Effective July 1, 2022, The Joint Commission has approved revisions to the Rights and Responsibilities of the Individual (RI) chapter for hospitals, critical access hospitals, ambulatory health care organizations, behavioral health care and human services organizations, home care organizations, and nursing care centers.
These revisions were made after an internal review and address a written policy on informed consent and organizational use of images, films, and recordings of patients.
The Joint Commission added a new bullet to Standard RI.01.03.01, Element of Performance (EP) 1, that requires organizational policies to include who is qualified under law and regulation to conduct informed consent discussions. The informed consent discussion is an opportunity to establish a mutual understanding between the patient and the licensed practitioner about a proposed procedure or treatment and the risks, benefits, and side effects of the proposed and alternative procedures or treatments.
In addition, for ambulatory health care organizations, the bullet stating, “Circumstances that would allow for exceptions to obtaining informed consent” will be deleted from RI.01.03.01, EP 1, because organizational policies that relate to informed consent should sufficiently address all procedures or treatments performed in the organization.
The Joint Commission also is deleting Standard RI.01.03.01, EP 3, that requires organizations to obtain patients’ informed consent prior to making and using recordings, films, or other images of patients. This requirement will be replaced with a new EP at Standard RI.01.01.01 that more broadly addresses issues related to protecting patients’ rights.
The Joint Commission recognizes that the ease of capture and portability of audiovisual information can potentially pose risks to patient privacy. However, such information also can be beneficial for treatment, payment, and health care operations, such as education and internal performance improvement. This new EP will require health care organizations to comply with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), when making and using recordings, films, or other images of patients. The Joint Commission will continue to evaluate compliance with applicable federal and state requirements.
View the prepublication standards.
Effective July 1, 2022, The Joint Commission has approved three new elements of performance (EPs) in the Environment of Care (EC) chapter applicable to hospices that provide inpatient care in their own facilities (freestanding inpatient hospices).
These EPs address power strips in the patient care vicinity, testing fuel quality of emergency power systems at least annually, and maintaining furnishings and equipment in good repair.
Joint Commission surveyors have observed that many hospices that provide inpatient care in their own facilities currently have these processes in place; however, these requirements are now included in the manual so inpatient hospices are aware of the expectations and surveyors can score noncompliance appropriately during survey. The Joint Commission conducted a three-week focused customer engagement with freestanding inpatient hospices to obtain feedback on the proposed EPs with favorable responses.
View the prepublication standards.
A Pioneers in Quality (PIQ) Expert to Expert webinar focusing on the median admit decision time to emergency department departure time (ED-2) electronic clinical quality measure (eCQM) is scheduled for Jan. 25.
The free webinar — which will take place from 9-10 a.m. PT / 10-11 a.m. MT / 11 a.m.-noon CT / noon to 1 p.m. ET — aims to provide a deep-dive into measure intent, logic, and other clinical/technical aspects of eCQMs to assist hospitals in their efforts to improve data use for quality improvement. At the end of this session, participants will be able to:
- Apply concepts learned about the logic and intent for the ED-2 eCQM.
- Prepare to implement the ED-2 eCQM for the 2022 eCQM reporting period.
- Identify common issues and questions regarding the ED-2 eCQM.
The Expert to Expert webinar series addresses the eCQM annual updates for 2022 eCQM implementation and incorporates content from The Joint Commission, Centers for Medicare & Medicaid Services, and Mathematica. Common questions from JIRA and other sources will be addressed and participants will be able to ask questions during a live Q&A session.
The webinar also offers 1.0 Continuing Education (CE) credit for those who:
- Individually register for the webinar.
- Listen to the live webinar in its entirety. Only those listening live during the session will be eligible to receive credit.
- Complete a post-program evaluation/attestation. The program evaluation/attestation link will be sent to your registered email after the webinar.
Register. The webinar recording and slides will be available several weeks later.
Effective July 1, 2022, Joint Commission-certified thrombectomy-capable stroke centers (TSCs) will be required to report outcome performance measure data on comprehensive stroke (CSTK) measure CSTK-10: Modified Rankin Score (mRS) at 90 Days.
Data collection for CSTK-10 will replace the currently required CSTK-02: mRS at 90 Days measure. Both measures focus on obtaining mRS data 90 days after a patient’s discharge from the hospital; however, TSCs now have processes in place to collect 90-day mRS data with aggregate performance at or above 90% for most facilities. Therefore, TSC data collection for the CSTK-02 process measure will be suspended.
The mRS is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It is the most widely used clinical outcome measure for stroke clinical trials.
CSTK-10 is composed of four strata or submeasures. The denominator population is stratified by the type of reperfusion therapy selected to treat acute ischemic stroke. The numerator population captures the patient’s functional status — independent or dependent — prior to their stroke and based on the mRS prior to the acute stroke event. All four strata roll up to report a CSTK-10 overall rate, with a good outcome reported as an mRS of 0, 1, or 2 at 90 days.
- CSTK-10: All ischemic stroke patients treated with intravenous (IV) alteplase or who undergo mechanical endovascular reperfusion therapy and have an mRS less than or equal to 2 at 90 days (≥ 75 days and ≤ 105 days).
- CSTK-10a: Ischemic stroke patients treated with IV alteplase only and have an mRS of 0, 1, or 2 documented prior to the stroke; or no mRS documented prior to the stroke.
- CSTK-10b: Ischemic stroke patients treated with IV alteplase only and have an mRS of 3, 4, or 5 documented prior to the stroke.
- CSTK-10c: Ischemic stroke patients treated with mechanical endovascular reperfusion therapy with or without IV/intra-arterial (IA) alteplase therapy and have an mRS of 0, 1, or 2 documented prior to the stroke; or no mRS documented prior to the stroke.
- CSTK-10d: Ischemic stroke patients treated with mechanical endovascular reperfusion therapy with or without IV/IA alteplase therapy and have an mRS of 3, 4, or 5 documented prior to the stroke.
Measure specifications are detailed in the Specifications Manual for Joint Commission National Quality Measures, Version 2022A1. Questions about these measures may be sent via the Performance Measurement Network Q&A Forum.
Cost containment has become more important than ever in health care, and perioperative services are often scrutinized — as they consume more than 30% of hospital budgets. The procurement, processing and use of sterile surgical inventory are a major component of the perioperative care budget and have been recognized as an area of operational inefficiency.
A new study in the January 2022 issue of The Joint Commission Journal on Quality Patient Safety — “Inventory Optimization in the Perioperative Care Department Using Kotter’s Change Model”— used an established change model to effectively implement inventory optimization (IO), driving improvements across inventory, efficiency and satisfaction metrics.
Researchers at the University of Toronto optimized inventory across four high-volume surgical services using the steps in Kotter’s Change Model (KCM):
- Create coalition
- Create vision for change
- Establish urgency
- Communicate the vision
- Empower broad-based action
- Generate short-term wins
- Consolidate gains
- Anchor change
The process evaluated inventory metrics, operational efficiency metrics and clinician satisfaction. The study found:
- Total inventory was reduced by 37.7%, with an average tray size reduction of 18%.
- This saved a total reprocessing time of 1,333 hours annually and labor costs of $39,995 annually.
- Depreciation cost savings totaled $64,320 annually.
- Case cancellation rates due to instrument-related errors decreased from 3.9 to 0.2%.
- Staff completely satisfied with inventory improved from 1.7% pre-optimization to 80% post-optimization.
The study is the first to report successful implementation of KCM to facilitate change in the perioperative setting.
Also featured in the January issue:
- Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management (U.S. Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California)
- Breaking Clinical Inertia in Heart Failure Management (editorial)
- A Simulation Systems Testing Program Using HFMEA Methodology Can Effectively Identify and Mitigate Latent Safety Threats for a New On-Site Helipad (Maine Medical Center, Portland, Maine)
- Comparison of Two Different Models to Predict Fall Risk in Hospitalized Patients (Northwestern Medicine, Chicago)
- Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too (sample of 42 U.S. short-term acute care and critical access hospitals and data from 7,939 Medicare beneficiaries)
- Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19 (NYU Grossman School of Medicine, New York University, New York)
- Don’t Go to the Hospital Alone: Ensuring Safe, Highly Reliable Patient Visitation (commentary)
Access the Journal.
Improvement Insights — Disparities after Discharge: One of the most vulnerable times in a patient’s hospitalization is at discharge, when they transition from the monitored setting of the hospital to their home. One way that hospitals have been identifying and tracking issues that arise during this care transition is with automated phone calls. Our hospital started a care transitions outreach program in March 2017, and now each patient discharged home from the hospital gets a phone call within 72 hours asking them about how they are doing in six domains, writes Lev Malevanchik, MD, and Sachin J. Shah, MD, MPH.