Effective immediately, The Joint Commission revised its requirements regarding the timeframe to evaluate a licensed practitioner’s ability to provide care, treatment, and services from two years to three years, unless law and regulation require a shorter period. This change was made to better align with the standard practice of evaluating licensed practitioners every three years.
These revisions apply to the following accreditation programs:
- Hospital
- Critical Access Hospital
- Ambulatory Health Care
- Behavioral Health Care and Human Services
- Nursing Care Centers
- Office-Based Surgery
View the prepublication standards or see the December 2022 issue of Perspectives for more information. Questions may be directed to the Department of Standards and Survey Methods.
The Joint Commission and the American Heart Association (AHA) have finalized the process for an automatic data transfer from the AHA’s Get with the Guidelines® - Coronary Artery Disease (GWTG-CAD) registry directly into the Certification Measure Information Process (CMIP) tool for Acute Heart Attack Ready (AHAR) and Primary Heart Attack Center (PHAC) programs. This process is available for all AHAR and PHAC programs to utilize.
For the data transfer to take place with The Joint Commission, an organization needs to ensure their contract with AHA permits the sharing of data by contacting certification@heart.org. Manual data entry should continue until confirmation of when the automatic data transfer will begin. As a reminder, organizations that allow the automatic data transfer from the registry into CMIP should check their data quarterly to ensure data accuracy.
Additionally, with the launch of Comprehensive Heart Attack Center (CHAC) program in 2022, there is a plan to expand this automatic data transfer to the CHAC program in 2023. More details to come on when this will be available for the CHAC program.
The data transfer schedule is as follows:
- Quarter 1 — June 15
- Quarter 2 — Sept. 15
- Quarter 3 — Dec. 15
- Quarter 4 — March 15
Please finalize data by 11:59 p.m. ET the night before each data transfer date.
The Joint Commission updated its 2023 ORYX® performance measure reporting requirements, effective Jan. 1, 2023. Key updates affecting Joint Commission-accredited hospitals and critical access hospitals include:
- Three new electronic clinical quality measures (eCQMs) to meet ORYX eCQMs submission requirements:
- Hospital Harm — Severe Hypoglycemia Measure (HH-01)
- Hospital Harm — Severe Hyperglycemia Measure (HH-02)
- ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (OP-40)
- Hospitals that are required or elect to submit eCQMs must provide eCQM data on a minimum of four eCQMs for all four quarters, starting with 2023 discharges.
- The Joint Commission will retire chart-abstracted Hospital-Based Inpatient Psychiatric Services (HBIPS-1) data.
The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) will include Perinatal Care eCQMs Cesarean Birth (PC-02) and Severe Obstetric Complications (PC-07) as optional measures for the 2023 measure collection year. View the specifications for the new eCQMs and the perinatal eCQMs on the Electronic Clinical Quality Improvement (eCQI) Resource Center website.
Learn more. Questions may be directed to the ORYX Help Line at HCOOryx@jointcommission.org.
Refreshed Accelerate PI™ Dashboard Reports are available for primary (PSC) and comprehensive stroke centers (CSC) 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 second quarter of 2022.
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.
NYC Health + Hospitals and Texas Children’s Pavilion for Women will be recognized as the co-awardees of the 2022 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity in a virtual ceremony at 10:30 a.m. CT on Nov. 29, 2022.
The award, named for late Kaiser Permanente Chairman and CEO and champion for healthcare equity Bernard J. Tyson, recognizes healthcare organizations and their partners that led initiatives that achieved a measurable, sustained reduction in one or more healthcare disparities.
NYC Health + Hospitals is recognized for its work that improved healthcare access among those who have historically had difficulty accessing healthcare, including the undocumented, under a citywide program called NYC Care. Their initiative is, “Making Healthcare a Human Right: Expanding Access to Healthcare to Undocumented New Yorkers.”
Texas Children’s Pavilion for Women is recognized for its initiative, “Quality Improvement Initiatives on Decreasing Racial Disparities in Maternal Morbidity,” under which they improved severe maternal morbidity due to hemorrhage among Black women by nearly 14%.
To learn more about these impressive achievements, join The Joint Commission and Kaiser Permanente in celebrating NYC Health + Hospitals and Texas Children’s Pavilion for Women. Register to attend.
U.S. Antibiotic Awareness Week, which is put on annually by the Centers for Disease Control and Prevention (CDC), began on Nov. 18 and ends on Nov. 24. This year’s theme is, “Prevention Puts a ‘Pause’ on Antimicrobial Resistance.”
The Joint Commission takes antimicrobial stewardship seriously, as there are at least 2.8 million antibiotic-resistance infections each year — contributing to 35,000 deaths, according to the CDC. Those numbers increase when factoring in Clostridioides difficile (3 million infections, 48,000 deaths). This makes optimizing the use of antibiotics a patient safety priority, with stewardship programs playing a critical role in supporting appropriate prescribing practices and reducing antibiotic resistance.
Effective Jan. 1, 2023, The Joint Commission is implementing new and revised antibiotic stewardship requirements for all hospitals and critical access hospitals to align with federal regulations and current recommendations from scientific and professional organizations. Twelve new and revised elements of performance (EPs) will be included in the Medication Management (MM) chapter and expand upon current expectations for antibiotic stewardship programs in the hospital setting.
The Joint Commission also has additional resources, such as:
- Antimicrobial Stewardship webpage
- Speak Up™: Antibiotics: Know the Facts
- Standards FAQ
- R3 Report, Issue 35: New and Revised Requirements for Antibiotic Stewardship
- Complimentary on-demand webinar
A Leading Hospital Improvement blog also was published on safe antibiotic use — “Safe Antibiotic Use: A Patient Safety Priority,” by Christina Cordero, PhD, MPH, Project Director, Healthcare Standards Development — highlighting the week’s importance.