Beginning Jan. 27, 2022, for applicable deemed program surveys in progress on that day, The Joint Commission will begin surveying to the “Omnibus COVID-19 Health Care Staff Vaccination” interim final rule published by the Centers for Medicare and Medicaid Services (CMS) in the Nov. 5, 2021 Federal Register. Further guidance was published by CMS on Dec. 28, 2021. This rule affects the following Joint Commission deemed programs: Ambulatory Surgical Centers, Critical Access Hospitals, Hospitals, Home Care, Home Infusion Therapy, and Hospice.
On Jan. 27, the COVID-19 staff vaccination requirements will be in effect in the following states: California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia, Washington, and Wisconsin, along with the District of Columbia and U.S. territories.
As a result of the U.S. Supreme Court’s decision on Jan. 13, health care organizations in the 24 states that were not previously subject to the “Omnibus COVID-19 Health Care Staff Vaccination” rule now are. Additionally, health care organizations in these 24 states need to demonstrate compliance utilizing the phased-in approach per the timelines (that begin Feb. 14, 2022) specified in the CMS memorandum issued Jan. 14. Therefore, beginning Feb. 14, surveyors will begin surveying to the vaccination requirements for these 24 states as follows: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia and Wyoming.
Changes to Joint Commission accreditation requirements for the affected deemed programs are under review, and accredited organizations will be notified of any changes via Joint Commission Perspectives. In the interim, for any findings related to the regulatory requirements for COVID-19 staff vaccination, The Joint Commission will score Leadership (LD) Standard LD.04.01.01, element of performance (EP) 2: The organization provides care, treatment, and services in accordance with licensure requirements, laws, and rules and regulations, along with the applicable Medicare conditions of participation/conditions for coverage.
The Joint Commission has published FAQs regarding the new vaccination requirements.
Effective July 1, 2022, a fully revised Emergency Management (EM) chapter, including new and revised EM standards, has been approved for all Joint Commission-accredited hospitals and critical access hospitals.
The Joint Commission undertook a thorough analysis and rewrite of the EM chapter that resulted in the following improvements:
- Creating 22 new elements of performance (EPs).
- Revising/consolidating 38 EPs.
- Reorganizing requirements.
- Renumbering standards.
The EM project was created to assist hospitals and critical access hospitals in developing a more comprehensive EM program and to be better prepared for emergencies or disasters (such as those faced during the COVID-19 pandemic) to meet the health, safety, and security needs of their facilities, staff, patient populations, and communities served. As a result, the new and revised EM requirements provide more clarity with greater emphasis on the following EM requirements:
- Assessment, applicability, and incorporation of the hazard vulnerability analysis throughout the entire EM chapter.
- Specific requirements for leadership involvement and oversight in all aspects of the EM program.
- An Emergency Operations Plan that addresses the following:
- Communication plans
- Surge plans
- Evacuation procedures
- Resource acquisition and management
- Continuity of operations
- Staff education and training with specific guidance for initial and ongoing EM training.
The following are other related changes resulting from the EM project:
- Revised Environment of Care (EC) Standard EC.02.03.01, EP 9, for critical access hospitals only.
- Added new Standard EC.02.05.07, EP 11.
- Revised Standard EC.02.06.05, EP 1.
- Revised Leadership (LD) Standard LD.04.01.10.
- Deleted Standard LD.04.01.10, EP 1.
The project’s program-specific R3 Report provides the rationales for the new and revised requirements, as well as references to the research articles and reports used to develop them. In addition to an extensive literature review, the new and revised requirements were developed based on voice-of-customer feedback resulting from the pandemic, public field review, and expert guidance from the following groups:
- Program-specific standards review panel composed of more than 50 members who have current roles in emergency management. Members included representation from critical access hospitals and hospitals or other professional organizations. The members provided a frontline point of view and insights into the practical application of the proposed standards.
- Internal Joint Commission EM work group composed of Life Safety Code® field directors, Standards Interpretation Group engineers, field staff clinical surveyors (physicians and nurses), and staff from the Department of Standards and Survey Methods.
The Joint Commission also worked with subject matter experts to develop surge planning requirements for instances when critical resources (for example, staff, space, supplies) could be rapidly exhausted, particularly during a sustained mass-casualty event such as a global pandemic. Those requirements will be implemented in the future for hospitals and critical access hospitals. Future EM chapter revisions will occur for other Joint Commission-accredited programs in 2022 and 2023.
View the prepublication standards or contact the Department of Standards and Survey Methods for more information.
Effective July 1, 2022, The Joint Commission has approved 29 new and 55 revised requirements for its Nursing Care Center (NCC) Accreditation Program. Additionally, 10 new and four revised requirements for the NCC Memory Care Certification (MCC) program have been approved.
The new and revised requirements span multiple chapters and address topics including infection prevention and control, dementia care, staff recruitment, retention and wellness, pressure injuries, and medication safety. These updates are being made to ensure that the NCC Accreditation and MCC Certification programs remain scientifically current and relevant. Several of the updates also reflect lessons learned from the COVID-19 pandemic.
Changes to the requirements reflect current scientific evidence and evidence-based practices in long-term care and memory care and align with recommendations and practice guidelines from the Alzheimer’s Association, U.S. Centers for Disease Control and Prevention, U.S. Centers for Medicare and Medicaid Services, National Coalition for Hospice and Palliative Care, and National Pressure Injury Advisory Panel.
Also, effective July 1, 2022, The Joint Commission will begin offering its NCC MCC program in collaboration with the Alzheimer’s Association — the leading voluntary health organization in Alzheimer’s care. The Joint Commission and the Alzheimer’s Association will work closely to better understand the underlying clinical issues affecting memory care and to inform the development of new standards and maintenance of existing standards and performance measures. Organizations achieving MCC on or after July 1, 2022, will be able to display a certification logo associated with both The Joint Commission and the Alzheimer’s Association.
View the prepublication standards or learn more in an issue of R3 Report. For more information about the collaboration with the Alzheimer’s Association, contact Mark Crafton, MPA, MT(ASCP), Executive Director, Strategic Alliances, at mcrafton@jointcommission.org.
The Joint Commission and the American Heart Association (AHA) have developed a new advanced disease-specific care (DSC) certification program for heart attack patient care.
The Comprehensive Heart Attack Center (CHAC) Certification Program, based on clinical practice guidelines and recommendations published in the AHA’s journal, Circulation, will be effective July 1, 2022, and is available for all Joint Commission-accredited hospitals or non-Joint Commission accredited hospitals that are compliant with applicable federal laws, including Medicare Conditions of Participation or Medicare Conditions for Coverage.
In the Circulation article, the American Heart Association Advocacy Coordinating Committee calls for the implementation of a system of care for all time-sensitive cardiovascular disorders to minimize delays in patient care. This includes emergency medical services routing protocols to transport patients to the most appropriate level of care. With the addition of the CHAC program, states, regions, and communities now have a comprehensive framework to build an effective system of care, including the Acute Heart Attack Ready (AHAR), Primary Heart Attack Center (PHAC), and CHAC certification programs.
Hospitals qualifying for this new advanced certification will be recognized for meeting standards denoting the highest level of commitment for providing consistent and optimal treatment for patients with acute coronary syndrome (ACS) — including ST-elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI), and unstable angina — in addition to complications related to ACS, such as cardiac arrest and cardiogenic shock. The CHAC certification focuses on the complete continuum of care as follows:
- Symptom onset and first medical contact (prehospital care and upon hospital arrival).
- Emergency department care and management.
- Procedural interventions, such as cardiac catheterization and/or cardiovascular surgery.
- Post-intervention/operative care.
- Discharge and rehabilitation.
CHAC Certification requires hospitals to provide 24/7 on-site coverage for primary percutaneous coronary intervention (PPCI) and cardiac surgical services. The program requires a multidisciplinary team approach that offers a full range of advanced hemodynamic support for the treatment of the most complex and critically ill patients, including those with cardiogenic shock and cardiac arrest.
The following standardized measures have been adopted from the AHA’s Get With The Guidelines® — Coronary Artery Disease:
- CHAC-1: Electrocardiogram (ECG) within 10 minutes of arrival at this receiving center.
- CHAC-2: PPCI ≤ 90 minutes.
- CHAC-3: Emergency medical services (EMS)/FMC to PCI ≤ 90 minutes.
- CHAC-4: Arrival at first facility to PPCI ≤ 120 minutes.
- CHAC-5: Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD) at discharge.
- CHAC-6: Cardiac rehabilitation patient referral from an inpatient setting.
- CHAC-7: ACE inhibitor or ARB prescribed at discharge for non-ST elevation-acute coronary syndrome (NSTE-ACS).
- CHAC-8: Cardiac rehabilitation patient referral from an inpatient setting for NSTE-ACS.
- CHAC-9: Dual antiplatelet therapy prescribed at discharge (NSTEMI).
Data collection for these measures will commence with discharges as of July 1, 2022. For organizations seeking initial certification, data collection must commence four months prior to the initial certification review visit. For example, hospitals whose initial certification review visit is scheduled in September must begin data collection in the previous May. Data collection is then ongoing thereafter for certified organizations.
Visit the Comprehensive Heart Attack Center Certification page for more information about this advanced certification program.
During the COVID-19 pandemic, health care providers have reported an increase in intimate partner violence (IPV).
According to the World Health Organization, “Intimate partner violence refers to behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours.” The Centers for Disease Control and Prevention (CDC) expands their definition of abuse to include stalking and provides uniform definitions.
IPV survivors seek medical care in many health care settings, but survivors often do not readily share their abuse experiences with providers unless specifically asked and if they are ready to accept help.
A new issue of Quick Safety addresses the issue of IPV, as well as safety actions to consider on how to help protect patients.
Read Quick Safety.
As health care workers face continued challenges posed by another spike of a COVID-19 variant, leaders are looking for ways to combat provider burnout and ways to retain staff. While this can seem daunting, The Center for Transforming Healthcare and Huron are teaming up to provide potential solutions.
Register for a two-part free webinar series focused on evidence-based, practical strategies for health care leaders to advance holistic change. Part 1 — “Fostering Resilience: Leveraging High Reliability Strategy to Revitalize and Retain the Health Care Workforce” — is scheduled for Feb. 8, from 9-10 a.m. PT / 10-11 a.m. MT / 11 a.m.-noon CT / noon-1 p.m. ET.
The webinar will explore the five hallmarks of high reliability and how organizational and individual health care worker resilience has been put to the test by the COVID-19 pandemic. Speakers will address issues of physical, emotional, and compassion fatigue, as well as challenges related to deflated individual agency, moral distress, and burnout. They also will provide guidance to health care leaders on fortifying organizational and individual resilience and alleviating current workforce challenges.
Participants can engage with content through an online chat function and a Q&A session after formal remarks.
The scheduled speakers are:
- Anne Marie Benedicto, Vice President of The Center for Transforming Healthcare
- Craig Deao, MHA, Managing Director at Huron
The webinar aims to teach the participants:
- The five hallmarks of high reliability.
- How to leverage the tenets of high reliability to mitigate health care worker issues of fatigue and burnout.
- Ways to ensure full engagement of the workforce.
Continuing Education (CE) credits are available for the live webinar only. Please note: CE credits will not be offered to viewers of the on-demand webinar replay.
Register for the webinar.
- Dateline @ TJC — What to Expect When You’re Expecting a Joint Commission Lab Survey: If your organization is accredited by The Joint Commission, the day will come when our surveyors show up at 8 a.m. If you are prepared for it, the experience should be a positive one, writes Amy Null, MBA, MT (ASCP), SBB, Associate Director, Standards Interpretation Group, and Surveyor.
- Ambulatory Buzz — Best of AmBuzz in 2021: In uncertain times, I find it helpful to focus on what unites us and on productive conversations. I cannot think of a better time to reflect on the issues and critical conversations taking place in the ambulatory care community over the past year, writes Pearl Darling, MBA, Executive Director, Ambulatory Health Care.
- Improvement Insights — Lessons Learned from Restricted Visitation: Given that COVID-19 may be around a lot longer than anticipated, we can no longer rely on best practices that used to work pre-pandemic, or even at the beginning of it. As the virus mutates and evolves, so must our operations. The progress we have made to embed patient and family engagement cannot be another casualty of the pandemic, writes Dr. Tejal Gandhi, MD, Chief Safety and Transformation Officer, Press Ganey.