Joint Commission Online - May 26, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
May 26, 2021
A new Assisted Living Community (ALC) Accreditation Program has launched to help assisted living organizations deliver consistent and reliable care for residents. Applications will begin to be accepted on July 1.
There are more than 30,000 ALCs in the United States, serving more than 800,000 residents. With growth in recent years, ALCs have been increasingly shifting from a mostly hospitality-based environment to a more health care-focused setting by offering services for medication management, skilled nursing, and dementia care. This shift has highlighted the need for national, consensus-based standards and accreditation.
The Joint Commission’s ALC Accreditation standards were developed with consideration of scientific evidence and best practices, as well as state regulations and Life Safety Codes. Experts in the field of geriatrics, dementia care, rehabilitation, infection control and senior housing were actively engaged in a collaborative effort to design standards that align with quality care delivery and safe practices. In addition to an extensive internal review of the standards by subject matter experts, feedback and expert guidance were received from learning visits, a Technical Advisory Panel (TAP), Standards Review Panel/TAP field review, public field review, and pilot testing.
The standards address:
- Emergency management
- Dementia care
- Medication management
- Provision of care and services
- Process improvement
In addition to the standards, the ALC Accreditation Program requires organizations to track and report on five standardized performance measures:
- Off-label antipsychotic drug use
- Resident falls
- Resident preferences and goals of care
- Advanced care plan/surrogate decision-maker
- Staff stability
“The Joint Commission is pleased to launch a new accreditation program, the first care continuum expansion in more than 20 years,” said Gina Zimmermann, Executive Director, Nursing Care Center and Assisted Living Community Services, The Joint Commission. “We are excited to offer the Assisted Living Community Accreditation Program to help organizations provide a safe living environment for their residents. Accreditation is an important marker to help demonstrate organizations’ commitment to providing safe and quality treatment and services.”
The new standards appear in the March 2021 E-dition® of the Comprehensive Accreditation Manual for Assisted Living Communities. Organizations may view the standards by requesting a free 90-day trial of E-dition.
May 26, 2021
Effective Jan. 1, 2022, editorial revisions will be made to the Care, Treatment, and Services (CTS) chapter of the Behavioral Health Care and Human Services standards.
Several requirements were moved to eliminate repetition and align with the outline at the beginning of the CTS chapter. The CTS standards affected are:
- CTS.02.02.01: Requires organizations to collect assessment data on each individual served.
- CTS.02.02.03: Requires that a complete, accurate assessment drives the identification and delivery of care, treatment, or services required by the individual served.
- CTS.03.01.01: Requires an organization to base its planned care, treatment, or services on the needs, strengths, preferences, and goals of the individual served.
- CTS.03.01.03: Requires that an organization develop a plan for care, treatment, or services that reflect the individual’s assessed needs, strengths, preferences, and goals.
These revisions do not change the requirements, but rather have been made to help the chapter flow and to provide clarity. (Contact: Stacey Paul, email@example.com)
May 26, 2021
A new study in the June 2021 issue of The Joint Commission Journal on Quality and Patient Safety implemented a non-pharmacologic sleep hygiene bundle intervention to improve patients’ sleep.
The study — “A Sleep Hygiene Intervention to Improve Sleep Quality for Hospitalized Patients” — used the Richards-Campbell Sleep Questionnaire (RCSQ) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question addressing quietness at night to measure self-reported sleep for patients on a general medicine unit. The study did not seek to decrease the frequency of medical interventions overnight, focusing only on sleep hygiene.
The sleep hygiene bundle is composed of a short script with sleep hygiene prompts, such as whether patients would like the shades closed or the lights turned off, as well as a sleep package including an eye mask, ear plugs, lavender scent pad and noncaffeinated tea. Relaxing music was played at bedtime, and signs promoting the importance of quietness at night were placed around the unit. Front-line champions were identified to aid with the implementation.
A total of 931 patients received the sleep intervention. In a sample of surveyed patients, the RCSQ global score increased from 6.0 to 6.2 from the pre- to post-intervention periods, as well as in three of the five individual survey components. Additionally, the HCAHPS “quietness at night” score increased from 34.1% to 42.5% from the pre- to post-intervention periods.
The researchers conclude that a nonpharmacologic sleep hygiene protocol, paired with provider education and use of champions, were associated with modest improvements in patients’ perceived sleep.
Also featured in the June issue are:
- Prescribing Naloxone to High-Risk Patients in the Emergency Department: Is it Enough? (editorial)
- Developing and Implementing a Dedicated Prone Positioning Team for Mechanically Ventilated ARDS Patients During the COVID-19 Crisis (New York Presbyterian Hospital)
- Use of a Novel Patient-Flow Model to Optimize Hospital Bed Capacity for Medical Patients (Northwestern Memorial Hospital, Chicago)
- Increasing Naloxone Prescribing in the Emergency Department Through Education and Electronic Medical Record Work-Aids (Duke University Hospital, Durham, North Carolina)
- Assessing Patients’ Experiences with Medical Injury Reconciliation Processes: Item Generation for a Novel Survey Questionnaire (University of New South Wales, Sydney, Australia)
- Development of a Novel and Scalable Simulation-Based Teamwork Training Model Using Within-Group Debriefing of Observed Video Simulation (Brigham & Women’s Hospital, Boston)
- Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS (The Joint Commission, Oakbrook Terrace, Illinois)
Access the Journal.
May 26, 2021
- Dateline @ TJC — Bernard J. Tyson Award: Calling Organizations Impacting Health Equity: In a new award program, The Joint Commission and Kaiser Permanente aim to recognize organizations that have addressed health care disparities. The Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity will acknowledge health care organizations and their partners that led initiatives that achieved a measurable, sustained reduction in one or more health care disparities, writes Ana Pujols McKee, MD, Executive Vice President, Chief Medical Officer, and Chief Diversity, Equity and Inclusion Officer.
- Ambulatory Buzz — Staff Safety in Ambulatory Surgery Centers: There are few areas where precision and accuracy matter more than within an ambulatory surgery center (ASC). It is difficult to identify another location that is under such intense time pressure and scrutiny. Surgical center procedures must be correct and time efficient. When patients enter an ASC, they are likely amid hundreds of thousands of dollars of life saving equipment, medications and instrumentation, writes Elizabeth Even, RN, Associate Director, Standards Interpretation.
- Quality in Nursing Center Care — Join Us for a Virtual Event on the New Assisted Living Community Accreditation Program: The Joint Commission is thrilled to invite you to participate in a June 8 virtual event, Distinction in Quality: New Accreditation for Assisted Living Communities, writes Gina Zimmermann, Executive Director, Nursing Care Center and Assisted Living Community Services.