The Joint Commission

What You Need to Know

What is It?

• Joint Commission created in 1951• Non-profit organization dedicated to raising

the level of safety and quality of care in all health settings

• Provides accreditation for health care organizations whose high standards meet their expectations

Mission

• To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value

Who can be Accredited?

• Ambulatory Care Accreditation • Behavioral Health Accreditation • Critical Access Hospital Accreditation• Home Care Accreditation• Hospital Accreditation• Laboratory Accreditation• Long Term Care Accreditation• Office-based Surgery Accreditation

Ambulatory Care Accreditation

• Established in 1975, this program covers:– Medical centers– Ambulatory surgical centers– Other ambulatory care organizations

• Currently over 1600 ambulatory health centers are Joint Commission accredited

Why be Accredited?

• Recognized by CMS• Improves community confidence in quality of

care• Improves risk management and risk

reduction• Ensures facility provide top care through

collaboration with nationally recognized service

Areas of Observation

• Environment of Care• Emergency Management• Human Resources• Infection

Prevention/Control• Information

Management• Leadership• Life Safety• Medication Management• National patient safety

goals

• Provision of Care , Treatment & Services

• Performance Improvement

• Record of care, treatment, services

• Rights/responsibilities of the individual

• Transplant Safety• Universal Protocol• Waived Testing

Environment of Care

• The goal of EOC is to provide a safe, functional, supportive, & effective environment for patients, staff & other individuals in TLCCS

Environment of Care; What is It?

• Key elements & issues that contribute to creating the way the space feels and works for patients, family, staff & others involved in receiving/providing healthcare at our sites and can include:– Light– Privacy– Security– Space size & configuration– Clarity of access– Color– Efficient layouts that support staffing & overall

function

Environment of Care, cont’d…

• Effective management of the environment of care will involve:– Reduction & control of environmental hazards &

risks– Prevention of accidents & injuries– Maintenance of safe conditions for patients, staff

& others coming into TLCCS’ facilities– Providing environment that is sensitive to

patients’ needs for comfort, social interaction & positive distraction

– Minimizing unnecessary environmental stress for patients, staff & others in TLCCS’ facilities

Emergency Management

• Emergencies cannot be predicted• An Emergency Management Plan is essential

to be prepared for unforeseen circumstances• Goal of Emergency Management is to ensure

TLCCS is adequately prepared in the event of an emergency

Emergency Management, cont’d…

• An effective Emergency Management Plan must account for how TLCCS will manage:– Communication– Resources and Assets– Security– Staff– Patients– Training & drills are also essential to effective plan

• TLCCS is required to respond to a patient’s immediate care & safety if an emergency occurs on site

Human Resources

• Goal is to ensure that TLCCS determines the qualifications and competencies for staff based on its mission, population, care, treatment & services

• To comply, TLCCS must:– Planning: define qualifications– Provide competent staff– Orienting, training & education staff– Assessing, maintaining & improving staff

competence– Promoting self-development & learning

Infection Prevention & Control

• Assess risk and design an infection control program based on that assessment

• The goal of an effective program is to reduce the risk of acquisition of Healthcare Associated Infections (HAIs), and it must:– Incorporate infection control program as major

component of safety & performance improvement programs

– Perform ongoing assessments to identify risks for acquisition & transmission of infective agents

– Conduct effective surveillance, collect & interpret data

Information Management

• Every episode of care generates health information that must be managed by TLCCS

• All information should be accurately captured and only accessible by authorized users

Leadership

• Leaders of TLCCS provide framework for planning, directing, coordination, providing & improving care, treatment & services in response to community & patient needs while improving healthcare outcomes

• Effective leadership depends on:– Governance– Management– Planning, designing, & providing services– Improving safety & quality of care– Use of clinical practice guidelines– Teaching & coaching staff

Life Safety

• General life safety design and building construction

• Means of egress, design of space, travel distance, illumination & signage

• Fire windows, stairs, smoke barriers, interior finishes

• Fire alarm notifications, audible and coded alarms

• Suppression of fire, sprinklers, extinquishers• Elevator safety• Decorations, furnishings, and portable

heaters

Medication Management

• A safe medication management system is essential for TLC to control the medication process, and should address:– Selection and procurement– Storage– Ordering and transcribing– Preparing and dispensing– Administration– MonitoringMedication Management includes stock meds, samples, emergent(crash cart) and implantables.

Medication Management, cont’d…

• It should support patient safety and improve quality of care by reducing practice variation, errors and misuse

• All medications should be handled in the same manner, including sample meds, TLC-wide

• Must include mechanisms for reporting potential and actual medication related errors

National Patient Safety Goals

• Intent is to improve overall care by addressing some of the most common healthcare mistakes

• See NPSG handout

Performance Improvement

• Measuring functions of important processes and services

• When indicated, identify changes that enhance performance

• Focuses on outcome of care, treatment & services• Requires environment in which patients, families,

staff & leaders can identify and manage actual or potential risks

• Should measure current performance through data collection, assess current performance, & have components for improving performance

• PDSA Rapid Cycle Improvement Process

Provision of Care, Treatment & Services

• Care, treatment & services are to be provided through successful coordination & completion of a series of processes including:– Initial needs assessment– Develop plan of care– Ongoing assessment to ensure meets patients’

needs– Successful transfer of patient for continuing

care

Provision of Care, Treatment & Services, cont’d…

• Four Core Elements– Assessing the patients’ needs– Planning care, treatment, & services– Providing care, treatment & services– Coordinating care, treatment & services

Provision of Care, Treatment & Services, cont’d…

• This also includes:– Providing access to appropriate levels of care

or discipline– Providing interventions based on the plan for

care, treatment & services– Providing patients with education related to

their care– Coordinating care if patient is referred or

transferred

Record of Care, Treatment & Services

• A clinical record comprises all data/information gathered about an individual served from the moment he/she enters TLCCS to the moment of discharge/transfer

• This record serves not only as a history of care, but a method of communication among staff to facilitate continuity of care

• The goal is that not only is patient care documented thoroughly, it is also consistent for all patients

• Documentation must be made only by authorized persons, and auditing must be performed to ensure compliance

Rights & Responsibilities of the Individual

• Goal is to– Improve care, treatment, services & outcomes

by recognizing & respecting rights of each patient, and conducting business in an ethical manner

– Patients deserve a safeguard of their personal dignity & respect, as well as cultural, psychosocial and spiritual values

Rights & Responsibilities of the Individual, cont’d…

• Addresses:– Managing TLCCS’ relationship with patients &

public in an ethical manner– Considering the values and preferences of

patients, including the decision to discontinue care, treatment or services

– Helping patients understand & exercise their rights

– Informing patients of their responsibilities in care, treatment & services

– Recognizing TLCCS’ responsibilities under the law

Rights & Responsibilities of the Individual, cont’d…

• Individual Rights – how does TLCCS respect the culture & rights of patients?

• Individual Rights & Responsibilities – does TLCCS identify the responsibilities of patients and their families in regards to their care, and educate them about these responsibilities?

Universal Protocol

Universal Protocol addresses the prevention of wrong site, wrong procedure and wrong person surgery.

• Every invasive procedure requires an informed consent signed BEFORE the procedure

• Every invasive procedures requires a documented TIME OUT performed BEFORE the procedure.

Waived Testing

• Refers to tests determined by FDA to be at level of simplicity that there is little room for error

• Treatment decisions can be based on waived testing results, correct test results are essential to patient outcomes

• Standards for waived testing developed in 1992, and remained unchanged until 2005

Because the Joint Commission Says So

• Few standards carry such specific definitions by the Joint Commission

• Most Joint Commission standards require TLCCS to set our policy, then follow it

• We aren’t following specific guidelines because “the Joint Commission says so”, we follow these guidelines because we have a written policy that states we perform tasks in this fashion

How Does the Joint Commission Affect Me?

• Unannounced survey: 18 – 36 months after last full survey, the Joint Commission will perform an “unannounced survey”; with no notification given prior to the multi-day survey

• Last Survey: March 26-28, 2014

Survey Process

• Joint Commission surveyors use the Tracer Methodology

• They use a patient chart to “follow” them through the care they received at TLCCS to ensure compliance with Joint Commission standards

Survey Process, cont’d…

• IS IT TIME TO PANIC WHEN THE JOINT COMMISSION COMES?

• Absolutely not!! TLCCS holds to the standards every day, the survey is our chance to prove it!

• WHAT IF I DON’T KNOW THE ANSWER?• You aren’t expected to know the answer to

any possible question the surveyor could ask. More important is that you know where to obtain the answer!

Key Points

• We can’t know every question the surveyor will ask, but we can ensure we know some of the key points they are looking for:– Know “Do Not Use” List– Performance Improvement measures in

departments – what does Peer Review focus on for your department? Don’t forget Diabetic Collaborative

– Patient Education– Current National Patient Safety Goals (NPSG)

Any Questions?