Joint Commission Online - July 1, 2020
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
July 01, 2020
Safety for Joint Commission-accredited organizations and Joint Commission staff continues to be the priority of The Joint Commission. As The Joint Commission has resumed select on-site surveys and reviews, some further clarifications have been made regarding what is and what is not being evaluated.
Compliance with Joint Commission standards will be evaluated from the time of the last full accreditation survey up until the public health emergency (March 1, 2020). Our survey will not focus on the time period of March 1 through either the date the organization has indicated they are ready to accept a survey or the end of the public health emergency — whichever comes first.
However, The Joint Commission will assess how an organization adapted their infection control and emergency management processes in response to the pandemic and will focus its review on current practices to ensure the organization continues to provide safe care and work in a safe environment.
Also, the Centers for Medicare and Medicaid Services-issued waivers are not applicable to Clinical Laboratory Improvement Amendments-certified laboratories. Therefore, laboratories can expect surveyors to include an evaluation of the organization’s ability to appropriately manage Emergency Use Authorizations (EUAs), as well as continued management of their quality control and proficiency testing throughout the full accreditation cycle.
In mid-March, The Joint Commission stopped all on-site accreditation surveys and certification reviews in response to the National Emergency Declaration and the COVID-19 pandemic. Since on-site survey and review activities ceased, some virtual, initial surveys were conducted.
In June, The Joint Commission resumed select on-site surveys and reviews. To determine where on-site activities would resume, The Joint Commission analyzed low-risk areas — by county — to identify organizations waiting to be scheduled for surveys or reviews. Next, account executives made readiness assessment calls to the identified health care organizations to gauge the continued impact of the pandemic on the organization. Account executives assessed the following items to determine whether an organization was ready for survey or review:
- Has the organization ceased emergency operations/deactivated their Emergency Management Plan/Emergency Operations Plan?
- Is the Organization utilizing any waiver, exception or deferment that would prevent them from being compliant with any Joint Commission requirement, State or Federal regulation?
- Has the organization closed their temporary/surge capacity facilities?
- Have any staff tested positive for COVID-19 in the past 14 days?
- Does the organization have any visitor restrictions in effect?
- Does the organization have any sites located outside of their state?
When an organization was determined to be ready for on-site activities, the organization was scheduled for survey or review and surveyors or reviewers were assigned.
In preparation, The Joint Commission examined its survey and review processes and implemented the following safeguards to ensure the safety of all individuals involved in a survey or review:
- Safe physical distancing
- Limiting the number of individuals in group sessions.
- Minimizing the number of staff that accompany a surveyor or reviewer during tracer activities.
- Driving in separate or, for surveyors and reviewers, their own vehicles to off-site locations or home visits.
- Personal protective equipment
- Requiring Joint Commission surveyors and reviewers to wear masks.
- Asking that health care organizations provide masks and/or other personal protective equipment to surveyors and reviewers.
- Enhanced technology
- Maximizing technology to support physical distancing (for example, using screen sharing or projection to conduct electronic medical record reviews, interviewing care recipients or staff).
- Incorporating audio/video conference calls to safely expand the number of meeting attendees.
As health care organizations continue to battle the COVID-19 virus, The Joint Commission continues to compile resources to provide health care staff with the most pertinent information to best meet their needs. Questions related to the resumption of survey and review activities may be directed to an organization’s designated account executive.
July 01, 2020
Effective today, July 1, The Joint Commission is expanding the role of the Life Safety Code surveyor in hospital on-site survey events to include an evaluation of the physical environment and Life Safety Code requirements at all off-site emergency department and hospital-based ambulatory surgical locations.
Historically, Life Safety Code surveyors have visited all inpatient locations during on-site survey events. Due to the complexity associated with the off-site emergency department and hospital-based ambulatory surgical settings, the evaluation of the physical environment and Life Safety Code requirements by the Life Safety Code surveyor will allow the clinical surveyor(s) time to focus on the quality of care and services provided in these settings.
All other off-site locations that are visited by clinical surveyors will continue to be evaluated for physical environment and Life Safety Code requirements by the clinical surveyor with an enhanced focus on the business occupancy Life Safety Code requirements.
For more information, organizations are encouraged to reach out to their assigned account executive.
July 01, 2020
The Joint Commission has made standards changes for deemed-status hospitals and critical access hospitals.
The first set of changes — which will go into effect on July 1 — are being made in response to the hospital deeming renewal application with the U.S. Centers for Medicare & Medicaid Services (CMS).
The second set of changes — which will go into effect on Sept. 13 — are being made to further revise requirements for both critical access hospitals and hospitals to align with CMS’ final rules on Burden Reduction and Discharge Planning published in March.
July 01, 2020
Joint Commission staff are on the front lines of caring for patients with COVID-19, and those experiences are being shared in the ‘Real Voices. Real Stories.’ series.
A domestic consultant for Joint Commission Resources, Steven Chinn, DPM, MS, MBA, is also an accreditation/regulatory officer at Stanford Health Care. He recently shared how prior experiences helped him adapt and cope with the COVID-19 pandemic.
“We have not been hit as hard as other organizations in the country, but we still had to prepare for the surge,” Chinn wrote. “When we found out that our sources for a certain N95 mask size were no longer available, I had to figure out processes to fit test over 4,000 employees, residents, and physicians to the masks that were in stock. For a few weeks, it was a 24/7 operation. We did things that might not normally be in the job description. That included helping with locating space for staff to get urgently screened for possible exposure. Much of this involved logistics, coordination, and knowing the organization.
“Some of the larger crisis situations that my colleagues and I have experienced in the past — including the 1989 Loma Prieta earthquake, 9/11, and the California wildfires — gave us experience to manage and adapt. Using a high reliability approach during these events, you plan for the worst, expect the unexpected, and hope for the best. You do the best you can with what you have and realize this is a marathon and not a sprint. It’s going to be several more months of this. Folks are planning on what it’s going to look like in the fall, even next winter. I think we have a way to go yet.”
Read more “Real Voices. Real Stories.”
July 01, 2020
There are many professional, cultural and structural barriers to teamwork, communication and patient engagement in hospital settings.
In January 2015, the University of Kentucky, Lexington, developed and implemented the Interprofessional Teamwork Innovation Model (ITIM) with the goal of bringing together providers, patients and their families to discuss plan of care, treatment and discharge planning. Initial research documented that ITIM was associated with a reduction in 30-day readmissions to the hospital while it yielded a cost-neutral result from the implementation.
A new study in the July issue of The Joint Commission Journal on Quality and Patient Safety — “Patient Perceptions and Real-Time Observations of Bedside Rounding Team Communication: The Interprofessional Teamwork Innovation Model” — details the findings after the study authors conducted observations and patient surveys in two hospital sites to examine relationships between observed teamwork structures, communication processes in the ITIM and clinical outcomes.
ITIM involves bedside rounds that include a:
- Bedside nurse
- Case manager or social worker
Researchers observed 68 ITIM teams that completed 685 patient visits in a 569-bed academic medical center (AMC) and an affiliated 302-bed community-based care hospital (CH). Patients also were asked to complete surveys about their experience with their ITIM team.
Findings showed team structures and communication processes were significantly associated with lower lengths of stay (LOS) in the CH, and communication processes were associated with lower LOS in the AMC. A variety of communication factors were operating in ITIM teams including the following:
- Soliciting questions from patients and staff
- Physician and nurse speaking percentages
- Team-oriented communication
“Findings suggest that when patients feel they are given opportunities to ask questions, speak without being interrupted and have their questions answered, they tend to be satisfied with their experience of care,” the study authors noted.
Additionally, the July issue also featured the 2019 John M. Eisenberg Patient Safety and Quality Award recipients:
- Individual achievement: “An Interview with Gordon D. Schiff”
- National level achievement: “SPOTting Sepsis to Save Lives: A Nationwide Computer Algorithm for Early Detection of Sepsis” (HCA Healthcare, Nashville, Tennessee)
- Local level achievement: “A Model Cell for Transformational Redesign of Sepsis Identification and Treatment: Aligning Digital Tools with Innovative Workflows” (WellSpan Health, York, Pennsylvania)
Access the Journal.
July 01, 2020
- Dateline @ TJC — New Child Welfare Standards Focus on Improving Support Services: Effective Sept. 13, 74 new elements of performance (EPs) and 12 revised EPs will be applicable to Joint Commission-accredited child welfare agencies, writes Stacey Paul, MSN, RN, APN/PMHNP-BC, project director, clinical, Standards and Survey Methods.
- Improvement Insights — Applying a Model Cell Concept in Health Care: Begun in 2017, the Central Alert Team is an innovative combination of technology, best practice processes and trained medical staff that leads to early sepsis intervention across our health system. By changing how we look for and respond to sepsis, a deadly infection, the team is saving lives, writes Steven L. Delaveris, DO.
- Ambulatory Buzz — Ambulatory Care Program Recovery Plans – Post COVID-19: The Joint Commission was pleased to resume its regular on-site surveys and survey process in June. The Joint Commission will review a variety of factors and criteria to determine where and which ambulatory care organization will be surveyed, including identifying and then prioritizing low-risk geographic areas we can safely survey. The on-site visit will look somewhat different, too, as we employ physical distancing practices to ensure the safety of all concerned, writes Kelley McCann, associate director, Accreditation & Certification Operations.