Joint Commission Online - March 1, 2023
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
March 01, 2023
A revision to Performance Improvement (PI) standard PI.01.01.01, Element of Performance (EP) 4, is going into effect immediately for hospitals, critical access hospitals, ambulatory care and office-based surgery practices.
This change was made after healthcare organizations expressed confusion with the requirement, which directs them to collect data on significant discrepancies between preoperative and postoperative diagnoses.
The revision provides:
- Details and examples to further clarify the intent for this data collection requirement and how the data can be used in an organization’s performance improvement efforts regarding diagnostic errors.
- Clarifies that the organization’s medical staff determine which unexpected postoperative diagnoses are clinically significant.
March 01, 2023
Severe maternal morbidity (SMM) is defined as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a person’s health, according to the Centers for Disease Control and Prevention (CDC). Healthcare organizations aim to improve maternal health outcomes and decrease SMM. While the CDC’s measure of SMM quantifies the prevalence of SMM, it is not restricted to potentially preventable SMM. As a result, the CDC SMM is not suitable for use as a quality indicator to compare hospitals or regions.
A new study in the March 2023 issue of The Joint Commission Journal on Quality and Patient Safety — by Moshe Fridman, PhD, and colleagues — proposes the use of performance SMM (pSMM), a modification of the CDC SMM, as a hospital performance measure. pSMM considers only those conditions that are hospital-acquired with a method for case-mix adjustment, thereby making it appropriate for comparison across hospitals. It identifies SMM cases that are potentially responsive to quality improvement initiatives. The researchers defined pSMM using these three guidelines:
- Exclusion of preexisting conditions from outcomes.
- Exclusion of inconsistently documented outcomes.
- Risk adjustment for conditions that preceded hospitalization.
To generate model-based expected pSMM values, the study classified California childbirth hospitals into four types: Community, Teaching, Integrated Delivery System (IDS) and IDS Teaching. Observed-to-expected (O/E) ratios were calculated for hospitals and used to categorize them as overperforming, average performing or underperforming. Performance categories were compared for pSMM vs. CDC SMM (excluding blood transfusion).
The overall rate of pSMM was 0.44%, which was less than half the previously published rate of CDC SMM (1.03%). Fewer than half of the observed cases of CDC SMM had the potential to be prevented through hospital practices, and therefore were attributable to hospital performance.
Higher rates of pSMM were observed in Teaching hospitals and IDS hospitals, compared to Community hospitals. The pSMM and CDC SMM also classified hospitals’ performance differently. The proportions of hospitals that changed performance categories when comparing pSMM to CDC SMM categorization were:
- Community: 12.1%
- Teaching: 25%
- IDS: 38.9%
- IDS Teaching: 66.7%
The researchers conclude that pSMM may be suitable for hospital comparisons, because it identifies potentially preventable, hospital-acquired SMM that should respond to quality improvement activities.
Also featured in the March issue:
- Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology (Stanford University School of Medicine, Stanford, California)
- Improving the Rates of Objective Monitoring of Patients with Depression with the PHQ-9 in an Outpatient Psychiatry Clinic: A Quality Improvement Initiative (Scarborough Health Network, Scarborough, Ontario, Canada)
- Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Healthcare Worker Well-Being (survey administered to 31 Midwestern hospitals)
- Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey (survey administered to 31 Midwestern hospitals)
- Rowing Together: Publicly Reported Quality of Care Measures, US Graduate Medical Education Accountability, and Patient Outcomes (commentary)
Access the Journal.
March 01, 2023
Get ready to share your organization’s successful healthcare equity improvement initiatives. The 2023 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity will accept applications starting March 15.
Bernard J. Tyson, the late CEO and chair of Kaiser Permanente, worked tirelessly to address the healthcare disparities that plague the U.S. healthcare system. Each year, The Joint Commission, in partnership with Kaiser Permanente, recognizes a healthcare organization for an intervention that led to a measurable and sustained reduction in at least one healthcare disparity.
Organizations are encouraged to start compiling the information needed to complete the application (including baseline, improvement and sustainment data) for their applications now. The 2023 application preview and eligibility criteria, an application tip sheet, as well as the 2022 awardee applications from NYC Health + Hospitals and Parkland Health, are available on the Tyson Award webpage to help you prepare.
All types of healthcare organizations that directly deliver healthcare and have addressed disparities for any vulnerable population, including but not limited to race/ethnicity, gender, sexual orientation, or socioeconomic status, may apply. In their application, organizations must provide data demonstrating how they have improved a disparity.
March 01, 2023
A new episode has launched in a special Take 5 podcast series interviewing the 2022 John M. Eisenberg Patient Safety and Quality Award recipients.
The third episode featured a conversation with Parkland Health’s Marjorie Quint-Bouzid, Senior Vice President of Nursing, Women and Infant’s Specialty Health, and David B. Nelson, Chief, Division of Maternal-Fetal Medicine, Associate Professor, Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center.
Parkland Health is the recipient of the 2022 Eisenberg Award for innovation in patient safety and quality at the local level for its Extending Maternal Care After Pregnancy program that provides access to care for 12 months after birth for women with the highest social needs — as well as limited access to physical clinic locations.
The Eisenberg Awards recognize major achievements to improve patient safety and healthcare 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 first episode featured a conversation with the national winner, North American Partners in Anesthesia (NAPA). The second episode was with individual award recipient Dr. Jason S. Adelman.
Listen to the podcast. [12:51]
March 01, 2023
Updated Accelerate PI™ Dashboard Reports are available for hospitals (HAP), critical access hospitals (CAH), ambulatory surgery centers (ASC), and nursing care centers (NCC) to provide performance measurement data on a select subset of quality measures.
The ASC reports contain data through the fourth quarter of 2021. The HAP-Other and CAH-Other reports contain data through the first quarter of 2022. The refreshed NCC reports contain data through the second quarter of 2022.
Data in the reports comes from the Centers for Medicare and Medicaid Services’ Compare website. The reports are intended to be a springboard for conversations on performance measures and quality improvement during the survey process, as well as a guide to support an organization’s quality journey.
These refreshed dashboard reports do not include ORYX data, as 2021 ORYX data is anticipated to be released in the second quarter of the year.
Reports are located under the “Resources and Tools” menu below the DASH heading in Joint Commission Connect®.
March 01, 2023
- Dateline @ TJC — One Catastrophic Error Led to a Career Preventing Wrong Patient Ordering Errors and Improving Health IT Safety: Dr. Jason S. Adelman penned this blog about his career as a hospitalist and how he was motivated to pursue patient safety after witnessing the sometimes-catastrophic medical errors that occur in the hospital environment. He was recently honored with the 2022 John M. Eisenberg Patient Safety and Quality Award for Individual Achievement for his extensive contributions to the field.
- Dateline @ TJC — Anesthesia Risk Alerts: A Novel Approach to Mitigating Risk in the OR: North American Partners in Anesthesia (NAPA) was recently honored with the 2022 John M. Eisenberg Patient Safety and Quality Awards National Level Innovation for its Anesthesia Risk Alerts (ARA) program. This effective protocol, implemented under NAPA’s Patient Safety Organization (PSO), provides anesthesia clinicians with novel mitigation strategies to better manage five high-risk clinical scenarios in the perioperative setting, writes NAPA’s Leo Penzi, MD, Chief Medical Officer; Julie Marhalik-Helms, BSN, RN, Vice President, Quality Improvement; and Brent Lee, MD, MPH, FASA, Director, Clinical Excellence and Performance Improvement.
- Improvement Insights — Mobile Application Improves Efficiency of Hand Hygiene Audits: A tool tutorial, published in the February 2023 issue of The Joint Commission Journal on Quality and Patient Safety, details an organization’s identification and implementation of a free mobile application to collect hand hygiene audits, writes Lesley Martinez, MPH, CPH, CIC, Infection Preventionist, Driscoll Children’s Hospital.