The Joint Commission (TJC) and Practice Standards

1. The Joint Commission (TJC) and Practice Standards Group 10 Jaime Carney, Angie Ditmar, Shelley Meyerholtz, Dana Sartorius

2. Origination of The Joint Commission • In 1951, a new entity, the Joint Commission on Accreditation of Hospitals was created by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association. • In 1987, the company was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, pronounced "Jay-co"). • In 2007, the Joint Commission on Accreditation of Healthcare Organizations underwent a major rebranding and simplified its name to The Joint Commission. (The Joint Commission, 2007)

3. The Joint Commission Cont.. • An independent, not-for-profit organization. • Founded in 1951 to improve health care for the public. • Develop standards of care based on input from health care professionals, providers, consumers, government agencies (such as CMS) and employers. • Publishes Standards for Hospital Accreditation. • TJC currently evaluates and accredits over 17,000 health care organizations and is an internationally recognized governing body.

4. Mission Statement of TJC • To continuously improve health care 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. (The Joint Commission, 2012) • This specifically speaks to setting practice standards that impact nursing. Certain standards must be upheld in order to achieve certification.

5. JCAHO’s Influences • Pain Management Standards—January 1, 2001 Implemented to address the assessment and management of pain as a result of consumer complaints of pain needs not being addressed. • “Speak Up” Initiatives—March 2002 JCAHO launched a national campaign with Centers for Medicaid/Medicare Services to encourage patients to become more involved active health care participants. • Official “Do Not Use” Abbreviations List—2004 Mandating JCAHO accredited organizations to develop and implement a “do not use” list in order to decrease errors and improve safety. • Universal Protocol—July 1, 2004 Requires a pre-procedure verification, site marking, and timeout prior to performing any invasive procedure; to prevent wrong site, wrong procedure, and wrong person mishaps.

6. Standards of Joint Commission • The Joint Commission’s standards set expectations for organization performance that are reasonable, achievable and surveyable (The Joint Commission, 2012). • The Joint commission directly observes the healthcare facility as well as all staff to assess and monitor their standards of care and performance. • All healthcare organizations that are joint commission accredited receive a copy of the standards. • “The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care” (The Joint Commission, 2012).

7. The Development of Standards “New Standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured” (The Joint Commission, 2012). The Joint Commission. (2012). Facts about Joint Commission accreditation standards. Retrieved from http://www.jointcommission.org.

8. Requirements in Standards The surveyed organizations show compliance through creating and implementing a plan that focuses on the following requirements in the standards: • Emergency Management • Life Safety • Fire safety • Safety and security management • Hazardous materials and waste management • Medical equipment management • Utilities management (ASHE, 2012)

9. Accreditation and Standards • According to The American Society for Healthcare Engineering of the American Hospital Association, or ASHE, the accreditation programs have individualized sets of standards. The standards are broken down into elements of performance or EPs. The EPs and standards may be common for many different accreditation programs or could be unique to certain programs.

10. Accreditation Programs of The Joint Commission • Ambulatory Care (AHC) • Behavioral Health (BHC) • Critical Access Hospitals (CAH) • Home Care (OME) • Hospitals (HAP) • Laboratories • Long-Term Care and Medicare/Medicaid Certification-Based Long-Term Care (LTC) • Office-Based Surgery (OBS) (The American Society for Healthcare Engineering of the American Hospital Association, 2012)

11. TJC Certifications • Organizations can earn certifications from The Joint Commission for focusing on chronic diseases and conditions. • Certifications are not required by the Joint commission. • Certifications show the community validation on the efforts on safety and quality of care. • It is a growing trend that insurance companies are requiring the Joint Commission certifications for eligibility for reimbursement and insurance contract binding. • “Meeting Joint Commission standards is an accomplishment recognized with the awarding of The Joint Commission’s Gold Seal of Approval. Certified organizations proudly display the Gold Seal to advertise their commitment to health care quality” (TJC, 2012)

12. The Survey Process • The Joint Commission issues National Patient Safety Goals that are based on findings of the survey process. The Joint Commission uses an onsite survey process to evaluate compliance with its standards. The surveys are unannounced to help ensure organizations are maintaining standards at all times. During the survey process, administrators and managers may not be on site. • This process “emphasizes the need for training and involvement of staff in managing the patient care environment.” (ASHE, 2012)

13. National Safety Patient Goals (NSPG) • The Joint commission reviews and publishes patient safety goals to improve overall healthcare. • New goals are not edited each year unless there are concerns about quality and safety of care. • 2010: The Joint commission approved the revision of all national safety patient goals. There were several goals that were deleted or changed to comply with ongoing changes in healthcare. No new goals were developed at that time. • 2011: Patient medication safety goal was revised • 2012: A new goal that focuses on catheter-associated urinary tract infection (CAUTI) for the hospital and critical access hospital accreditation programs.

14. NSPG’s for hospitals • Identify patients correctly- at least 2 identifications • Improve Staff communication- getting important information to the correct staff member • Use medicines safely- double check that all meds are labeled, take precaution with those on blood thinners, go over meds with patients and compare to at home meds • Prevent infections- hand washing, PPE (includes newest goal of catheter infections) • Identify patient safety risks- highest risk of suicide • Prevent mistakes in surgery- correct patient, surgery, place on body (The Joint Commission Accreditation Hospital, 2012)

15. RELATED TO: Heart attack Heart failure Pneumonia Surgery Children’s asthma Inpatient psychiatric services VTE (venous thromboembolism) Stroke QUALITY IMPROVEMENT STANDARDS Save lives. Contributes to better health and quality of life for patients. Reduces health care costs. Improving Quality and Safety

16. Spectrum Health and TJC • TJC is the accrediting body for Spectrum Health. • There are other accrediting bodies that hospitals can choose to utilize. • TJC sets standards of care called “core measures” for specific disease states such as AMI, Heart Failure etc. • These core measures set the quality indicators that hospitals can benchmark to • These indicators help provide structure for measuring performance

17. TJC impact on Angie’s career • In my current practice area of Cardiovascular Services at Spectrum Health,JCAHO practice standards influence my nursing practice by providing regulations for accreditation that drive a structure for compliance. • This structure helps to organize and delineate workflow in order to achieve these regulations

18. Shelley’s career and TJC impact • In my current practice area, which is a cardiology physician office , we are not Joint Commission Accredited so TJC does not affect me daily. We follow the standards or OSHA more than TJC. • I am credentialed at Spectrum health so TJC impacts my career when I am rounding on patients in the hospital. TJC provides standards of care that I follow to ensure safety of the patients. • I follow the patient safety goals that TJC publish to improve the overall quality of care.

19. The Joint Commission and Dana’s Career • Pine Rest is an accredited organization that must keep current with the Joint Commission’s standards of practice and takes part in the survey process. In addition to maintaining accreditation, which can be a condition of licensure, the survey can help determine whether the organization will receive Medicaid reimbursement. Inspections generally take place three times per year with records of the results made publicly available.

20. The Joint Commission and Dana’s Career • Examples of Pine Rest’s adherence to maintaining standards can be seen through EPs. According to Courage (2009), some of the recent changes and additions to the EPs by the Joint Commission were: • PC.03.05.03, EP 2: The use of restraint or seclusion is in accordance with a written modification to the patient's plan of care. • PC.03.05.05, EP 3: The attending physician is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion. • Both of these changes impacted how we document the restraint or seclusion occurrence. We have to provide detailed records that the Joint Commission can review when they come to survey Pine Rest. Our unit strives to be proactive and not reactive. We try to exceed the standards set by the Joint Commission to maintain our accreditation.

21. Joint Commission’s Influence on Nursing (Jaime) • TJC’s influence on nursing as a profession is apparent everywhere I look, from how patients are assessed, treated, and cared for to how healthcare workers communicate and document. • The implementation of standardized protocols are based off reported core quality measures provided to TJC from accredited organizations. • At Munson, TJC is evident in the way nurses document (pain assessment tasks, fall risk assessments), communicate (lab-critical value tasks, reporting those values in timely manner). • Munson also has universal protocols (two patient identifiers) in place, which are followed before any procedure or surgery to help circumvent errors. • TJC influences the way all healthcare workers practice.

22. References Courage, S. (2009, March). Joint Commission change to align with CMS. Accreditation Monthly. Retrieved from: http://www.hcpro.com/QPS-229536-1000/Joint-Commission-Changes-to-Align-with-CMS.html. History of the Joint Commission. (2012). Retrieved from: http://www.joint commission.org/about_us/history.asp. Joint Commission Perspectives. (2009). Approved: 2010 national patient safety goals: some changes effective immediately. Joint Commission Perspectives, October 2009, Volume 29, Issue 10. Retrieved from: http://www.allhealth.org/Briefing Materials/JointCommission-Oct2009-2010NationalPatientSafetyGoals-1722.pdf. The American Society for Healthcare Engineering of the American Hospital Association. (2012). Joint Commission standards and the survey process. Retrieved from: http://www.ashe.org/advocacy/organizations/TJC/standards.html.

23. References Cont.. The Joint Commission Accreditation Hospital. (2012). 2012 hospital national safety patient goals. Retrieved from: http://www.jointcommission.org/assets/ 1/6/2012_NPSG_ HAP.pdf. The Joint Commission Launches New Brand Identity. (2007, July). Retrieved from: http://www.jointcommission.org/AboutUs/brand.htm. The Joint Commission. (2012). About our standards. Retrieved from: http://www.joint commission.org/standards_information/standards.aspx. The Joint Commission. (2012). Facts about Joint Commission accreditation standards. Retrieved from: http://www.jointcommission.org. The Joint Commission. (2012). What is certification? Retrieved from: http://www.joint commission.org/standards_information/standards.aspx.