2016 JOINT COMMISSION UPDATE 2016 The Joint Commission 2016 JOINT COMMISSION UPDATE PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047 McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Major Influences continue for 2016 CMS Deeming Status Competition DNV ties to ISO Now The Joint Commission moving to tie to ISO – not much action (high amount of turnover in TJC) McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Scoring for 2016 A’s and C’s only (C’s may go) EP’s 0, 1, 2 Timeline for Correcting Criticality and Immediacy of Risk 45 – 60 days McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Standard Based Leadership Conditions Failures Don’t just fail one (Governing Body) Infection Control, Physical Plant and Surgical Services About 95% fail two conditions McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Sessions Remain same right now Opening Conference Leadership (High Reliability) Medication Management Infection Prevention Control
The Joint Commission 2016 Sessions cont'd Data Management Environment of Care (Big trouble) Emergency Management Competency Credentials
The Joint Commission 2016 Tracers – most significant Cleaning, disinfectant and sterilization (1 ½-2 hrs in OR, Endo) from procuring, to storage, to distribution, to use
The Joint Commission 2016 Starts upon arrival Evaluation of Physical Plant Starts upon arrival Specified OR time (1 ½-2 hrs) Single document list http://www.jointcommission.org/life_safety_code_information_resources/
The Joint Commission 2016 Diagnostic Imaging (July 2015) Ask for policies to show compliance with new standards Minimum qualifications for CT techs – still on hold
The Joint Commission 2016 Chapters (Alphabetized) Accreditation Participation Requirement (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention & Control (IC) McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Chapters cont'd Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM) Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR) Patient Safety Systems (PS) McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Chapters cont'd Provision of Care (PC) Performance Improvement (PI) Record of Care, Treatment and Services (RC) Rights and Responsibilities (RI) Transplant Safety (TS) Universal Protocol (UP) Waived Testing (WT) McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Most Significant Findings that will follow us into 2016 NPSG – Labeling of meds Anesthesia Dating large volumes Syringes including auto-injections
The Joint Commission 2016 Most Significant Findings that will follow us into 2016 cont’d Alarm Management – fully implemented Rights/Responsibilities Informed Consent Advanced Directives
The Joint Commission 2016 Most Significant Findings that will follow us into 2016 cont’d Record of Care, Treatment and Services Dating/timing Post procedural Note Immediate Legibility
The Joint Commission 2016 Provision of Care Pain Assessment/Reassessment ED triage OP areas Histories and Physicals Ambulatory Problem List Restraints Moderate Sedation
The Joint Commission 2016 Provision of Care Anesthesia Immediate Reassessment Post anesthesia visit Plan of Care Individualized Updated to current discharge plan New diagnosis
The Joint Commission 2016 Medication Management Security Anesthesia Labor and Delivery Emergency medications Reason for medication
The Joint Commission 2016 Medication Management Titrated orders Pitocin Diprivan High risk drug disposal Compounding – Doctor’s office practices
The Joint Commission 2016 Medication Management Multidose vials Fluids Expired medications
The Joint Commission 2016 Infection Control Sterilization, High Level Disinfectant Job descriptions Competencies Observe employees following manufacturer’s instructions Brushes Storage of sterile items
The Joint Commission 2016 Infection Control Sterilization, High Level Disinfectant cont’d Contact time for cleaning Temperature of chemicals Standardized i.e. enzymatic soaks Scopes hang freely Semi-critical items – stored with impervious covers Air quality
The Joint Commission 2016 Transplant Safety Bidirectional Lot number of anything used with Staff involved FDA Alarms
The Joint Commission 2016 Performance Improvement Leadership findings Complex organization
The Joint Commission 2016 Leadership Contracts Policies and Procedures Failure to hold accountable
The Joint Commission 2016 Environment of Care Eyewashes Ventilation systems Oxygen storage Egress Relative humidity Behavioral – ligature risk McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Life Safety Fire Doors Smoke barriers Penetrations Fire proofing beams Non-coded storage Things hanging from sprinklers Trash receptacles
The Joint Commission 2016 Emergency Management 96 hours sustainability Drills/events
The Joint Commission 2016 Human Resources Doctor’s offices Primary Source Overstepping scope (compounding)
The Joint Commission 2016 Information Management Accurate Computer Information McKenna Consulting www.McKennaConsulting.com 304-988-1047
The Joint Commission 2016 Nursing Over stepping scope Oversight
The Joint Commission 2016 Medical Staff Standards OPPE FPPE Bylaw requirements Radiology/Nuclear Qualifications
The Joint Commission 2016 Waived Testing Quality Controls
References Joint Commission (2016). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2016 AIA Academy Of Architecture for Health, United States. Dept of Health and Human Services. Guidelines for design and construction of hospital and healthcare facilities. American Institute of Architects Press, 2010 (Facility Guidelines Institute – FGI)
References Centers for Disease Control http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf Accessed: 10-27-2015 http://www.jointcommission.org/sea_issue_52/ http://www.jointcommission.org/sea_issue_55/ http://www.jointcommission.org/life_safety_code_information_resources/ Accessed: 10-27-2015
Thank you jatkins@mckennaconsulting.com McKenna Consulting 2016 The Joint Commission Thank you jatkins@mckennaconsulting.com McKenna Consulting Post Office Box 3187 Charleston, WV 25332 304-988-1047 McKenna Consulting www.McKennaConsulting.com 304-988-1047