Joint Commission Update 2014

1. Joint Commission Update 2014 Nancy Claflin RN PhD CCRN NEA-BC CPHQ FNAHQ VHA-CM

3. New Approaches Necessary toImprove Health Care • The way health care conducts improvement is itselfin need of improvement • Help health care make progress toward high reliability • Achievement of extremely high levels of safety maintained over long periods of time • Safety comparable to that demonstrated by the commercial air travel, nuclear power, and amusement park industries

4. Improve Healthcare • 1. Eliminate Overuse of Health Services • Avoiding tests, treatments, and procedures that do not provide significant benefit has the potential to both improve quality and reduce costs • Examples: • Antibiotics for colds • Early elective deliveries without a medical indication

5. Improve Healthcare • 2. Recognize that one size does not fit all • Using process improvement tools and methods such as Robust Process Improvement™ (RPI) enables health care organizations to find unique solutions • Approach differs from long-standing efforts that emphasize evidence-based guidelines, checklists, and toolkits that typically are not customized

6. Improve Healthcare • 3. Create a culture of safety • Stopping intimidating & disrespectful behaviors could help encourage candid reporting of and dialogue about errors, close calls, and unsafe conditions • Reporting and learning from blameless errors and unsafe conditions doesn’t eliminate need for personal responsibility • Accountability for adhering to agreed-upon safe practices is also a key component of a culture of safety

7. Focused Standards Assessment • Joint Commission began requiring organizations accredited under ambulatory care, behavioral health care, home care, hospital, and laboratory programs to submit Focused Standards Assessment (FSA) in February 2013 • Critical access hospitals and nursing homes are required to submit the FSA effective January 1, 2014 • While office-based surgery practices can still use theFSA for self-assessment, they are not required (or able) to submit an FSA

8. Changes to Accreditation Decisions • Change to Contingent Accreditation • Modified Contingent Accreditation (CONT) CONT01 • Accreditation Committee will determine if the organization’s corrective action is sufficient to change the decision from Preliminary Denial of Accreditation (PDA) to Contingent Accreditation • Occurs after Immediate Threat to Life (ITL) finding at survey and follow up visit verified sufficient corrective action to remove ITL

9. Changes to Accreditation Decisions • Added the failure to successfully address all Requirements for Improvement (RFIs) in submitting an Evidence of Standards Compliance (ESC) or Measure of Success (MOS) to CONT05 • Introduced new certification decision rules due to a revised decision process in which the only two possible outcomes are Certified or Not Certified

10. Nursing Care Center Accreditation Program • The Joint Commission’s reinvented Long Term Care Accreditation Program newname • Nursing Care Center Accreditation Program • Reflects reinvented program’s focus on organizations that provide complex nursing care, which could include post-acutecare and other services for both short-stay patients and long-term residents

11. Behavioral Health Home Certification • BehavioralHealth Home (BHH) certification accredited under the Behavioral Health Care Accreditation Program effective January 1, 2014 • Focuses on coordinating & integrating behavioral & physical health care for individuals with serious mental illness, children with serious emotional disturbances, adults with developmental/ intellectual disabilities, & patients in opioid treatment programs • People with serious mental illness die 25 years earlier than general population • Suicide &injury account 30% to 40% • 60% due to medical conditions (cardiovascular, pulmonary, infectious)

12. ORYX • Increased ORYX® performance measure reporting requirements for accredited general medical/surgical hospitals • From a minimum of four (4) sets of core measures to at least six (6) sets of core measures for discharges • Effective January 1, 2014 • Additional measure set selections include both mandatory & discretionary measure sets

13. Mandatory Measure Sets • Acute myocardial infarction (AMI) • Heart failure (HF) • Pneumonia (PN) • Surgical Care Improvement Project (SCIP) • Perinatal care (PC)—for hospitals with 1,100 or more live births per year

14. Discretionary Measure Set • Discretionary sixth measure set • (Or fifth and sixth measure sets, for hospitals with fewer than 1,100 births per year) • Can be chosen from among the remaining complement of core measure sets

15. Discretionary Measure Set • Children’s asthma care (CAC) • Hospital-based inpatient psychiatric services (HBIPS) • Hospital outpatient (OP) • Immunization (IMM) • Emergency department (ED) • Venous thromboembolism (VTE) • Stroke (STK) • Tobacco treatment (TOB) • Substance use (SUB) • Perinatal care (PC)—for hospitals with fewer than 1,100 live births per year

16. Laboratory Standards Revision • Revision to Quality System Assessment for Nonwaived Testing (QSA) Standard QSA.05.01.01 (EP) 4 • How frequently policies/procedures of blood transfusion services are reviewed for laboratoryaccreditation program • Revised requirement allows blood transfusion service director/technical supervisor to review blood transfusion policies/procedures every two years instead of annually

18. Emergency Management • Requirements for Emergency Management Oversight • Hospital effectively manages its programs, services, sites, or departments • EP 12 Leaders identify an individual to be accountable for the following:

19. LD.04.01.05 • Staff implementation of 4 phases of emergency management (mitigation, preparedness, response, & recovery) • Staff implementation of emergency management across 6 critical areas (communications, resources & assets, safety & security, staff responsibilities, utilities, and patient clinical & support activities) • Collaboration across clinical & operational areas to implement emergency management hospital wide • Identification of & collaboration with community response partners

20. EM.03.01.01 • Hospital evaluates effectiveness of its emergency management planning activities • EP 4 The annual emergency management planning reviews are forwarded to senior hospital leadership for review (See also LD.04.01.01 EP 25)

21. EM.03.01.03 • Hospital evaluates the effectiveness of its Emergency Operations Plan • EP 13 • Based on all monitoring activities & observations, including relevant input from all levels of staff affected, hospital evaluates all emergency responses exercises and all responses to actual emergencies using a multidisciplinary process (which includes Licensed Independent Practitioners (LIPs))

22. EM.03.01.03 • EP 15 • The deficiencies & opportunities for improvement identified in the evaluation of all emergency response exercises and all responses to actual emergencies, are communicated to the improvement team responsible for monitoring environment of care issues and to senior hospital leadership.

23. LD.04.04.01 • Leaders establish priorities for performance improvement • Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following:

24. LD.04.01.01 • Review of the annual emergency management planning reviews • Review of the evaluations of all emergency response exercises and all responses to actual emergencies • Determination of which emergency management improvements will be prioritized for implementation

26. Patient Flow • Revisions approved June 2012 • Most became effective January 2013 • Two EPs became effective January 2014 • Standards impacted • LD.04.03.11 The hospital manages the flow of patients throughout the hospital • PC.01.01.01 The hospitals accepts the patient for care, treatments, and services based on its ability to meet the patients’ needs (Perspectives, July 2012)

27. Patient Flow LD.04.03.11 • Revisions address the following: • Leadership use of data and measures to identify, mitigate, and manage issues affecting patient flow throughout the hospital (effective January 2014) • Management of the Emergency Department throughput as a system-wide issue • Safety for boarded patients • Leadership communication with behavioral health providers and authorities to enhance coordination of care

28. Patient Flow LD.04.03.11 • All EPs related to risk • Patient flow throughout organization including boarding • Not just Emergency Department • Monitoring • Managing • Anticipating and mitigating • Observing for trends • Clear goals & accountability for improvement

29. Patient Flow PC.01.01.01 • Revision addresses safety for boarded patients with behavioral health emergencies in the following areas: • Environment of care, location • Staffing and orientation/training • Assessment, reassessment, and the care provided

30. Patient Flow PC.01.01.01 • Behavioral patients boarded for extended periods of time may not receive the safe, quality care needed • Staff may not be prepared to deal with this vulnerable, challenging population • Environment may not be suited to the needs of the behavioral health population • Policies and practices in the community may contribute to making this a complex issue

32. Clinical Alarms • NPSG.06.01.01 Improve the safety of clinical alarms • Implementation in two phases • Phase I beginning January 2014 • Hospitals required to establish alarms as an organization priority and identify the most important alarms to manage based on their own internal situations

33. Clinical Alarms • NPSG.06.01.01 Improve the safety of clinical alarms • Phase II beginning January 6 • Hospitals expected to develop and implement specific components of policies and procedures • Education of those in the organization about alarm system management will also be required

34. Elements of Performance • NPSG.06.01.01 • 1. As of July 1, 2014, leaders establish alarm system safety as a hospital priority • 2. During 2014, identify the most important alarm signals to manage based on the following: • Input from medical staff and clinical departments • Risk to patients if the alarm signal is not attended to or if it malfunctions

35. Elements of Performance • NPSG.06.01.01 • 2. During 2014, identify the most important alarm signals to manage based on the following: • Whether specific alarm signals are needed or unnecessarily contribute to alarm noise & alarm fatigue • Potential for patient harm based o internal incident history • Published best practices and guidelines

36. NPSG.06.01.01 • 3. As of January 1, 2016, establish policies/ procedures for managing alarms identified in EP 2 that at a minimum address the following: • Clinically appropriate settings for alarm signals • When alarm signals can be disabled • When alarm parameters can be changed • Who in the organization has the authority to set alarm parameters • Who in the organization has the authority to change alarm parameters

37. NPSG.06.01.01 • 3. As of January 1, 2016, establish policies/ procedures for managing alarms identified in EP 2 that at a minimum address the following: • Who in the organization has the authority to set alarm parameters to “off” • Monitoring and responding to alarm signals • Checking individual alarm signals for accurate settings, proper operation, and detectability

38. Alarm Management • Staffing patterns • Care model • Patient population • Technology capabilities & configuration • Architectural layout • Alarm coverage model • Ancillary technology • Delineation of responsibility • Culture

39. Preventing URFOs • Sentinel Event Alert Issue 51 • How to avoid leaving items (sponges, towels, instruments) in a patient’s body after surgery • Unintended retention of foreign objects (URFOs) or retained surgical items (RSIs)serious patient safety issue may cause death or physical and emotional harm • >770 voluntary reports of URFOs, 16 resulting in death during past 7 years • 95% additional care and/or extended stay • $200,000 in medical and liability payments each

40. URFOs • Soft goods (sponges and towels) • Small miscellaneous items, including unretrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains • Needles and other sharps • Instruments, most commonly malleable retractors

42. Most Frequently Reported Sentinel Events January – June 2013 • Wrong-patient, wrong-site, or wrong-procedure—60 • Unintended retention of a foreign object—56 • Delay in treatment—56 • Falls—48 • Other unanticipated events—40 • Operative/postoperative complication—37 • Suicide—35 • Criminal event (assault/rape/homicide)—26 • Medication error—20 • Perinatal death/injury—15

43. Most Frequently Identified Root Causes January – June 2013 • Human factors (such as fatigue or distraction)—314 • Communication (such as among staff, across disciplines, or with patients)—292 • Leadership (regarding lack of performance improvement infrastructure or community relations)—276 • Assessment (such as patient observation processes or its documentation)—246 • Information management (such as patient identification of confidentiality)—101

44. Most Frequently Identified Root Causes January – June 2013 • Physical environment (such as emergency management or hazardous materials)—70 • Care planning (planning and/or interdisciplinary collaboration)—49 • Continuum of care (includes transfer and/or discharge of patient)—48 • Medication use (such as storage/control or labeling)—48 • Operative care (such as blood use or patient monitoring)—45

45. Hospitals

46. Hospitals

47. Critical Access Hospitals

48. Critical Access Hospitals

49. Nursing & Rehabilitation Centers

50. Nursing & Rehabilitation Centers