirements for hospitals and critical access hospitals. The revisions are for:
- MS.01.01.01, element of performance (EP) 3, which was deleted as it is informational only and noncompliance with the EP would be scored at an appropriate EP that follows in this standard.
- MS.06.01.05, EP 11, which is being revised to allow the time period for acting on completed applications to be addressed in medical staff bylaws, rules and regulations, or policies and procedures.
- MS.13.01.01, EP 1, which is being revised to allow hospitals to credential and privilege licensed independent practitioners providing telemedicine through either the hospital’s own credentialing information or the credentialing and privileging information or decision of a distant site that is either Joint Commission-accredited or a Medicare-participating organization.
View the prepublication standards. (Contact: Laura Smith, firstname.lastname@example.org)
February 24, 2021
The Joint Commission has developed templates to evaluate and score the requirements in the Medical Staff (MS) chapter of the Comprehensive Accreditation Manual for Hospitals and Comprehensive Accreditation Manual for Critical Access Hospitals. The templates are the result of a six-month project – that included a group of physician surveyors – to increase survey consistency and scoring of MS requirements.
Surveyors are using the new templates during current triennial surveys to focus on standards and elements of performance (EPs) within the MS chapter, including the following topics:
- Medical staff bylaws
- Structure and role of medical staff executive committee
- Medical staff role in oversight of care, treatment, and services
- Medical staff role in graduate education programs
- Medical staff role in performance improvement
- Credentialing and privileging
- Appointment to medical staff
- Evaluation of practitioners
- Acting on reported concerns about a practitioner
- Fair hearing and appeal process
- Licensed independent practitioner health
- Continuing education for practitioners
- Medical staff role in telemedicine
The templates were developed in part to streamline the documentation review specific to these requirements. During an organization’s next triennial survey — based on the surveyor’s ability to conduct a thorough evaluation — organizations will be asked what, if any, changes have occurred to their MS bylaws, rules or regulations, and policies over the past three years. If no changes are reported, those specific pieces of the MS requirements will not need to be surveyed. However, focused professional practice evaluation (FPPE), ongoing professional practice evaluation (OPPE), and other components of credentialing will continue to be evaluated during every triennial survey. If changes have occurred, MS bylaws, rules or regulations, and policies also will be evaluated.
Due to the numerous topics of documents reviewed in the MS chapter, a variety of templates were developed to appropriately evaluate the different types of documentation, including:
- General medical staff credentialing and privileging system tracer session template
- Bylaws template
- Credentialing file review template
- Graduate medical education verification template
The templates are available to Joint Commission-accredited hospitals in the 2021 Survey Activity Guide on the organization’s Joint Commission Connect® extranet site. For more information, contact Patsy Buckberg, DNP, PNP, MSN, CSN, Field Director, Division of Accreditation and Certification Operations, or Theresa Hendricksen, FACHE, MS, BSN, RN, Field Director, Division of Accreditation and Certification Operations.
February 24, 2021
In July 2020, the Global Enteral Device Suppliers Association (GEDSA) announced dates to phase out legacy feeding devices and transitional adaptors in order to meet the requirements of the International Organization for Standardization (ISO) standard 80369-3, more commonly known as ENFit®. The dates are as follows:
- July 1, 2021: Legacy feeding tubes and cross-application adaptors will no longer be manufactured.
- Jan. 1, 2022: Transition sets and adaptors sold separately from other devices will no longer be manufactured.
The Joint Commission is a supporting organization of GEDSA. A Sentinel Event Alert – Issue 53: Managing risk during transition to new ISO tubing connector standards – also was issued on the topic, discussing how tubing misconnections continue to cause severe patient injury and death.
February 24, 2021
Improvement Insights – Virtual Antimicrobial Stewardship in a Hospital Setting During a Pandemic: In an article from the March 2021 issue of The Joint Commission Journal on Quality and Patient Safety, my colleagues and I discuss handshake stewardship during the COVID-19 pandemic, writes Tracy N. Zembles, PharmD, BCPS-AQ ID.