Joint Commission Online - Sept. 29, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
September 29, 2021
New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. The Joint Commission has reviewed 569 sentinel events from Jan. 1 through June 30, 2021 with the majority of these — 91% (516) — being voluntarily self-reported by an accredited or certified entity. The remaining 53 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization.
Despite the continued challenges presented by COVID-19, the number of sentinel events remained comparable to previous years.
“COVID continues to impact patient care and health care operations in myriad ways,” stated Raji Thomas, DNP, MBA, CPHQ, CPPS, Director of the Office of Quality and Patient Safety (OQPS), The Joint Commission. “However, we have seen the unrelenting resilience of health care organizations and their commitment to patient safety and quality of care. The emergence of newer variants of COVID pose additional challenges to organizations, including difficulty ensuring safe staffing and clinician well-being. In the midst of this pandemic, voluntary sentinel and safety event reporting to the Joint Commission’s OQPS remains the same as before the pandemic, which further indicates that health care organizations are committed to providing safe, quality care.”
Patient safety specialists in OQPS help organizations to conduct a credible and thorough analysis of sentinel events to identify causative factors and implement relevant system solutions to prevent future harm.
“Earlier this year, OQPS introduced user-friendly safety event-specific templates that allow organizations to respond to requests from our office for written responses to safety events in a systematic manner,” Thomas stated. “These tools ensure that the specifics provided in the response are relevant to the type of event they are evaluating. Organizations have provided valuable positive feedback on these new templates, and we are committed to adding more tools to the repository of templates. As we develop and implement new tools, we will continue to seek input from health care organizations to ensure their value and usefulness.”
The summary data of sentinel event statistics for the first half of 2021 covers 16,695 incidents reported from 1995 through June 30, 2021. These events affected a total of 14,105 patients (as multiple patients may be affected by a single event):
- 47% of sentinel events led to a patient’s death.
- 24% led to unexpected additional care.
- 11% led to severe temporary harm.
- 6% led to permanent loss of function.
- 2% led to permanent harm.
- 2% led to a psychological impact.
An estimated fewer than 2% of all sentinel events are reported to The Joint Commission. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.
September 29, 2021
A new study in the October issue of The Joint Commission Journal on Quality and Patient Safety — “Sustainability Initiatives in the Operating Room,” by Samantha Wu and Elizabeth Cerceo, MD, FACP, FHM, at Cooper University Healthcare, Camden, New Jersey — conducted a narrative review to identify evidence-based green practices and sustainability strategies to reduce waste in the operating room (OR).
The strategies identified include:
- Forming an OR committee or a hospital Green Team dedicated to environmentally sustainable initiatives.
- Changing the supply chain with preferences for reusable devices, effective recycling, repurposing instruments and donating items to divert waste away from landfills.
- Reducing unnecessary packaging and instruments to eliminate excess in the waste stream.
- Curtailing energy and water usage to improve cost and environmental savings.
- Transitioning away from certain inhaled anesthetics to minimize greenhouse gas impact.
- Educating staff across all levels of the health care system to drive and maintain change.
Also featured in the October issue are:
- Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide (University of Massachusetts – Boston Center for Survey Research, Boston)
- Implementation of Collection of Patients’ Disability Status by Centralized Scheduling (University of Colorado Health System, Aurora, Colorado)
- Persistent Gaps in the Care of Patients with Disability: Laws Are Necessary but Not Sufficient (editorial)
- Workplace Violence Against Physicians Treating COVID-19 Patients in Peru: A Cross-Sectional Study (Universidad Católica de Santa María, Peru)
- Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility (U.S. Department of Veterans Affairs Boston Healthcare System, Boston)
- Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU (Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville)
- Patient Safety and Ethical Implications of Health Care Sick Leave Policies in the Pandemic Era (commentary)
Access the Journal.
September 29, 2021
After implementation of The Joint Commission's associated changes to the Centers for Medicare & Medicaid Services' (CMS) Interoperability and Patient Access final rule from June 2020, The Joint Commission revised one of its Rights and Responsibilities of the Individual (RI) requirements.
The change — which is now in effect for deemed hospitals and critical access hospitals accredited by The Joint Commission — is at RI.01.02.01, element of performance (EP) 1 to better reflect CMS's Conditions of Participation. The revisions will go into effect for non-deemed hospitals on April 1, 2022.
The revisions address that notifications go beyond just patient admissions and that they also include discharges and transfers. Note 1 for deemed hospitals and critical access hospitals clarifies that patients have the right to determine whether they want this information shared with their primary care providers or provider entities and that organizations need to have a way to inform patients of this automatic notification process. All relevant state or federal laws and regulations related to the privacy of patient information still apply.
View the prepublication standards.
September 29, 2021
- Dateline @ TJC — Syphilis in Infants Reaching Epidemic Proportions: This week, the Centers for Disease Control and Prevention (CDC) published preliminary data showing nearly 2,100 cases of newborn, or congenital, syphilis in 2020. Rates are increasing across the country in this disease that was considered eliminated 20 years ago, writes Mark Pelletier, MSN, RN, Chief Operating Officer and Chief Nursing Officer.
- Leading Hospital Improvement — Committing to Suicide Prevention During a Pandemic: In 2020, COVID-19 was listed as the third-leading cause of death, dropping suicide to the 11th overall cause of death. However, this figure is deceiving as most mental health experts have attested to a probable increase in suicides due to social isolation, lockdowns, additional anxiety over health or finances, and other pandemic-related reasons, writes Stacey Paul, Project Director, Clinical; Gina Malfeo-Martin, Associate Director, Standards Interpretation; Scott Williams, Director, Department of Research; Suellen Daum, Patient Safety Specialist, Office of Quality and Patient Safety; and Kenneth Hebert, Associate Director, Standards Interpretation.
- Improvement Insights — Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU: Quality improvement (QI) initiatives can improve patient outcomes but tackling a QI project can be daunting. The task is even larger when scaling up and coordinating multiple teams and projects within a unit, clinic, or organization. In 2015, our Neonatal Intensive Care Unit (NICU) at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, set a goal to build a program to support our QI teams, writes M. Eva Dye, DNP, APRN, NNP-BC.
September 29, 2021
The Joint Commission’s Director of Corporate Robust Process Improvement® (RPI®) Patty Chappell recently had an editorial published in Quality Progress from the American Society for Quality.
The article, “A Look Back And Ahead At The Joint Commission’s RPI Culture,” details The Joint Commission’s culture of continuous improvement and the accomplishments made throughout the enterprise that have been supported by RPI since the department’s inception 13 years ago.
RPI is a set of strategies, tools, methods, and training programs adopted by the Joint Commission for improving our business processes. Methodologies that shape RPI include Lean Six Sigma, Facilitating Change®, and Advanced Meeting Facilitation. RPI is part of every area of the Joint Commission enterprise, helping improve our processes, products and services, touching areas like information technology, digital marketing, and surveys and reviews.
Through RPI, The Joint Commission helps health care organizations improve patient care. To learn more about how The Joint Commission uses RPI every day, read the article from Quality Progress.