Joint Commission Online - June 15, 2022
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
June 15, 2022
Managing commercially prepared sterile supplies and devices can be challenging for healthcare organizations. To protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must:
- Identify the best location to store the supplies so that staff can readily access them.
- Ensure the supplies are being stocked to the most optimal par levels.
- Check that items have not passed their expiration dates.
- Maintain the storage area so that supplies are stored safely, kept in good condition, and protected from contamination.
A new issue of Quick Safety examines this issue and provides guidance for managing and storing packaged sterile supplies within a facility — with the goal of keeping patients safe from infection and other potential harm caused by expired or compromised supplies and devices.
Read Quick Safety.
June 15, 2022
Healthcare facilities aim for zero avoidable patient harm. Toward that aim, healthcare organizations continuously identify, assess, and remediate sources of risk. Reactive risk assessments (RRAs) such as incident reporting and root causes analysis and proactive risk assessments (PRAs) like failure mode and effects analysis are tools to reduce risk; however, they are generally conducted independently.
A new study in the June/July issue of The Joint Commission Journal on Quality and Patient Safety, “Combined Proactive Risk Assessment: An Approachable Method for Unifying Proactive and Reactive Risk Assessment Techniques in Healthcare,” suggests that RRA and PRA complement one another and proposes Combined Proactive Risk Assessment (CPRA) as an innovative, approachable, scalable, and generalizable technique for identifying vulnerable points in healthcare processes.
CPRA aligns patient safety reporting data with process steps and failure modes to assess risk. The study used PRAs from several Veterans Health Administration (VHA) facilities and national patient safety data from the VHA National Center for Patient Safety’s database related to outpatient blood draws to develop a comprehensive process flow diagram and list of potential failure modes.
Aggregating PRAs from multiple facilities identified 220% more failure modes and integrating incident reports into PRA identified 310% more failure modes than the single facility average. Overlaying safety reports onto a comprehensive process flow diagram revealed 86% of events occurred during three of seven process steps. Accuracy of this technique was generally above 85%.
The study shows that CPRA is promising for increasing the return on investment of safety reporting systems, monitoring risk within key healthcare processes, and proactively directing safety and quality improvement resources based on real data.
Also featured in the June issue:
- Reduction of Unnecessary Gastrostomy Tube Placement in Hospitalized Patients (Columbia University Irving Medical Center, New York)
- Ensuring Quality in Patients Receiving Enteral Nutrition Catheters (editorial)
- Systems-Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration (Medical University of South Carolina, Charleston)
- Utility of an Electronic Health Record Report to Identify Patients with Delays in Testing for Poorly Controlled Diabetes (Johns Hopkins Health System, Baltimore)
- Handoffs and Teamwork: A Framework for Care Transition Communication (Cincinnati Children’s Hospital Medical Center, Cincinnati)
- Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19 (commentary)
Access the Journal.
June 15, 2022
In late 2019, The Joint Commission began discussing opportunities for improving its Emergency Management chapter, leading to 22 new and 38 revised elements of performance (EPs) for the Hospital (HAP) and Critical Access Hospital (CAH) accreditation programs. These new and revised emergency management standards are effective July 1, 2022.
The Joint Commission first proposed a standard relating to the development of a “crisis standards of care plan” (CSC) during a field review in 2021. While there was favorable feedback from many healthcare organizations that already had CSC plans, some organizations described challenges with developing a CSC plan. Based on this feedback, The Joint Commission decided not to move forward with CSC requirements at that time. However, since the approval of these standards, experts in the field of CSC and surge planning participated in an advisory panel to further discuss and evaluate the impacts of crisis standards of care. The proposed standard and EPs includes recommendations provided by the advisory panel, as well as those obtained from other sources of literature.
Comment now on the proposed changes. Feedback will be accepted until July 22.
June 15, 2022
Refreshed Accelerate PI™ Dashboard Reports are available for primary stroke centers (PSCs) and comprehensive stroke centers (CSCs) to provide updated performance measurement data on the quality measures selected for advanced PSC and CSC certification programs. The refreshed reports contain data through the fourth quarter of 2021.
The dashboards provide performance measurement data on all the measures that PSCs and CSCs 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 process, as well as a guide to support an organization’s quality journey.
Reports are located under the “Resources and Tools” menu below the DASH heading in Joint Commission Connect®. Users must select “Certification” on the home screen prior to accessing the menu.