1. 2016 JOINT COMMISSION UPDATE
2016 The Joint Commission
2016 JOINT COMMISSION
UPDATE
PO Box 3187
Charleston, WV 25332
McKenna Consulting

2. 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)
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3. 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
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4. 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
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5. The Joint Commission 2016 Sessions Remain same right now
Opening Conference
Leadership (High Reliability)
Medication Management
Infection Prevention Control

6. The Joint Commission 2016 Sessions cont'd Data Management
Environment of Care (Big trouble)
Emergency Management
Competency
Credentials

7. 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

8. The Joint Commission 2016 Starts upon arrival
Evaluation of Physical Plant
Starts upon arrival
Specified OR time (1 ½-2 hrs)
Single document list

9. 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

10. The Joint Commission 2016 Chapters (Alphabetized)
Accreditation Participation Requirement (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention & Control (IC)
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11. 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)
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12. 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)
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13. 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

14. 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

15. 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

16. The Joint Commission 2016 Provision of Care
Pain Assessment/Reassessment
ED triage
OP areas
Histories and Physicals
Ambulatory Problem List
Restraints
Moderate Sedation

17. The Joint Commission 2016 Provision of Care
Anesthesia
Immediate Reassessment
Post anesthesia visit
Plan of Care
Individualized
Updated to current discharge plan
New diagnosis

18. The Joint Commission 2016 Medication Management
Security
Anesthesia
Labor and Delivery
Emergency medications
Reason for medication

19. The Joint Commission 2016 Medication Management
Titrated orders
Pitocin
Diprivan
High risk drug disposal
Compounding – Doctor’s office practices

20. The Joint Commission 2016 Medication Management
Multidose vials
Fluids
Expired medications

21. The Joint Commission 2016 Infection Control
Sterilization, High Level Disinfectant
Job descriptions
Competencies
Observe employees following manufacturer’s instructions
Brushes
Storage of sterile items

22. 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

23. The Joint Commission 2016 Transplant Safety
Bidirectional
Lot number of anything used with
Staff involved
FDA
Alarms

24. The Joint Commission 2016 Performance Improvement
Leadership findings
Complex organization

25. The Joint Commission 2016 Leadership
Contracts
Policies and Procedures
Failure to hold accountable

26. The Joint Commission 2016 Environment of Care
Eyewashes
Ventilation systems
Oxygen storage
Egress
Relative humidity
Behavioral – ligature risk
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27. The Joint Commission 2016 Life Safety
Fire Doors
Smoke barriers
Penetrations
Fire proofing beams
Non-coded storage
Things hanging from sprinklers
Trash receptacles

28. The Joint Commission 2016 Emergency Management
96 hours sustainability
Drills/events

29. The Joint Commission 2016 Human Resources
Doctor’s offices
Primary Source
Overstepping scope (compounding)

30. The Joint Commission 2016 Information Management
Accurate Computer Information
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31. The Joint Commission 2016 Nursing
Over stepping scope
Oversight

32. The Joint Commission 2016 Medical Staff Standards
OPPE
FPPE
Bylaw requirements
Radiology/Nuclear Qualifications

33. The Joint Commission 2016 Waived Testing
Quality Controls

34. 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)

35. References Centers for Disease Control
Accessed:
Accessed:

36. Thank you jatkins@mckennaconsulting.com McKenna Consulting
2016 The Joint Commission
Thank you
McKenna Consulting
Post Office Box 3187
Charleston, WV 25332
McKenna Consulting