1. Joint Commission this week published the 2010 National Patient Safety Goals and Universal Protocol. While there are no new requirements for 2010, remember that the goals for Healthcare Acquired Infections that were introduced in 2009 must be fully implemented by January 1, 2010. Changes to the 2010 NPSGs resulted in some deletions of requirements that were not applicable to certain programs, the integration of some requirements into existing standards and the modification of others to assist with compliance efforts.
2. The Joint Commission will conduct follow-up surveys for organizations that receive a Condition Level Requirement for Improvement (RFI) during survey. This decision rule, known as “FOLL_U,” is effective for all organizations whose survey began on or after July 1, 2009. RFIs related to the CMS Conditions of Participation (CoPs) are noted on the organization’s survey report and indicate whether the deficiency is at the Standard Level or Condition Level.
3. The Centers for Medicare & Medicaid Services (CMS) conduct random validation surveys on approximately 5% of all accredited organizations. This includes organizations surveyed by the three approved accrediting organizations – The Joint Commission, Det Norske Veritas Healthcare (DNV) and the Healthcare Facilities Accreditation Program (HFAP). The purpose of these surveys is to validate appropriate assessment of healthcare organizations’ compliance with CMS Conditions of Participation. TJC accredits over 4,200 hospitals; DNV currently accredits approximately 40 hospitals; and HFAP accredits around 200 hospitals.
4. Joint Commission’s Sentinel Event policy requires Measure of Success (MOS) follow-up activity for organizations that have had a submitted Root Cause Analysis accepted by TJC. Resulting risk reduction strategies associated with a TJC Element of Performance are expected to have a compliance rate based on the requirements of that EP. For “A” category EPs = 100%; for “C” category EPs = 90%. If a risk reduction strategy can’t be linked directly to a standard or National Patient Safety Goal, the compliance expectation must be at least 85%.
5. When submitting Evidence of Standards Compliance (ESC) after survey, organizations must implement their action plans prior to their submission deadlines for Requirement for Improvements identified during survey. For those Elements of Performance requiring a Measure of Success, TJC is no longer requiring full compliance upon ESC submission deadline. Required compliance is expected to be demonstrated by an average of the data gathered over the four month MOS period.
6. Check out recent postings to TJC’s FAQ site, including:
- TJC published an updated FAQ on June 15th noting that defibrillators are considered life-sustaining equipment and, therefore, should be included on your life support equipment inventories, maintained and tested. Remember your AEDs!
- Summary lists are required in all outpatient settings where there will be recurring visits. The list must be started by the third visit and needs to be readily available to all practitioners. The summary list must be updated as necessary to include all components of care a patient may be receiving, i.e., physical therapy, cancer care, etc.
7. TJC Survey reports now indicate the level of criticality for all scored EPs. Review your report carefully to determine if any Situational Decision Rules (Criticality Tier 2) have been identified. All survey reports containing Tier 2 (2 in a triangle) RFIs are reviewed by TJC Central Office and a decision is made whether the finding supports an adverse decision rule, such as Conditional Accreditation or Preliminary Denial of Accreditation, or if the finding should be addressed through the normal ESC process. Work closely with your Account Representative when reviewing your report.
8. ECRI Institute, in its July 2009 “Hazard Report Update,” noted its current recommendation that blanket warmers have a maximum temperature of 130 degrees Fahrenheit and solution warming cabinets at maintained at no more than 110 degrees Fahrenheit.
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