Joint Commission Online - July 21, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
July 21, 2021
Starting Jan. 1, 2022, new revisions to the Sentinel Event Policy will apply to all Joint Commission accreditation and certification programs, except for the Health Care Staffing Services and Integrated Care certification programs.
The Joint Commission’s Office of Quality and Patient Safety (OQPS) revised its definition of a sentinel event and clarified some of the event-specific examples in the Sentinel Event Policy. The revisions clarify expectations regarding a health care organization’s partnership and collaboration with OQPS and include editorial revisions to improve the flow of the chapter.
OQPS revised the definition to clarify the differences between severe harm (which may or may not be permanent) and permanent harm (regardless of severity). The revised definitions include:
- Sentinel event: A patient safety event (not primarily related to the natural course of the [patient’s] illness or underlying condition) that reaches a [patient] and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).
- Severe harm: An event or condition that reaches the individual, resulting in life-threatening bodily injury (including pain or disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or a surgery, invasive procedure, or treatment to resolve the condition.
- Permanent harm: An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline.
The final substantive revisions clarify the expectations for health care organizations’ collaboration with OQPS, which include the following:
- Removed redundant verbiage and duplicative content.
- Clarified guidance on how to complete a comprehensive systematic analysis and development of an action plan to align with current Joint Commission requirements.
- Reorganized content to flow in a more logical order.
- Clarified content to determine whether a patient safety incident meets criteria for sentinel event review.
The most current version of the Sentinel Event Policy can be found in the SE chapter in the E-dition or Comprehensive Accreditation Manual. (Contact: email@example.com)
July 21, 2021
Thinking about submitting an application to be considered for the Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity from The Joint Commission and Kaiser Permanente? Time is running out as the application deadline is Aug. 6. There is no cost to apply.
For those with questions or who need help determining if their organization has an initiative that may be eligible for the award, email TysonAward@jointcommission.org.
The award recognizes health care organizations and their partners that led initiatives that achieved a measurable, sustained reduction in one or more health care disparities. All types of health care organizations that directly deliver health care and have addressed disparities for any vulnerable population — including but not limited to race/ethnicity, gender, sexual orientation, or socioeconomic status — may apply.
Applicants are encouraged to submit their award application describing the implementation of a well-defined intervention that resulted in a measurable, sustained reduction in disparities. Initiatives submitted for consideration must demonstrate measurable improvement.
The award honors the memory of the late Bernard J. Tyson was chairman and chief executive officer of Kaiser Permanente, and he worked tirelessly to address the disparities that plague the U.S. health care system.
Apply for the Bernard J. Tyson National Award.
July 21, 2021
In celebration of the 2020 John M. Eisenberg Patient Safety and Quality Award recipients, a new special Take 5 podcast series launched to showcase the winners and the extraordinary work they are doing.
The Eisenberg Awards — which are named after the late John M. Eisenberg, MD, MBA, former administrator of the Agency for Healthcare Research and Quality — were launched in 2002 and recognize major achievements by individuals and organizations to improve patient safety and health care quality. There are three recipients each year: for an individual; an organization impacting quality care at a national level; and an organization impacting quality care at a local level.
The third episode focused on the Veterans Health Administration (VHA) Rapid Naloxone Initiative, which won the national award. Elizabeth M. Oliva, PhD, the VA National Opioid Overdose Education and Naloxone Distribution (OEND) Coordinator was interviewed. Oliva received her PhD in Developmental Psychopathology and Clinical Science from the University of Minnesota, studying the etiology of substance use from adolescence to early adulthood. Her areas of expertise include the etiology of substance use disorders, substance use disorder treatment research and strategies to address the opioid crisis.
The series also features episodes recognizing:
Listen to the podcast. [18:34]
July 21, 2021
- Leading Hospital Improvement — 7 Items for Hospitals to Include in Written Plans for Use of Personal Insulin Pumps and CGM Systems: Many patients prefer continuing to use their personal insulin pump or CGM system when hospitalized. The American Diabetes Association endorses this practice, but it can create risk for the organization. The Joint Commission outlined seven safety considerations for hospitals to implement if they choose to allow patients to continue using their personal insulin pumps and CGM systems, writes Robert Campbell, PharmD, BCSCP, Director, Clinical Standards Interpretation and Medication Management for Hospital/Ambulatory Programs, and Maura Naddy, MSN, RN, Associate Director, Standards Interpretation Group.
- Improvement Insights — Improving Quality and Safety of Telehealth: The Joint Commission Journal on Quality and Patient Safety is interested in publishing studies on telehealth, including retrospective analyses of quality and safety issues and prospective studies of strategies to improve quality, safety, access to care and utilization, writes David W. Baker, MD, MPH, FACP, Executive Vice President for Health Care Quality Evaluation, The Joint Commission, and Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety.
- Improvement Insights — Lesser Known Uses of Simulation in Health Care: David M. Gaba, MD, Staff Anesthesiologist and Founder & Co-Director, Patient Simulation Center at VA Palo Alto Health Care System, and Associate Dean for Immersive & Simulation-based Learning and Professor of Anesthesiology, Perioperative & Pain Medicine, Stanford School of Medicine, was the 2020 recipient of the John M. Eisenberg Patient Safety and Quality Award for Individual Achievement. The award in part recognizes his work in simulation, especially high-fidelity mannequin-based single and multiple participant scenarios, as a means to study and improve patient safety.
- Ambulatory Buzz — Tips for Your First Ambulatory Survey: In 2021, The Joint Commission is conducting a high number of inaugural surveys. We survey more than 1,100 ASCs annually, so we are more than familiar with the ambulatory environment. Here are several tried-and-true tips to make the survey experience run smoothly, writes Lorrie Cappellino, RN, MS, CNOR, Surveyor, Ambulatory Health Care.