Joint Commission Online - Jan. 27, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
January 27, 2021
A new episode of Take 5 discusses The Joint Commission's new activities focusing on diversity and racial equity in health care.
The conversation features Joint Commission officers Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer, Chief Diversity and Inclusion Officer, and David W. Baker, MD, MPH, FACP, Executive Vice President, Division of Health Care Quality Evaluation.
“The Joint Commission has a leading role in addressing what is really a patient safety concern,” Dr. McKee said during the podcast. “We have to start thinking that if someone is not getting the right care at the right time because of their race or language difference or religion or gender identity that that’s a safety concern.
“The Joint Commission needs to make the case that this is a safety concern and every organization should be trying to identify opportunities to reduce the inequities in care, whether it is in mammogram use or vaccination — but they need to start. The Joint Commission will be encouraging organizations to take the first and necessary steps to address this problem.”
Dr. Baker said one of the first things that is needed to address these issues is to identify leading practices and to help disseminate them through the internet and through The Joint Commission’s surveyors.
“I think a lot of organizations [have] the motivation and their hearts are in the right place, and they want to address these issues,” Dr. Baker said. “But, honestly, they don’t know where to begin. So, we need to be able to overcome that. But that might not be enough, so we need to be able to think about standards to be able to encourage organizations to begin to address this.”
Listen to the conversation. [13:05]
January 27, 2021
The Joint Commission and Joint Commission Resources (JCR), Inc. have launched a new data transparency initiative – DASH™ (Data Analytics for Safe Healthcare) — that offers three business intelligence tools in the form of dashboards and performance improvement resources to power customers’ performance improvement efforts on their journey to zero harm.
The three business intelligence tools include:
- Accelerate PI™ (The Joint Commission): Provides data on quality measures selected because of their validity, importance and known evidence-based improvement strategies. It compares an organization to national, state and Joint Commission-accredited organization averages.
- SAFER™ Dashboard (The Joint Commission): Presents the findings from accreditation survey reports in a dashboard to empower timely, data-driven decisions that drive the delivery of safe, high-quality care.
- Illuminate Analytics™ (JCR): Offers greater visibility on the collective performance of a JCR customer to help draw meaningful, actionable conclusions from disparate data sources (i.e. Tracers with AMP® and consulting data).
“The data DASH provides will help organizations see at a glance their greatest needs and opportunities for improvement in key areas,” said David W. Baker, MD, MPH, FACP, Executive Vice President for Health Care Quality Evaluation, The Joint Commission. “With DASH, health care leaders can easily see how they compare to their peers and to the performance of leading organizations.”
DASH’s three business intelligence tools are or are anticipated to be available to select Joint Commission accredited health care organizations and/or select JCR E-product customers in 2021 – spanning across ambulatory surgery center, home health and hospice, hospital, and nursing care center settings for select dashboards. There is no additional fee to use DASH or any of its business intelligence tools.
January 27, 2021
In December, The Joint Commission launched Accelerate PI™ Dashboard Reports for accredited organizations certified under the advanced Comprehensive Stroke Center (CSC) and Primary Stroke Center (PSC) certification programs. The dashboards — which were developed in collaboration with the American Heart Association (AHA) — provide performance measurement data on all the measures that CSCs and PSCs 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 review process, as well as a guide to support an organization’s quality improvement journey. The new reports use the most recent and available data on all the standardized, advanced certification measures.
The dashboard reports are posted in the “Resources and Tools” tab of a certified organization’s secure Joint Commission Connect® extranet site. The reports represent each organization’s relative performance on each of the selected measures. For each measure, the dashboard shows the organization’s performance compared to various benchmarks. The dashboard is not a scorable element during the certification review process, but rather, a tool to facilitate discussion about ongoing quality improvement work. For example, reviewers may ask an organization how it addresses the subset of performance measures in the report and what action(s) the organization is taking to improve processes.
The Joint Commission will provide an orientation to the dashboard tool for all PSCs and CSCs early in 2021. Subsequently, The Joint Commission and the American Heart Association will analyze aggregate performance in each of these measures and identify the measures for which the greatest opportunities for improvement exist among PSCs and CSCs. Based on those findings, educational resources and learning collaboratives that address the high-opportunity topics will be developed and deployed to the field.
For more information, questions may be directed to the organization’s designated account executive.
January 27, 2021
Effective July 1, 2021, the Door to Transfer to Another Hospital performance measure for The Joint Commission’s Acute Stroke Ready Hospital Certification —ASR-OP-2 — will be retired. ASR-OP-2 will be replaced with the Door to Transfer to Another Hospital — STK-OP-1 — measure that also is collected for Primary Stroke Center
ASR-OP-2 was one of two outpatient measures designed to evaluate the management of both ischemic and hemorrhagic stroke patients in hospitals and critical access hospitals that can quickly diagnose stroke, initiate IV thrombolytic therapy for eligible patients, and transfer the patient to a higher-level primary or comprehensive stroke center for advanced therapies and services when indicated. “Door In – Door Out” times for stroke patients transferred from the emergency department of an acute stroke ready hospital to a higher-level acute stroke center are reported for three stroke patient groups:
- Hemorrhagic stroke
- Ischemic stroke — IV thrombolytic (t-PA) therapy prior to transfer
- Ischemic stroke — no IV thrombolytic (t-PA) therapy prior to transfer
Primary stroke centers also report transfer times for stroke patients; however, the STK-OP-1 measure includes additional strata for ischemic stroke patients with large vessel occlusions (LVO) who may or may not be eligible for mechanical endovascular reperfusion therapy. Endovascular therapy is the standard of care for treatment of acute ischemic stroke due to LVO. Faster transfer times and rapid reperfusion with mechanical thrombectomy in ischemic strokes with LVO leads to significant reduction in morbidity and mortality.
Since both acute stroke ready hospitals and PSCs collect similar data, measure alignment makes sense and may promote the use of data for comparative evaluation across hospitals and certification programs. Recent revisions to the STK-OP-1 measure strata — also effective July 1, 2021 — were made to assist health care organizations and Joint Commission stroke reviewers to better assess organizational performance around “Door In – Door Out” times for different groups of stroke patients and identify opportunities for improvement. Revisions involved the stratum for ischemic stroke—IV thrombolytic (t-PA) therapy prior to transfer. Three strata were added to differentiate LVO patients who may or may not be eligible for mechanical endovascular reperfusion therapy following IV alteplase initiation from those ischemic stroke patients transferred post-IV alteplase initiation for other reasons.
The revised STK-OP-1 measure will be detailed in the Specifications Manual for Joint Commission National Quality Measures, future Version 2021B, and available around Feb. 1, 2021, at https://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx. Questions about these measures may be sent via the Performance Measurement Network Q&A Forum at https://manual.jointcommission.org.
January 27, 2021
- Ambulatory Buzz — Three Ways Primary Care Medical Home Survey Preparation Prepared Medical Centers for COVID-19: Just before the COVID-19 crisis began gripping the nation, I was asked to present a lecture to a group of Joint Commission accredited Federally Qualified Community Health Centers on their preparation for Primary Care Medical Home (PCMH) certification. As the severity of COVID-19 became more apparent, it struck me that the steps organizations had taken to prepare for their accreditation and PCMH certification surveys exactly mirrored the actions they needed to plan for and execute amid COVID-19, writes Charles Darke, DDS, MPH, Surveyor, Ambulatory Care Services.
- Quality in Nursing Center Care — Florida Medicaid Prospective Payment System Deadline Approaching in May: Florida nursing homes still seeking to receive incentive payments this fall under Florida’s Medicaid Prospective Payment System (PPS) must act quickly to meet the May 31, 2021 deadline. Under Florida’s Medicaid PPS, nursing homes need to achieve specific quality metrics and outcomes, including a recognized quality credential such as The Joint Commission’s Nursing Care Center Accreditation, to receive additional quality incentive payments (QIP) or reimbursements, writes Monnette Geronimo, Manager, Business Development.