Joint Commission Online - March 30, 2022
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
March 30, 2022
A new Direct Data Submission Platform (DDSP) is anticipated to be available in the second half of 2022.
The Joint Commission has been working to develop in-house capability for performance measurement data submission. To accelerate this work, The Joint Commission teamed up with Dynamic Health IT (DHIT) to support the development of the new DDSP and electronic clinical quality measure (eCQM) engine.
The DDSP will enable the submission of quality measurement data directly to The Joint Commission from the approximately 3,500 accredited hospitals and critical access hospitals that are required to submit this data to meet accreditation requirements. The DDSP also will provide accredited hospitals with near real-time eCQM performance data.
DHIT will develop the platform underpinning the DDSP and apply its CQMsolution® – an Office of the National Coordinator for Health Information Technology-certified Clinical Quality Language measure engine – to calculate, display and generate eCQMs. The Joint Commission will develop the chart-abstracted measure data collection tool and provide customer support.
Questions may be directed to firstname.lastname@example.org.
March 30, 2022
New Accelerate PI™ Dashboard Reports are available for ambulatory surgery centers (ASCs) and nursing care centers (NCCs) to provide updated performance measurement data on a select subset of quality measures. The refreshed ASC reports contain data through the fourth quarter of 202o. The refreshed NCC reports contain data through the third quarter of 2021.
Data in the reports comes from the Centers for Medicare and Medicaid Services (CMS) 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.
Reports are located under the “Resources and Tools” menu below the DASH heading in Joint Commission Connect®.
March 30, 2022
Attention: Acute Heart Attack Ready (AHAR) and Primary Heart Attack Center (PHAC) certification programs!
The American Heart Association (AHA) provides submission of its Get with the Guidelines® – Coronary Artery Disease measure results, required for AHAR and PHAC certifications, to The Joint Commission's Certification Measure Information Process (CMIP) application upon request.
In order to request this, organizations should contact their AHA quality improvement (QI) manager.
March 30, 2022
Rapid response (RR) systems provide a process for early detection and management of clinically deteriorating patients to prevent out-of-ICU cardiopulmonary arrest (CPA) and mortality. Because evaluations of RR systems traditionally rely on CPA and mortality, rare in children, alternative pragmatic metrics for pediatric RR evaluation are needed.
A report from the April 2022 issue of The Joint Commission Journal on Quality and Patient Safety — “Longitudinal Evaluation of a Pediatric Rapid Response System with Realist Evaluation Framework,” by Darlene E. Acorda, PhD, RN, CNE, CPNP-PC — represents part of ongoing work of a multidisciplinary team led by Aarti Bavare, MD, MPH, at Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas. The team developed a new metric called REACT (Rapid Escalation After Critical Transfer) to review clinical outcomes after RR events to appraise pediatric RR systems and identify improvement opportunities.
The researchers applied the realist evaluation (context-mechanism-outcomes) framework to review significant RRs defined as REACT events, including all with CPA and/or ventilation and/or hemodynamic support instituted within 24 hours after RR. A continuous quality improvement process was employed to identify, debrief and review REACT events to recognize and act on RR mechanistic and contextual deficiencies.
From 2015 to 2019, 5,581 RR events occurred, of which 67.2% were transferred to the ICU, and 24.9% were identified as REACTs. In the first two years, 100% identification and review within three months of 90% of REACTs was accomplished. Findings showed after five years:
- Proportion of REACTs with crisis resource management (CRM) gaps decreased from 62.3% to 26.5%.
- Proportion of REACTs with multiple deficiencies reduced from 72.5% to 23.2%.
- CPAs outside ICUs decreased from 15 to 3 per year.
- The realist evaluation framework facilitated a holistic assessment of an RR system. Review of REACTs yielded useful information to guide systemwide improvement.
Also featured in the April issue are:
- 2021 Bernard J. Tyson Award for Excellence in Pursuit of Healthcare Equity recipient: Prioritizing Child Health: Promoting Adherence to Well-Child Visits in an Urban, Safety-Net Health System During the COVID-19 Pandemic (UMass Memorial Health, Worcester, Massachusetts)
- An Initiative to Improve Performance on a National Transition of Care Measure and to Reduce Readmissions in an Academic Psychiatric Hospital (Yale New Haven Psychiatric Hospital, New Haven, Connecticut)
- Virtual Education for Patient Self-Testing for Warfarin Therapy Is Effective During the COVID-19 Pandemic (University of California, San Francisco)
- Patient Care Extra-Aedificium: The Time is Now (editorial)
- Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure (Kaiser Permanente Southern California, Los Angeles)
- Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication (Brigham and Women’s Hospital, Boston)
- The Joint Commission’s New and Revised Workplace Violence Prevention Standards for Hospitals: A Major Step Forward Toward Improved Quality and Safety (open access commentary)
Access the Journal.
March 30, 2022
- Ambulatory Buzz — 8 Tips for Avoiding Common Pitfalls in Your Ambulatory Surgery Center Survey: It has been a full year since The Joint Commission returned to surveys at full capacity and, as expected, most high-risk findings at ambulatory surgery centers (ASC) are related to infection control, medication management and leadership. My goal today is to offer my perspective on steps accredited organizations can take to avoid a finding in the first place, writes Susan Annicelli, MSN, MS, RN, Field Surveyor.
- Dateline @ TJC — Suicide Risk Screening in Healthcare Organizations: The Joint Commission revised National Patient Safety Goal (NPSG) 15.01.01 to reduce the risk for suicide. This NPSG went into effect on July 1, 2019, for hospitals and behavioral healthcare and human services (BHC) organizations and on July 1, 2020, for critical access hospitals. The revised goal is more specific, instructional, and aligns with current research and recommendations from The Joint Commission’s Technical Advisory Panel. Now that more than two years have passed since implementation of the revised goal, we are able to see how accredited organizations are adapting to the requirements. In this blog series, we will be discussing what our surveyors are identifying in the field in terms of compliance and interpretation of the various elements of performance (EPs) related to suicide prevention, writes Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group, and Stacey Paul, MSN, PMHNP-BC, Project Director, Standards Interpretation Development.
- Dateline @ TJC — Introducing the Physical Environment Department: The Joint Commission’s Engineering Department is made up of experts in facilities operations, biomedical equipment technology, emergency management, environmental safety, and more. Because of the name, our stakeholders, both internal and external, did not have a full understanding of the department’s scope of work. For that reason, in 2022, we established a new name for the department: the Physical Environment Department. In addition, staff who were once called Engineers are now Physical Environment Specialists, writes Herman McKenzie, MBA, CHSP, Director, Physical Environment Department.