The Joint Commission reviewed 1,197 sentinel events in 2021, with the majority of these 89% (1,068) being voluntarily self-reported by an accredited or certified entity. Bear in mind that far more than just eyewash issues can be scored here, such as failure to provide or use appropriate PPE for handling hazardous chemicals. There is also a link to the OSHA guidance that was issued during the height of the pandemic in April 2020 that had discussed reprocessing of respirators. Crisis care planning is not yet a requirement of the standards, but we have read that TJC will be revising the standards in the near future. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Accordingly, The Joint Commissions surveyors and reviewers will remain masked while onsite at an organization, adhere to social distancing and follow other guidelines as recommended by the Centers for Disease Control and Prevention. 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. 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. QSA.02.11.01: The laboratory conducts surveillance of patient results and related records as part of its quality control program. View them by specific areas by clicking here. As is customary, TJC provides recommended actions, and in this case eight. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. These tools are a great start, but remember if you find an additional item that could be a ligature hazard, you need to add it to the risk assessment tool. New Joint Commission Requirements Effective 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21. CMS and Joint Commission have been examining this data to determine suitability for survey. Consequently, the inspection, testing and maintenance (ITM) tasks are contracted. The table below identifies the Top 5 Joint Commission requirements identified most frequently as "not compliant" during surveys and reviews from Jan. 1 through Dec. 31, 2021. 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. Drive performance improvement using our new business intelligence tools. EC.02.02.01: The organization manages risks related to hazardous materials and waste. HR.01.06.01: Staff are competent to perform their responsibilities. 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. MM.06.01.01: The hospital safely administers medications. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. Four very important clinical issues are discussed this month including inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and sharing of lancets or lancet holders. 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. 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. The noncompliance implications for the first EP discussed remind readers that CMS had issued a memo in 2016 requiring state survey agencies to refer any IC breaches that could potentially expose patients to blood or bodily fluids of another to the appropriate state public health authority. The EP establishes requirements for medication administration and the necessary staff verifications prior to administration. In 2021, the most challenging ambulatory care standards fell in the realm of: Weve gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. The ninth most frequently scored EP was again from NPSG.15.01.01, EP 4. Official position of SIG Engineering on challenging standards and EPs. The second element of performance scored very often in the high and moderate risk category is IC.02.02.01, EP 2, which establishes requirements for high level disinfection and sterilization. Privacy Policy. The bad news is we see some slippage in end of April data with more red and yellow counties, and fewer green counties. Copyright 2023 Becker's Healthcare. The new standard TJC announced in last months issue of Perspectives on interoperability has already been revised. We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. By not making a selection you will be agreeing to the use of our cookies. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. 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. They're as follows: Life Safety Requirements for Business Occupancies The Joint Commission is a registered trademark of the Joint Commission enterprise. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. As with all ITM activities, documentation of these tasks must be current, accurate and made available to Joint Commission staff when requested on survey. Patient Safety Topics. We can help you overcome the year-of-the-pandemic and support your preparation for survey. Learn how working with the Joint Commission benefits your organization and community. All Rights Reserved. The Joint Commission has identified several standards that have been frequently cited during survey activity over the past few years. The fifth most frequently scored EP is EC.02.05.01, EP 15 deals with air pressure relationships in critical spaces such as operating rooms, sterile compounding, or central sterile supply areas. The keywords TJC has now built into their survey report tool now include safe environment, interior spaces, dirty ceiling tiles, porous surfaces and sterile compounding area. Get more information about cookies and how you can refuse them by clicking on the learn more button below. 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 If so, we have important feedback about current high focus areas we're seeing in 2021 surveys. [email protected], John Rosing, MHA We have reproduced that link again for your use. Linking and Reprinting Policy. Learn more about the communities and organizations we serve. Find the exact resources you need to succeed in your accreditation journey. Identify risks associated with home oxygen therapy such as home fires. Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. [email protected], 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. See how our expertise and rigorous standards can help organizations like yours. While Joint Commission accredited and CMS-deemed organizations can share certain information, the hiring organization is responsible to ensure that all EPs under HR.02.01.03 are completed for each provider. 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. View them by specific areas by clicking here. 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. 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. Herman McKenzie is currently the director, Department of Engineering in the Standards Interpretation Group at The Joint Commission. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Medical Gas Room Signage, COVID-19 Test Positivity Rates If this rate continues in the second half of the year, total sentinel event reports will likely surpass the 1,197 sentinel events reported in 2021, which represented the highest annual level seen since the accrediting body started publicly reporting them in 2007. The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. View them by specific areas by clicking here. See how our expertise and rigorous standards can help organizations like yours. The decision on who an organization brings in to care for its patients is arguably the most important decision an organization makes. This caught our attention because of the hemorrhage and preeclampsia content. The Joint Commission is a registered trademark of the Joint Commission enterprise. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. They house a variety of materials and equipment that can cause harm. The 10 most frequently reported sentinel events for the first half of 2022: Copyright © 2023 Becker's Healthcare. 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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 5 most challenging requirements for 2021, Joint Commission asking healthcare staff to remain masked while interacting with surveyors, reviewers, Up in the blogosphere with The Joint Commission, Required Policies and Procedures in Suicide Prevention Program, Avoiding Unintended Retained Foreign Objects in Ambulatory Surgery Care. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. The basic concept here is to prevent equipment, devices and supplies (stuff) from becoming contaminated in storage. HRM.01.02.01: The organization verifies and evaluates staff credentials. 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. Reader Interactions. All Rights Reserved. The accrediting body received 1,197 reports of sentinel events last year, 89 percent of which healthcare organizations voluntarily reported. Alternative Equipment Maintenance (AEM) Strategies: The lead article in EC News is a lengthy discussion of alternative equipment maintenance strategies. Drive performance improvement using our new business intelligence tools. This keyword logic may be helpful at your own organization to assist staff in correct identification of a standard and EP to score for an issue they see. Thus, these will still be high on the radar in 2022. Name 5 of the top 10 findings seen during surveys by The Joint Commission in 2010. Human Resources Behavioral Health Care and Human Services. In last months wording, your EMR system needed to send notifications to post-acute service providers as applicable and now the requirement says to all applicable.. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . (Contact: Standards Interpretation Group, 630-792-5900 or online question form). When this is the case, organizations must ensure they set up maintenance intervals that align with National Fire Protection Association (NFPA) code requirements, be it quarterly, semi-annually or annually. . We then noted the third column TJC published in this article titled Keywords/Topics. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. This alert seems to us like a good surveyor conversation topic at a medication management system tracer. HR.02.01.03: The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. Building is shaped like the Star of Life. The fourth most frequently scored EP is MM.06.01.01, EP 3, which somewhat surprised us. 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. The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. Reducing the risk of hospital-acquired infections was the most challenging compliance standard for hospitals in 2021, according to The Joint Commission. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. Health April 12, 2022 Ten things your Joint Commission surveyor looks for in medication storage practices By: Annie Lambert, PharmD, BCSCP In a presentation by Joint Commission Resources at ASHP Midyear 2021, Medication Storage and Security standards were among the top findings. 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. We use cookies to optimize our website and our service. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. The organization identified the top. 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. Top 10 High & Moderate Risk Findings for 2020: This month we will not be breaking our discussion into high or lower priorities since Perspectives has some good information about scoring practices experienced in 2020. However, Joint Commission surveyors were able to identify Requirements for Improvement (RFIs) in key areas for improvement. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Environment of Care 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. The table below identifies the Top 5 Joint Commission requirements identified most frequently as not compliant during surveys and reviews from Jan. 1 through Dec. 31, 2021. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. It is most commonly cited for failure to ensure that reusable medical devices are reprocessed as per intended use and MIFU, and for failure to store medical equipment, devices and supplies in a manner to protect them from contamination. The second most common issue falls into the maintenance of provider files, including issues related to licensure verification prior to the expiration date and renewal of privileges prior to when the current privileges expire. And recently The Joint Commission Top 10 Read more Interoperability Standard Revisions Did you get a chance to read our May issue of the Patton Post? As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. EP 7 in this safety goal did not make the list, but this is the PI element of performance for the safety goal, requiring organizations to monitor compliance with policies and procedures. They also point out that some glucometers are approved by the FDA for single patient use and others are approved for multi-patient use. It is very informative, and while AEM is acceptable to TJC and CMS, it is not a program we see many organizations choosing to implement. This EP requires documentation of the overall risk for suicide and the plan to mitigate that risk. 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. Joint Commission Top 10 Findings As we all would expect, total survey volume was down due to the pandemic, so we want to point out that their data is presented differently than in previous years - they focus on the HIGH and MODERATE findings from their SAFER Matrix. 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. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. Copyright 2023 Becker's Healthcare. This year the presentation format is more granular and identifies specific elements of performance where surveyors used the TJC SAFER Matrix to identify the particular finding as high risk or moderate risk. Leave a Reply Cancel reply. The hospital reduces the risk of infections associated with medical equipment, devices and supplies. If you have the staff and resources and have implemented AEM already, then this article is a good opportunity to verify your program is compliant or fine tune it. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. CMS points out that this may require two notices, one stating that the patient has registered for treatment in the ED, and a second notice stating the patient has been admitted to the hospital. PC.01.03.01: The organization plans the patients care. Introduction. Find the exact resources you need to succeed in your accreditation journey. TJC supplies guidance here from ISMP that monitoring should actually be in real time and alerts should be received when infusions are bypassing programmed dose limits. Remembering which sign is required in different situations is difficult. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. We help you measure, assess and improve your performance. The software in the pump that contains the library of correct dosages and infusion rates, which many readers know as guardrails, now is described with a new acronym called DERS, or dose error reduction software..

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