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THE JOINT COMMISSION 2015

THE JOINT COMMISSION 2015. PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047. Healthcare Educators of Alabama May 1, 2015. The Joint Commission 2015. Relationship between The Centers for Medicare/Medicaid and The Joint Commission. The Joint Commission 2015.

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THE JOINT COMMISSION 2015

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  1. THE JOINT COMMISSION 2015 PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047 Healthcare Educators of Alabama May 1, 2015

  2. The Joint Commission 2015 • Relationship between The Centers for Medicare/Medicaid and • The Joint Commission

  3. The Joint Commission 2015 History • 1965 - Medicare formed • The Joint Commission asked and received automatic deeming authority (deemed status) • 2008 – CMS required The Joint Commission to apply

  4. The Joint Commission 2015 • Two Year Application Process • Received Deemed Status • Must re-apply periodically (now every 6 years)

  5. The Joint Commission 2015 • Resulted in changes to The Joint Commission’s Standards to align with Conditions of Participation • 2014 – Immediate Threat to Health and Safety for Infection Control issues

  6. The Joint Commission 2015 • Conditions of Participation in Federal Registry • Interpreted Guidelines Issued for State Surveyors

  7. The Joint Commission 2015 • The Joint Commission uses the Conditions of Participation (CoP) – Not • The Interpretive Guidelines

  8. The Joint Commission 2015 • Causes differences when State Surveyors do “For Cause” or 2 year certification for Loss of Deemed Status • Examples: Tissue Committee, Meeting Timeframes

  9. The Joint Commission 2015 • Three CMS Worksheets influencing surveys • Infection Control • Discharge Planning • Quality Assessment -Planning

  10. The Joint Commission 2015 • For Causes on the Rise • Restraints – Education becomes critical • Suicides

  11. The Joint Commission 2015 Chapters (Alphabetized) • Accreditation Participation Requirement (APR) • Environment of Care (EC) • Emergency Management (EM) • Human Resources (HR) • Infection Control (IC) • Information Management (IM)

  12. The Joint Commission 2015 Chapters cont’d • Leadership (LD) • Life Safety (LS) • Medication Management (MM) • Medical Staff (MS) • National Patient Safety Goals (NPSG) • Nursing (NR) • Provision of Care (PC)

  13. The Joint Commission 2015 Chapters cont’d • Performance Improvement (PI) • Record of Care, Treatment and Services (RC) • Rights and Responsibilities (RI) • Transplant Safety (TS) • Universal Protocol (UP) • Waived Testing (WT)

  14. The Joint Commission 2015 Conditions of Participation • CoP – Compliance with Federal, State and Local Laws • CoP – Governing Body • CoP – Patients Rights • CoP – Quality Assessment and Performance Improvement • CoP – Medical Staff

  15. The Joint Commission 2015 Conditions of Participation cont’d • CoP – Nursing Services • CoP – Medical Record Services • CoP – Pharmaceutical Services • CoP – Radiologic Services • CoP – Laboratory Services • CoP – Food and Dietetic Services • CoP – Utilization Review

  16. The Joint Commission 2015 Conditions of Participation cont’d • CoP – Physical Environment • CoP – Infection Control • CoP – Discharge Planning • CoP – Organ Tissue and Eye Procurement • CoP – Surgical Services • CoP – Anesthesia Services

  17. The Joint Commission 2015 Conditions of Participation cont’d • CoP – Nuclear Medicine • CoP – Outpatient Services • CoP – Emergency Services • CoP – Rehabilitation Services • CoP – Respiratory Services

  18. The Joint Commission 2015 Structure of CMS’ CoP’s • Condition • Standard • Substandard

  19. The Joint Commission 2015 Medicare Condition Level Deficiency • Can be due to noncompliance with requirements in a single Medicare standard or several standards within the condition • Or a single part representing a severe or critical health or safety breach

  20. The Joint Commission 2015 Medicare Condition Level Deficiency • Small breach in critical actions or at critical times can result in a fatal outcome • The Joint Commission resurveys within 45 days

  21. The Joint Commission 2015 Other Regulators • DNV GL– Integrated Healthcare Survey • HFAP – American Osteopathic Association

  22. The Joint Commission 2015 Legend – The Joint Commission • Scoring – A = all or nothing C = frequency based • D - Documentation • R - Risk • M - Measure of Success • Direct Impact • Rules

  23. The Joint Commission 2015 Human Resource Requirements • A Full-time Pharmacist over Pharmacy HR.01.01.01, EP 28 A (DS) • Job description HR.01.02.01, EP 1 A • Current license, registration, certification HR.01.02.05, EP 2 CMD

  24. The Joint Commission 2015 Human Resource Requirements • Primary source verification HR.01.02.05, EP 1 A D • Education/experience requirements HR.01.02.05, EP 3 CMD

  25. The Joint Commission 2015 • Criminal background (per policy) HR.01.02.05, EP 4 CMD • Health screening (per policy) HR.01.02.05, EP 5 CMD

  26. The Joint Commission 2015 • Evidence of information used to make decisions regarding job description HR.01.02.05 EP 6 A

  27. The Joint Commission 2015 Non-employee Competency Review • Documentation that hospital assessed qualifications and competence of non-employee HR.01.02.05 EP 7 A • Non-employee qualifications reviewed at same frequency as hospitals employees HR.01.07.01, EP 5 C M

  28. The Joint Commission 2015 Advance Practice • PA and Advance Practice RN • Credentialed HR.01.02.05, EP 10 A • Equivalent Process HR.01.02.05, EP 11 A • Evaluation of Credentials HR.01.02.05, EP 12 A D

  29. The Joint Commission 2015 • PA and Advance Practice RN -cont’d • Current Competency HR.01.02.05, EP 13 A D • Peer Recommendation HR.01.02.05, EP 14 A D • Input HR.01.02.05, EP 15 A

  30. The Joint Commission 2015 • PA and Advance Practice RN -cont’d • Director of Psychiatric Nursing – RN Masters or Equivalent HR.01.02.05, EP 16 A • Social Worker - Masters HR.01.02.05, EP 18 A • Practice within Scope HR.01.02.07, EP 2 A

  31. The Joint Commission 2015 Orientation Includes: (based on hospital policy & as appropriate to Joint Commission requirements) • Mission/goals HR.01.04.01, EP 3 CMD • Hospital-wide policies HR.01.04.01, EP 3 CMD

  32. The Joint Commission 2015 Safety & Infection Control Relevant to Unit, Setting, or Program Specific Policies & Procedures • Specific Job Duties HR.01.04.01, EP 4 CMD • Cultural diversity/sensitivity HR.01.04.01, EP 5 CMD • Rights/Ethics HR.01.04.01, EP 6 CMD

  33. The Joint Commission 2015 Safety & Infection Control Relevant to Unit, Setting, or Program Specific Policies & Procedures cont’d • Orient External law enforcement HR.01.04.01, EP 7 CM • Restraints PC.03.05.17, EP 2 CM, EP 3 C, EP 4 A, EP 5 CMD

  34. The Joint Commission 2015 • Abuse, Neglect, Exploitation PC.01.02.09, EP 3 CM • Reporting Adverse Events/errors HR.01.05.03, EP 7 CMD • Fall Reduction HR.01.05.03, EP 8 CDM

  35. The Joint Commission 2015 • Early Warning Signs of Changes to Patient’s Condition HR.01.05.03, EP 13 C MD • Influenza Vaccine IC.02.04.01, EP 3 A • Organ Procurement Sensitivity TS.01.01.01, EP 5 A

  36. The Joint Commission 2015 Competency • Orientation HR.01.06.01, EP 5 CMD • Ongoing HR.01.06.01, EP 6 CMD • For staffing performing waived testing WT.03.01.01, EP 2-4 CMD, EP 5 A

  37. The Joint Commission 2015 Ongoing Education includes: (based on hospital policy & as appropriate Joint Commission requires) • Abuse, Neglect, Exploitation PC.01.02.09, EP 3 C M • Restraints PC.03.05.17, EP 2 CM, EP 3 C, EP 4 A, EP 5 CMD • Unique needs of dying patients PC.02.02.13, EP 2 CM

  38. The Joint Commission 2015 Ongoing Education cont’d • Training when job changes HR.01.05.03, EP 4 CMD • Pain MS.03.01.03, EP 2 A • Based on patient population HR.01.05.03, EP 5 CMD • Safety/Infection Control HR.01.05.03, EP 1 CMD

  39. The Joint Commission 2015 Ongoing Education cont’d • Team Training HR.01.05.03, EP 6 CMD • Reporting Adverse events/errors HR.01.05.03, EP 7 CMD • Anticoagulant Therapy NPSG.03.05.01, EP 7 C M • Health Care associated infections NPSG.07.03.01, EP 2 C M

  40. The Joint Commission 2015 Ongoing Education cont’d • Critical Alarms (Jan 2016) NPSG.06.01.01, EP 4 C • Central Line – associated bloodstream infections & prevention NPSG.07.04.01, EP 1 CM • Surgical Site Infections & Prevention NPSG.07.05.01, EP 5A • Flu Prevention annually IC.02.04.01, EP 2CM

  41. The Joint Commission 2015 Ongoing Education cont’d • Contractors • Considered “staff” • Orientation, training and health screening based on role

  42. The Joint Commission 2015 Ongoing Education cont’d • Vendors • Considered “staff” • Orientation, training and health screening based on role

  43. The Joint Commission 2015 Ongoing Education cont’d • Students • Can use health screen from school if aligns • Orientation to your policies and procedures; especially level of supervision

  44. The Joint Commission 2015Human Resources STRATEGIES FOR FILE REVIEW • Organize your documents • Identify where documents can be found when key people are off • Generate a list of key components for orientation for each job description

  45. The Joint Commission 2015Human Resources STRATEGIES FOR FILE REVIEW cont’d • Have the right people in the competency assessment session • Have personnel file available in the room • Do a history on the person, i.e., hired, transferred, etc.

  46. The Joint Commission 2015Human Resources STRATEGIES FOR VENDORS, CONTRACTORS AND NON-EMPLOYEES • Have a list of vendors and contractors • Create a list of documents you expect to see – put it in a packet • Consider requiring the vendor/contractor to belong to a verification credentialing organization • Practice a manual pull periodically

  47. References • Joint Commission (2015). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2015 • CMS Worksheets: Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-12.html • Centers for Medicare & Medicaid Services: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

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