Beginning July 1, 2024, acute care hospitals with ORYX® performance measurement requirements and that are required through a U.S. Centers for Medicare & Medicaid Services (CMS) program to participate in the U.S. Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) system will be required to join the Joint Commission NHSN Group. Participation in the Joint Commission NHSN Group will be optional for critical access hospitals where participation in CMS programs is not required.
The Joint Commission identified the NHSN system as a data source to evaluate patient safety and clinical quality performance by Joint Commission-accredited hospitals – many of which already participate in NHSN as a CMS program requirement.
How to join the Joint Commission NHSN Group
In April 2024 The Joint Commission will e-mail the primary accreditation contact on file for the organization to determine the appropriate contact person to correspond with regarding the Joint Commission NHSN Group. After the contact has been identified, detailed instructions for joining the Group will be provided, and onboarding will take place May through June 2024.
Measures for the Joint Commission NHSN Group
Hospitals will grant The Joint Commission access to deidentified data on the following five CDC NHSN HAI measures from the NHSN application. Currently, all these measures are in the CMS Hospital Value-Based Purchasing (VBP) Program and the Hospital-Acquired Condition (HAC) Reduction Program.
- Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
- Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure
- Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
- Colon and Abdominal Hysterectomy Surgical Site Infection (SSI) Outcome Measure
- Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure
The time period parameter will be set to begin with events that occurred in Q1 2021. The Joint Commission selected a look-back period because historical data more accurately depict trends and hospital performance over time.
The view options for patient-level data will be set for no patient identifiers. The Joint Commission will have access to facility-level data only. Hospital data will remain confidential and will not be shared with other Joint Commission-accredited hospitals. In accordance with NSHN Group rules, “A facility that joins a Group does not have access to any data from other facilities in the Group.” The Joint Commission does not plan to publicly report NHSN data.
The Joint Commission completed a rigorous evaluation process of technology components to ensure that privacy and security standards are met.
Information about the Joint Commission NHSN requirement was previously communicated in the November 2023 issue of Perspectives and the 2024 ORYX Performance Measures Reporting Requirements document. Additional information regarding the NHSN Group for The Joint Commission is available via the ORYX FAQs or the NHSN Group for The Joint Commission page.
Revised Accelerate PI™ Dashboard Reports containing data through the fourth quarter of 2022 are available for accredited hospitals and critical access hospitals. These revised reports replace the previous reports published in September 2023 and correct potential inaccuracies resulting from an electronic clinical quality measures (eCQM) aggregation calculation error.
Data in the reports comes from chart-abstracted quality measures and eCQMs data reported by hospitals to The Joint Commission under the ORYX® program. The dashboards, available to both Joint Commission surveyors and accredited hospitals, are intended to be a springboard for conversations on data, performance measures, and quality improvement during the survey process.
Accelerate PI Dashboard Reports are located under the Resources and Tools menu below the DASH heading in JC Connect®.
Effective July 1, 2024, The Joint Commission approved new and revised workplace violence prevention requirements for all Joint Commission-accredited behavioral health care and human services (BHC) organizations. The new and revised requirements provide a framework to guide BHC organizations in developing effective workplace violence prevention strategies. The requirements address:
- Defining workplace violence, including a formal definition added to the Glossary
- Outlining leadership oversight
- Developing worksite analysis processes
- Developing policies and procedures to prevent workplace violence
- Reporting systems, data collection, and analysis
- Implementing post-incident strategies
- Providing training and education to decrease workplace violence
A Resource Center is being developed for the Joint Commission’s website. Additional information about the revised standards is available in the R3 Report. The new and revised requirements are posted on the Prepublication Standards page of The Joint Commission’s website and will publish online in the spring 2024 E-dition® update to the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (CAMBHC). For those customers who purchase it, the CAMBHC 2024 spring update service will include these new and revised requirements.
Workplace violence requirements were implemented in 2022 for Joint Commission-accredited critical access hospital and hospital programs (see the July 2021 issue of Perspectives) in response to workplace violence directly affecting the safety of patients and staff. A literature review and public field review were conducted to determine the applicability of similar requirements for BHC settings and services. A technical advisory panel of individuals representing various public and private organizations, as well as Joint Commission-accredited BHC programs, provided knowledge and expertise in examining the relevance of workplace violence prevention requirements to BHC providers.
For more information contact the Department of Standards and Survey Methods.
The Joint Commission launched its Sustainable Healthcare Certification (SHC) Resource Center on Sept. 18, 2023. The resource center provides sustainability strategies, tools and tips, Spotlights on leading organizations, cost savings examples, and other key resources to assist in reducing your carbon footprint. While it was designed with certification in mind, it can be an on-ramp for any organization, whether they seek accreditation or not, and wherever they are on their environmental sustainability journey.
Since the launch, several new and exciting Spotlights have been added to the resource center from leading organizations, including Beth Israel Deaconess Medical Center (BIDMC), Seattle Children’s Hospital, Boston Medical Center, and more are coming.
BIDMC provided Spotlight examples for several environmental sustainability domains: assessment, measurement, and improvement, waste reduction strategies (including training and going paperless) and anesthetic gases. Please click on each below to learn more.
- Assessment, measurement, and improvement strategies: BIDMC recently hired a Senior Sustainability Data Analyst within their Sustainability Department, aiming to establish baseline metrics, track sustainability goals, and drive environmental impact reductions through advanced technologies and data-driven insights.
- Implementing annual sustainability E-Training: In order to achieve their Zero Waste by 2030 initiative, and build an organization-wide skill set, they implemented annual interactive E-training on Sustainability & Regulatory Training, educating over 12,000 employees in 2023.
- Implementing a Paperless Strategy Committee: The committee represents 22 departments and has achieved a 25% reduction in paper use for the first year.
- Reducing emissions related to anesthetic gases: BIDMC successfully reduced anesthetic gas emissions by approximately 90% since 2016. Read more to learn how.
Note: Complete the form at each link to get full access to the Spotlights and Cost Savings resources. Please watch for more Spotlights from other leading organizations!
(Contact: Brette Tschurtz, btschurtz@jointcommission.org)