Joint Commission Online - Nov. 9, 2022
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
November 09, 2022
The Joint Commission and Kaiser Permanente announced NYC Health + Hospitals, New York, and Texas Children’s Pavilion for Women, Houston, as co-awardees of the 2022 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity.
The award is named for late Kaiser Permanente Chairman and CEO Bernard J. Tyson, who was a champion for healthcare equity. The award 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 initiative, “Making Healthcare a Human Right: Expanding Access to Healthcare to Undocumented New Yorkers.” In 2019, NYC Health + Hospitals, the largest municipal healthcare system in the nation, launched NYC Care, a citywide healthcare access program for New Yorkers who are ineligible for or cannot afford health insurance, including undocumented individuals. The city estimates that there are more than 400,000 undocumented immigrants who are uninsured and are more likely to forego essential primary and preventive care.
- Enrolled more than 100,000 members, who made 264,976 primary care visits and 227,481 specialty visits by February 2022.
- Improved clinical outcomes: After six months of enrollment, 51% of enrollees with diabetes had improved hemoglobin A1C, and 68% of enrollees with hypertension had improved blood pressure.
Texas Children’s Pavilion for Women is recognized for its initiative, “Quality Improvement Initiatives on Decreasing Racial Disparities in Maternal Morbidity.” In March 2019, Texas Children’s Pavilion for Women began stratifying data by race and ethnicity and determined that non-Hispanic Black women had the highest rates of severe maternal morbidity from hemorrhage (SMM-H). A gap analysis identified interventions to reduce morbidity from hemorrhage for all pregnant patients.
Prior to implementation of the identified strategies, there was a statistically significant difference between Black and white women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138), and the rate of SMM-H in Black women decreased significantly from 45.5% to 31.6% (p=0.011).
The awardees will be recognized in a public, virtual ceremony on Tuesday, Nov. 29, from 10:30-11:30 a.m. CT. Register to attend the ceremony.
November 09, 2022
Dr. Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, President and CEO of The Joint Commission, was interviewed for a special report from STAT News on pressure growing in the healthcare industry to reduce its climate pollution.
Decarbonization is one of The Joint Commission’s top priorities, having joined the Biden Administration’s Health Sector Climate Pledge to reduce the carbon contributions emanating from the healthcare sector and to help make healthcare organizations more resilient to the effects of climate change. The Joint Commission has pledged to reduce emissions by a minimum of 50% by 2030 and achieve net zero emissions by 2050.
In the STAT report, Dr. Perlin said climate change is “a health equity issue, because the same individuals in communities with disenfranchisement from health care are also the least able to compensate for the effects of climate change.”
Dr. Perlin also told STAT The Joint Commission is convening a technical advisory panel with nationally recognized experts to evaluate the inclusion of climate-related standards. The climate standards may be introduced in 2023, and they would be “directional rather than prescriptive,” he said in the report.
Read the special report, “‘If I were a hospital, I’d be reading the tea leaves’: Pressures grow on the health care industry to reduce its climate pollution.”
November 09, 2022
Reducing diagnostic errors (such as missed, delayed or wrong diagnoses) is a major challenge for most healthcare organizations. The complexity of defining and measuring diagnostic errors poses challenges in developing solutions compared to other types of patient safety concerns. A need exists for pragmatic guidance for healthcare organizations to address diagnostic errors.
A study in the November 2022 issue of The Joint Commission Journal on Quality and Patient Safety, “Developing the Safer Dx Checklist of Ten Safety Recommendations for Healthcare Organizations to Address Diagnostic Errors,” identified potential practices based on literature reviews, reports by national and international organizations, interviews with quality/safety leaders and input from additional experts.
After preparing an initial list of practices, the researchers conducted a Delphi expert panel, followed by an online expert panel, to prioritize 10 practices. The prioritization process considered impact on patient safety and feasibility of practice implementation with a one- to three-year time frame. The Top 10 practices were developed into a checklist paired with implementation guidance, which was followed by cognitive walkthroughs of the checklist for a face-validity check with end users. Data from each study step was analyzed to look for themes related to prioritization or checklist implementation.
A total of 71 practices for prioritization were identified through the Delphi panel of 28 experts; 65% of participants reached consensus on 28 practices. The multidisciplinary panel of 10 experts helped prioritize and refine the Top 10 practices, which highlighted the following focus areas to help healthcare organizations address diagnostic error:
- Organizational leadership builds a “board-to-bedside” accountability framework.
- A just culture and psychologically safe environment for diagnostic safety.
- Creation of feedback loops to increase information flow.
- Multidisciplinary perspectives, including cognitive science and human factors, in analysis of diagnostic safety events.
- Patient and family feedback to identify and understand diagnostic safety concerns.
- Patient review of their health records and mechanisms in place to help patients understand, interpret, and/or act upon diagnostic information.
- Prioritization of equity in diagnostic safety efforts by segmenting data to understand root causes and implementing strategies to address and narrow equity gaps.
- Standardized systems and processes to encourage direct, collaborative interactions between treating clinical teams and diagnostic specialties.
- Standardized systems and processes to ensure reliable communication of diagnostic information between care providers and with patients and families during handoffs and transitions.
- Standardized systems and processes to close the loop on communication and follow up on abnormal test results and referrals.
The study was led by Hardeep Singh, MD, MPH, a professor of medicine at Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston.
Also featured in the November issue:
- The Journey to Achieve Healthcare Equity: The New Joint Commission Accreditation Standard and Call for Papers (editorial)
- Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity (Stanford University School of Medicine, California)
- Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative (cross-sectional analysis of data for 220 emergency departments)
- Mi Plan: Using a Pediatric-Based Community Health Worker Model to Facilitate Obtainment of Contraceptives Among Latino Immigrant Parents with Contraceptive Needs (Johns Hopkins School of Medicine, Baltimore)
- An Asset-Based Quality Improvement Tool for Healthcare Organizations: Cultivating Organization-Wide Quality Improvement and Healthcare Professional Engagement (Banner Health, Gilbert, Arizona)
- An Injury Mitigation Program Highlights the Importance of Adhering to Current Infection Control Policies (research note)
- How to Mitigate the Effects of Cognitive Biases During Patient Safety Incident Investigations (commentary)
- High Primary Cesarean Section Rates: Strategies for Improvement (commentary)
Access the Journal.
November 09, 2022
Refreshed Accelerate PI™ Dashboard Reports are available for accredited hospitals and critical access hospitals to provide updated performance measurement data on a select subset of quality measures. The refreshed “Other” reports contain data through the third quarter of 2021.
Data in the reports comes from the Centers for Medicare & Medicaid Service (CMS) Compare website. The dashboards, available to both Joint Commission surveyors and accredited hospitals and critical access hospitals, are intended to be a springboard for conversations on data, performance measures, and quality improvement during the survey process. Reports are located under the Resources and Tools menu below the DASH heading in Joint Commission Connect®.
November 09, 2022
A free, 90-minute Expert to Expert webinar on the 2023 annual update for perinatal care (PC) electronic clinical quality measures (eCQMs) PC-02, PC-05 and PC-07 is scheduled for Dec. 6 at 11 a.m. PT / noon MT / 1 p.m. CT / 2 p.m. ET.
The Expert to Expert webinar series provides a deep-dive into measure intent, logic, and other clinical/technical aspects of eCQMs to assist hospitals to improve data use for quality improvement. The webinar series incorporates content from The Joint Commission, Centers for Medicare & Medicaid Services (CMS), and Mathematica. Common questions from JIRA and other sources will be addressed.
The webinar aims to help participants:
- Navigate the eCQI Resource Center website to locate measure specifications, value sets, measure flow diagrams and technical release notes.
- Apply concepts learned about the logic and intent for the PC-02, PC-05 and PC-07 eCQMs.
- Prepare to implement the PC-02, PC-05 and PC-07 eCQMs for the 2023 eCQM reporting period.
- Identify common issues and questions regarding the PC eCQMs.
To earn 1.5 CE credit, participants must:
- Individually register for the webinar.
- Attend the entire live broadcast. Only those listening to the live session will be eligible to receive credit.
- Complete a post-program evaluation/attestation. The program evaluation/attestation link will be sent to your registered email after the webinar.
Program slides will be available for download from within the webinar platform approximately one hour before the broadcast begins. Also, the recording and presentation slides will be available on The Joint Commission website within several weeks of the broadcast.