Joint Commission Online - Oct. 6, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
October 06, 2021
It is undeniable that racism is a patient safety issue. The Joint Commission has standards to guide its accredited and certified organizations to help ensure that all people receive care that is free from discrimination.
Speak Up™ Against Discrimination, a new patient safety campaign from The Joint Commission, focuses on what rights patients have and what they can do if they feel they are being discriminated against and receiving substandard care.
These educational resources include:
- An infographic poster/flyer in three sizes (8.5x11, 11x17 and 24x36).
- An animated video to incorporate in health care facilities.
- A distribution guide with recommendations on how health care organizations can use and provide the materials for patients and their families, caregivers, and advocates.
The infographic and video are available in both English and Spanish.
Launched in 2002, the award-winning Speak Up™ program has been used in more than 70 countries. It encourages patients to be their own advocates and to:
- Speak up
- Pay attention
- Educate yourself
- Advocates (family members and friends) can help
- Know about your new medicine
- Use a quality health care organization
- Participate in all decisions about your care
October 06, 2021
The Joint Commission has begun utilizing a hybrid survey approach with a document review surveyor (DRS). This approach has been approved by the Centers for Medicare and Medicaid during the public health emergency. The Joint Commission is currently utilizing the hybrid approach during deemed hospital reaccreditation surveys meeting eligibility criteria — primary of which is a fully electronic health record.
The hybrid approach consists of a Joint Commission surveyor working remotely to review patient records, documents, and human resources and credentialing files while the remaining members of the organization’s survey team are onsite. The survey team will need use of either Zoom or Microsoft Teams for the hybrid approach.
The remote surveyor’s primary responsibility will be to review closed patient records through the shared screen function, such as:
- Transfers (higher and lower levels of care)
- Death records, including autopsies and organ donation
- Patients with grievances with grievance policy application
- Patients with care provided by a contracted service so evaluation of contracted services can be performed
- Patients with critical tests
- Patients with blood transfusions
Documents also may need to be reviewed by the remote surveyor. Those documents will be uploaded into a secure SharePoint site and deleted after the survey. The remote surveyor will ask for names of individuals who will need access to SharePoint to upload the requested documents. Examples of documents that may be requested are:
- Medical Staff bylaws and rules and regulations
- Pharmacy Sterile Compounding Room Reports
- Pharmacy Hood Certifications (may include Pharmacy staff competencies)
- Infection Control Plan and Evaluation
- Organ Donation Policies
- Autopsy Policy
- Agreement with outside blood supplier
- Agreement with organ/tissue procurement organizations
Organizations should plan to have a scribe and another staff member present who can easily navigate the electronic health record and has access to all record components. Questions on the hybrid approach can be directed to the organization’s designated account executive.
October 06, 2021
- Leading Hospital Improvement — Reuniting Families After a Disaster: Recent unforeseen disasters, including the tragic collapse of a 13-story condo building in Surfside, Miami, and Hurricane Irma, underscore the importance of having a family reunification plan. Following the condo collapse, scenes at the ED became quite chaotic when victims appeared without identification and family members congregated to search for their loved ones. Family members expected answers from staff who were also handling unconscious patients. Historically, hospitals have naturally functioned as the congregating place in a community after a disaster, writes Jim Kendig, Field Director.
- Ambulatory Buzz — Three Reasons Why You Should Attend The Joint Commission Virtual Ambulatory Care Conference: The annual Ambulatory Health Care Conference is just around the corner. It is a three half-day event, scheduled for Nov. 3-5. The conference will be a live virtual educational program. This year’s theme is “Navigating Ambulatory Health Care in Uncertain Times.”