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. If contractors are used, they need to provide service for the entire complement of devices and provide detailed reports to the organization on each item that has successfully passed its test. The EP establishes requirements for medication administration and the necessary staff verifications prior to administration. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. Sentinel Event Alert Infusion Pumps, Alternative Equipment Maintenance (AEM) Strategies 2. HR.02.01.03 This standard is again a challenge for many of our accredited organizations. IC.02.01.01 This standard, requiring organizations to implement IC activities, is commonly cited for failure to implement IC activities or required evidence-based guidance such as Standard Precautions. 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 The top five most challenging requirements for hospitals in 2021: 1. The Joint Commission (TJC) is an independent, not-for-profit organization created in 1951 that accredits more than 20,000 US health care programs and organizations. You want to ensure that all staff using multi-patient use glucometers adhere to the IFU for cleaning and have the required cleaning agents recommended by the manufacturer. Find the exact resources you need to succeed in your accreditation journey. The Becker's Hospital Review website uses cookies to display relevant ads and to enhance your browsing experience. Whether you need help with fire protection, utility systems or means of egress, youll find the support you need to achieve compliance. We help you measure, assess and improve your performance. Environment of Care Learn about the priorities that drive us and how we are helping propel health care forward. Not having appropriate content in these policies is one potential risk, but more often it is non-adherence to these policies that leads to RFIs. 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. We have reproduced that link again for your use. We can make a difference on your journey to provide consistently excellent care for each and every patient. This portal will provide information to reduce findings of non-compliance. 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. 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. 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. If clean and dirty items are managed in the same room or area, there needs to be a workflow or process in place to provide clear separation of clean and dirty items. But if the tool fails to include all of the risks present in the hospitals actual environment, staff often forget to add a line and list the newfound risk unique to their hospital. Remembering which sign is required in different situations is difficult. 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. The Joint Commission (TJC) discussed this in their Consistent Interpretation column from their May issue of Perspectives and it is worth bringing up to you again. The 10 most frequently reported sentinel events for the first half of 2022: Copyright © 2023 Becker's Healthcare. For example, if 30 smoke detectors were tested in the last reporting period then the expectation is that 30 devices will appear on the current report. Thus, a low risk and widespread issue that is scored in 80% of the organizations surveyed will not display in this data. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. These are as follows: 90% Flu Vaccination Goal: Infection Control Chapter (IC.02.04.01 EP 5) MM.06.01.01: The hospital safely administers medications. Interoperability Standard Revision If you havent yet, its going to be a great resource for your continuing accreditation and compliance efforts and encourage you to do so. Copyright 2023 Becker's Healthcare. For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. The organization identified the top. Despite the pandemic and the year we thought would never end, we're already halfway through 2021! The bad news is we see some slippage in end of April data with more red and yellow counties, and fewer green counties. We can make a difference on your journey to provide consistently excellent care for each and every patient. The tenth most frequently scored EP is IC.02.02.01, EP 4 which establishes infection prevention requirements for safe storage of medical equipment, devices, and supplies. Drive performance improvement using our new business intelligence tools. In addition, one potential defect in the HLD/sterilization process potentially affects many patients, not just one patient. 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. 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. Hospitals and other health care facilities are unique. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. 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. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. 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. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. Official position of SIG Engineering on challenging standards and EPs. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. EP 5 was one of the new requirements added a couple of years ago which requires adherence to written policies and procedures in the care of patients at risk for suicide. European Commission President Ursula von der Leyen's silence about her dealings with drugmaker Pfizer leading to the EU's biggest COVID-19 vaccine contract is hurting public trust and is a . Protecting patients from harm involves more than safe treatments and procedures. That plus the deterioration of reputation that results should make all readers of our newsletter and this column convinced that similar situations will never be allowed to occur in your organization. Provided is a detailed look into scoring patterns identified last year (2020) for all accreditation programs. New Speak Up Video As you might expect, in the hospital accreditation program the issue that is most often scored with high or moderate risk is related to suicide safety. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. Reduce the risk for. As with any Sentinel Event Alert, there is no mandate from TJC to implement all of the recommendations contained in the alert. 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. But if you have one that is used by psychiatric patients you need to document that you recognize the risk and have mitigated that risk through staff supervision. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing: At times we discuss the Consistent Interpretation column because it adds clarity to understanding an existing or newly published requirement, or the article speaks to a standard that is cited frequently. Alternative Equipment Maintenance (AEM) Strategies: The lead article in EC News is a lengthy discussion of alternative equipment maintenance strategies. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). 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. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) . Recommendation two in general discusses maintenance of the drug library, but there are actually six specific sub-recommendations incorporated into this section. Name 5 of the top 10 findings seen during surveys by The Joint Commission in 2010. 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. IC.02.01.01: The organization implements its infection prevention and control plan. Privacy Policy. 124 Most Common Findings from Joint Commission Surveys The primary goal of this session should be integration of process improvement into the daily activity of the . All Rights Reserved. Learn about the priorities that drive us and how we are helping propel health care forward. 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 We frequently refer to this EP as the eyewash EP where a lack of access to an eyewash, an improper eyewash, or failure to test an eyewash could potentially be scored. Copyright © 2023 Becker's Healthcare. 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. One of the keywords they have included from this element of performance is titration rates. As we have all seen for maybe the last five years, medication titration adjustments and documentation have been one of the more frequently scored issues on survey. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. View them by specific areas by clicking here. So, if your patient has a PCP and a cardiologist or other specialist the patient identifies as primarily responsible for their care, you would want to ensure that both providers receive the aftercare notice. 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, Top Compliance Challenges for Ambulatory Care Organizations in 2021, manufacturers instructions for use (MIFU) and/or processes, instruments used for surgery and/or procedures. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. 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. The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. We use cookies to optimize our website and our service. 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. Due to the pandemic, total survey volume was less than in prior years. 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. They basically advise that given the increased supplies now available such reprocessing should no longer be needed. See how our expertise and rigorous standards can help organizations like yours. Discretion to not enforce or discretion to enforce. EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste. Over the last several years, The Joint Commission has noticed a pattern of challenges related to certain Environment of Care and Life Safety standards. Drive performance improvement using our new business intelligence tools. 10 64% IC.02.01.01 The Hospital Implements its infection prevention and control plan . The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. Not only should the top discrepancies be included, but also novel best practices seen in 2010. Given the detailed high-level disinfection work that staff perform for intracavitary probes this means keeping the now clean probe clean until it is used again, which may require a cover or cabinet to protect it. We can make a difference on your journey to provide consistently excellent care for each and every patient. The first CMS tag touched is A-0470 and it requires notice be sent for registration as an inpatient or emergency room patient to external providers. If so, you likely will remember seeing that we had two . Additionally, medical equipment, devices and supplies should be protected from contamination during storage. TJC announced a new Speak Up video they have developed for new parents. EC.02.02.01: The organization manages risks related to hazardous materials and waste. Learn about the "gold standard" in quality. EC.02.05.01: The hospital manages risks associated with its utility systems. Learn about the "gold standard" in quality. 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. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. 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. This section of the manual describes the data elements required to calculate category assignments and measurements for The Joint Commission's National Quality Measures. This would be an organizational decision and the organization will be surveyed to the process approved by leadership. One of the ways in which we typically see hospitals maintaining their drug library is by obtaining management reports, or feedback on how many times the DERS is bypassed, and for which drugs. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. MM.06.01.01: The critical access hospital safely administers medications. Included in this standard are the devices that signal the fire alarm system to activate and notify first responders to a fire emergency. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. Interoperability Standard Revisions. . 46% of sentinel events led to a patients death. Learn about the development and implementation of standardized performance measures. This EP was scored in the moderate risk category more than twice as often as high. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Ensure compliance when reprocessing reusable medical devices, including but not limited to: Following the MIFU for any devices, instruments, products, accessories or equipment used ensures they are being cleaned and disinfected or sterilized as per intended use. They're now conducting both . All Rights Reserved. Learn how working with the Joint Commission benefits your organization and community. Rank Incidence of High Harm Percent High Harm Clinical or Environmental Association with ITL Clinical High-level disinfection and sterilization IC.02.02.01 EP02 2000 2 790 40% Clinical 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. 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. Linking and Reprinting Policy. LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services. The Joint Commission is a registered trademark of the Joint Commission enterprise. IC.02.01.01: The organization implements the infection prevention and control activities it has planned. Then in 2020 we experienced a pandemic that stressed the system and really tested the effectiveness of our planning efforts in the extreme. 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.. Today, many organizations are faced with reprocessing complex instruments and devices. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. There are no immediate action requirements as a result of new standards or revised interpretations of existing standards. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. 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Unmatched knowledge and expertise, we help you measure, assess and patient... Survey activity over the past years experience and refine your EOP you may want to consider this.! Egress, youll find the support you need to achieve compliance we have reproduced that link for. Reprocessing should no longer be needed so, you likely will remember seeing that had. Harm, and fewer green counties leading practices, unmatched knowledge and expertise, we help you measure assess., we & # x27 ; s goal and mission are to ensure quality healthcare for patients, harm! From this element of performance is titration rates are helping propel health care forward ensure quality healthcare for,... Protecting patients from harm involves more than twice as often as high date with the! Patient advocacy 10 most frequently reported sentinel events for 2021: Editor 's note: this article was Feb.!