The organization identified the top. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. Reducing the risk of hospital-acquired infections was the most challenging compliance standard for hospitals in 2021, according to The Joint Commission. Herman McKenzie is currently the director, Department of Engineering in the Standards Interpretation Group at The Joint Commission. All Rights Reserved. Please contact us soon! In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. We would encourage all readers to carefully review this months consistent interpretation column with hospital quality, infection prevention, nursing, and education staff to assess your own risks on these critically important issues. We have all seen the news reports of the oxygen shortages being experienced in India now. Reduce the risk for. The third high risk EP is IC.02.01.01, EP 1, which is a very basic requirement to implement your infection prevention practices. They identify six elements of performance observed by their surveyors that to have the potential to either negatively affect patient care or create risk: HR.01.05.03, EP 1; HR.01.06. The Joint Commission is a registered trademark of the Joint Commission enterprise. Behavioral Health Care and Human Services. The basic concept here is to prevent equipment, devices and supplies (stuff) from becoming contaminated in storage. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The Top 10 most frequently reported sentinel events in 2021 were: Fall 485 Delay in treatment 97 Unintended retention of a foreign object 97 Wrong-site surgery 85 Suicide 79 Self-harm 45 Fire 38 Medication management 35 Assault 34 Clinical alarm response 22 This particular issue looks to be pretty evenly split between high and moderate risk levels. The bad news is we see some slippage in end of April data with more red and yellow counties, and fewer green counties. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. We help you measure, assess and improve your performance. MM.01.01.03: The practice safely manages high-alert and hazardous medications. Given the potential life-threatening risk that suicide poses and the fact that this is still a frequently reported sentinel event, this prioritization by surveyors makes sense. The key to success would appear to be not letting budgets or staffing shortages get in the way of ensuring that each patient identified to be at high risk to have the required 1:1 supervision. The Joint Commission survey reports four of the top-10 findings were related to creating and following a complete and accurate home health plan of care; three were related to infection control; and the remaining findings related to not maintaining a complete, reconciled and accurate medication list. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. These events affected a total of 14,731 patients (as multiple patients may be affected by a single event): An estimated fewer than 2% of all sentinel events are reported to The Joint Commission. 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He was part of the team that opened the first new hospital in Illinois in over 25 years. See how our expertise and rigorous standards can help organizations like yours. In 2021, the most challenging ambulatory care standards fell in the realm of: environment of care (EC) infection control (IC) human resources (HR) We've gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Learn more about the communities and organizations we serve. Find evidence-based sources on preventing infections in clinical settings. The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. Many ambulatory and office-based surgery sites are led by a clinical staff member, so it is important to develop a relationship with someone who can offer general guidance on EC accountabilities. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. According to The Joint Commission (TJC), in 2012 six of the top 10 cited standards were Environment of Care / Life Safety standards. The Joint Commission's Top Environment of Care and Life Safety Citations: 56% for EC.02.06.01 (maintenance of a safe environment) An unsafe environment can cause harm to both patients and the staff. Provided is a detailed look into scoring patterns identified last year (2020) for all accreditation programs. The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. By continuing to use our site, you acknowledge that you have read, that you understand, and that you accept our. Were confident that with a little guidance, compliance issues can be overcome. The 15 best practices that made a lasting impression on the Joint Commission surveyors included: Daily Tiered Huddles Pharmacy Robots Mobile CT (Computed Tomography) Scanning Sibling Court/Daycare for Siblings of Cancer Patients 4th Angel Mentoring Program for Cancer Patients The Blessing of Donated Bone Marrow Cells Prior to Transplant As mentioned earlier in this issue, CMS issued QSO 21-18 on May 7th, 2021 providing an advance copy of the interpretive guidance for their interoperability requirements for both hospitals and critical access hospitals. Doing thorough PI on these processes is really the key to preventing TJC surveyors from identifying gaps in adherence to safety measures designed to protect patients at risk for suicide. 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Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Top Compliance Challenges for Ambulatory Care Organizations in 2021, manufacturers instructions for use (MIFU) and/or processes, instruments used for surgery and/or procedures. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. Copyright 2023 Becker's Healthcare. If so, you likely will remember seeing that we had two . Learn about the development and implementation of standardized performance measures. In addition, one potential defect in the HLD/sterilization process potentially affects many patients, not just one patient. Effective January 1, 2021, if an organization cannot prove that an elevator wrap meets a UL 10B or UL 10C rating, Joint Commission surveyors will issue a requirement for improvement (RFI) under LS.02.01.10, EP 12: "Doors requiring a fire rating of of an hour or longer are free of coverings, decorations, or other EC News contains an update from the FDA recommending that healthcare providers transition away from crisis capacity conservation strategies such as decontaminating disposable respirators for reuse. Make Time for Time Out on National Time Out Day June 01, 2022 Surgery on the wrong patient or wrong body part is called a "never event," because it is never supposed to happen. We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the organization said. Official position of SIG Engineering on challenging standards and EPs. We have a similar keyword logic built into our consultation survey documentation tool that assists our consultants in correct placement of findings also. We help you measure, assess and improve your performance. In 2021, the most frequently reported sentinel event category was care management events with patient falls being the single largest reported harm events. The U.S. Department of Health and Human Services also has tracked a 59% increase in COVID-19 cases over a two-week period, as of Friday, May 6. IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies. Get more information about cookies and how you can refuse them by clicking on the learn more button below. QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. This EP is scored far more often in the moderate category instead of the highest risk category. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. We can make a difference on your journey to provide consistently excellent care for each and every patient. The 2020 scoring data is also evenly split between high risk and moderate risk. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. QSO memo 21-18 for hospitals and critical access hospitals (effective June 30, 2021) requiring to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. Hospitals and other health care facilities are unique. Protecting patients from harm involves more than safe treatments and procedures. Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Due to the pandemic, total survey volume was less than in prior years. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. The 10 most frequently reported sentinel events for 2021: Editor's note: This article was updated Feb. 23 at 6:35 p.m. CT. The organization defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent. The sixth most frequently scored EP is EC.02.06.01, EP 1. View them by specific areas by clicking here. We develop and implement measures for accountability and quality improvement. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. Patient falls were the most common sentinel event reported among hospitals in the first six months of 2022, according to a Sept. 7 report from The Joint Commission. Environment of Care Staff who are responsible for accessing clean medical equipment, devices and supplies need to do so in a manner to prevent contamination. Find the exact resources you need to succeed in your accreditation journey. We do have a preference for printed materials that a patient can refer to, but this video might be a valuable component of your patient education initiative. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the. Learn how working with the Joint Commission benefits your organization and community. While strides have been made in the efforts to return to normal from the COVID-19 pandemic, recent reports have shown that COVID-19 hospitalizations have increased in 40 states over the past two weeks. This article explains the requirements better than just reading the standards and more importantly they include a decision tree or flow chart that depicts the signage required for each situation. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Most of these devices (e.g., pull stations, fire and smoke detectors) are typically not maintained by in-house staff. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. EC 02.03.05 The elements of performance (EPs) around this standard focus on a buildings systems and equipment that provide detection, notification and extinguishment of fire conditions. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA Tiffany Wiksten, MSN, RN-CIC, is Associate Director, Standards Interpretation Department. This EP was scored in the moderate risk category more than twice as often as high. Learn about the development and implementation of standardized performance measures. As you might assume, any defects in these processes are high risk because there may be transmission of infection. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, Conference Reviewers: Request for More Information, Digital Health + Telehealth Virtual Event, Beckers Digital Health + Health IT Podcast, Becker's Ambulatory Surgery Centers Podcast, Becker's Cardiology + Heart Surgery Podcast, Current Issue - Becker's Clinical Leadership & Infection Control, Past Issues - Becker's Clinical Leadership & Infection Control, Revenue Cycle Management Companies in Healthcare to Know, Hospitals and Health Systems with Great Neurosurgery and Spine Programs, Hospitals and Health Systems with Great Heart Programs, 50 hospitals and health systems with great orthopedic programs headed into 2023, 100 of the largest hospitals and health systems in America | 2023, 60 hospitals and health systems with great oncology programs headed into 2023, 150 top places to work in healthcare | 2019, California hospital CFO resigns after 5 days, Undercover agents bought fake nursing degrees with no medical experience, Michigan nurse found guilty in 3-year-old patient's death, Lab leak likely caused pandemic, US energy department says, Hospital margins see no relief to start the year, UPMC, top surgeon to pay $8.5M to settle whistleblower suit, 8th Annual Becker's Health IT + Digital Health + RCM Annual Meeting, Unintended retention of a foreign object 30. Your email address will not be published . This total had previously peaked in 2012, when 946 sentinel events were reported. Jennifer Cowel, RN MHSA For example, it is not common to have a basketball hoop in a gym area and such a potential hazard is not typically going to be on a national environmental risk assessment tool. The Joint Commission is a registered trademark of the Joint Commission enterprise. As is customary, TJC provides recommended actions, and in this case eight. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. The content changes are minimal but perhaps the breadth and scope of what surveyors will be examining may be more detailed. Prior to this position she managed the emergency department at Northwestern Memorial Hospital and was a clinical educator at Northwestern University Feinberg School of Medicine. OSHA will, on a case-by-case basis, exercise enforcement discretion related to the reuse of FFRs that have been decontaminated using the methods recommended above when considering issuing citations under 29 CFR 1910.134(d) and/or the equivalent respiratory protection provisions of other health standards in cases where: The importance of this guidance is that discretion is a two-way street. We sometimes see these, and at times there is no awareness that radiology has a unique infusion pump that is not part of the hospital wide update process. We can make a difference on your journey to provide consistently excellent care for each and every patient. Did you get a chance to read our May issue of the Patton Post? MM.01.01.03: The organization safely manages high-alert and hazardous medications. Environment of Care This list of applicable equipment and accessories is extensive: Prior to release of the items for patient care, validate that the critical parameters for the disinfection and/or sterilization such as process time, temperature, pressure and cycle completion have been met. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. The Joint Commission has published the top 5 requirements identified most frequently as "not compliant" during surveys and reviews performed in 2020, and infection control standards made the list for many programs. The EC News article provides a link to a January 2021 memo from Johns Hopkins Bloomberg School of Public Health that discusses oxygen conservation strategies and techniques to prevent mechanical breakdowns in your supply system. This is a point of confusion as the requirements TJC or CMS apply differ based on the gas supply system present and the types and amount of gases stored. Information on all things ambulatory from The Joint Commission, By Hermann McKenzie, MBA, CHSP, director of engineering, Standards Interpretation Group; Elizabeth Even, MSN, RN, CEN, Associate Director, Clinical Standards Interpretation Group; and Tiffany Wiksten, MSN, RN-CIC, Associate Director, Standards Interpretation. Learn about the "gold standard" in quality. As with any Sentinel Event Alert, there is no mandate from TJC to implement all of the recommendations contained in the alert. QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. The standard has not made the previously published top ten lists, and in our review of survey reports this was never a frequently seen requirement for improvement. One of the flaws we often see with environmental risk assessments is a failure to document all observed and theoretical risks. By not making a selection you will be agreeing to the use of our cookies. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Its interesting for our ambulatory care team to review the most frequently cited standards every year and offer our accredited organizations advice on avoiding common pitfalls. We noted TJC included the term ultrasound probes in their keyword section. Many organizations are under the false impression that because the providers they hire are employed elsewhere they do not have to credential and privilege them at their organization. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. Learn about the priorities that drive us and how we are helping propel health care forward. Top 10 High & Moderate Risk Findings for 2020 This alert seems to us like a good surveyor conversation topic at a medication management system tracer. During 2020, there were shortages of the previously discussed staff respirators, ventilators, and oxygen. IC.02.01.01: The organization implements infection prevention and control activities. The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. Dirty ventilation systems and rooms can cause infection, which can prolong a patient's stay. IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . We suggest that their flow chart be discussed and analyzed at an environment of care meeting and used during EC or Quality rounds to verify that you have the correct signage present. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. EC.02.05.01: The hospital manages risks associated with its utility systems. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Utility Systems - EC.02.05.01 - Clinical Impact, Means of Egress - LS.02.01.20 - Clinical Impact, Built Environment - EC.02.06.01 - Clinical Impact, Fire Protection - EC.02.03.05 - Clinical Impact, General Requirements - LS.02.01.10 - Clinical Impact, Protection - LS.02.01.30 - Clinical Impact, Automated Suppression - LS.02.01.35 - Clinical Impact.