Joint Commission Online - March 10, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
March 10, 2021
Over the last nine months, traditional onsite survey activity has been delayed or interrupted due to the restrictions and strain on the health care system caused by COVID-19. During the past few months, The Joint Commission’s account executives have reached out to organizations to determine their readiness for survey. This return to unannounced surveys does not apply to freestanding Behavioral Health Care and Human Services facilities or Disease-Specific Care and Health Care Staffing Certification programs.
As COVID-19 incidence and caseloads across the country are decreasing, beginning March 15, 2021, The Joint Commission will return to its usual procedures prior to the pandemic. Organizations will no longer be receiving a phone call or email from their account executive when it has been determined the area is low risk for The Joint Commission’s accreditation survey team to visit. All available resources will be utilized to conduct onsite, unannounced accreditation surveys.
Organizations should continue to monitor the Notification of Scheduled Events section of their Joint Commission Connect® extranet page for notification on the first day of the unannounced survey. Additionally, the organization’s primary accreditation contact and chief executive officer will continue to receive email notification of the scheduled event on the first day of the unannounced survey.
As a reminder, Joint Commission surveyors are considered essential workers and are following the most up-to-date guidelines from the Centers for Disease Control and Prevention. While the survey team will be onsite, they will continue to:
- Practicing safe physical distancing by limiting the number of individuals in group sessions, minimizing the number of staff who accompany a surveyor or reviewer during tracer activities, and driving in separate vehicles (or, for surveyors and reviewers, their own vehicles) to offsite locations or home visits.
- Wearing personal protective equipment by requiring Joint Commission surveyors and reviewers to wear masks and asking that health care organizations provide masks and/or other personal protective equipment to surveyors and reviewers.
- Utilizing enhanced technology to support physical distancing, such as: using screen sharing or projection to review electronic medical records and interview care recipients or staff; and incorporating audio/video conference calls to safely expand the number of meeting attendees.
The Joint Commission will continue to work with the Centers for Medicare and Medicaid Services (CMS) as an accrediting organization with deeming authority to conduct Medicare surveys by prioritizing organizations with accreditation due dates that are past due. An organization’s existing accreditation remains in effect until a new survey takes place and a new accreditation decision has been rendered.
If an onsite survey is not possible in an organization’s area, an account executive will contact the organization to determine whether the survey event can be performed offsite/virtually, with an onsite evaluation taking place for those that meet the follow-up requirement. If there are extenuating circumstances that pose a significant challenge to the organization’s ability to participate in a survey, organizations are asked to contact their account executive.
March 10, 2021
Many patients are not seeking preventative care because of fear of being exposed to COVID-19 — potentially placing their health in jeopardy.
A new issue of Quick Safety — “Issue 58: Keeping patients on track with preventative care during pandemic” — examines this problem, while including safety strategies and actions health care organizations can use to encourage their patients to not delay seeking care or treatment.
Data over the past year has shown that an estimated 40.9% of adults in the U.S. have avoided medical care during the pandemic because of concerns about COVID-19. This includes 12.0% who avoided urgent or emergency care, and 31.5% who avoided routine care. Health-related screenings also are down, with breast cancer screenings down 89.2% and colorectal cancer screenings down 84.5%.
Read Quick Safety.
March 10, 2021
The Joint Commission and Kaiser Permanente have established the Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity — an annual award to recognize health care organizations and their partners that achieved measurable, sustained reductions in health care disparities. Applications will be accepted from May 17 to July 5.
The award honors the memory of Bernard J. Tyson, the late chairman and chief executive officer of Kaiser Permanente, who worked tirelessly to remedy the health care disparities that plague the U.S. health care system and our society more broadly.
Organizations of all types that directly deliver health care are encouraged to apply for the award, regardless of their care setting. To be considered, the applicant must have addressed disparities affecting vulnerable populations.
The Joint Commission and Kaiser Permanente hope that the award will inspire organizations to launch projects to address health care disparities and provide concrete examples for others to emulate. Applicants are encouraged to submit proposals that describe the implementation of a well-defined intervention and that resulted in a measurable, sustained reduction in disparities. Applications that do not report measurable improvements will not be considered.
More information will be provided in Joint Commission Online in the coming weeks.
March 10, 2021
The Joint Commission has made standards and glossary changes for both deemed-status hospice organizations and deemed-status home health agencies to match more closely with the Centers for Medicare and Medicaid Services’ (CMS) Conditions of Participation (CoPs). The changes for hospices were made in response to The Joint Commission's application for continued deeming authority, and the changes for home health organizations were made in response to revisions to the CMS CoPs.
The changes go into effect on March 14.
Last year, CMS released two final rules that updated requirements for home health agencies:
- Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
- Home Health Prospective Payment System Rate Update, Home Health Quality Reporting Program Requirements, and Home Infusion Therapy Services and Supplier Enrollment Requirements; and Home Health Value-Based Purchasing Model Data Submission Requirements
CMS will now permit an allowed practitioner to perform many duties previously granted only to physicians in its regulations. An allowed practitioner includes a:
- Clinical nurse specialist
- Nurse practitioner
- Physician assistant
Though CMS has made this change to the CoP, state laws may have additional restrictions or requirements. The Joint Commission will survey to the highest standard.
March 10, 2021
- Leading Hospital Improvement — Improving Efficiency of Medical Staff Chapter Review for Hospitals: Many hospitals and critical access hospitals asked The Joint Commission to streamline its review of the Medical Staff (MS) chapter during the triennial survey. To address this, a group of physician surveyors worked on a six-month project to help surveyors more efficiently evaluate and score the requirements in the MS chapter. The project resulted in the development of MS chapter templates for surveyors to use during the triennial survey, writes Patricia Buckberg, DNP, PNP, CNS, BA, RN, Field Director.
- Improvement Insights — How to Let Clinicians Know They Missed A Diagnosis: In the February 2021 issue of The Joint Commission Journal on Quality and Patient Safety, we describe findings from a pilot program to provide frontline clinicians feedback on their cases that involved missed opportunities to make correct and timely diagnoses, writes Divvy K. Upadhyay, MD, MPH, Ashley N.D. Meyer, PhD, and Hardeep Singh, MD, MPH.