These are as follows: TJC eliminated the requirement for having the goal of a 90% compliance rate for flu vaccination. | Privacy Policy, Phenelle Segal on the Healthcare Worker COVID-19 Vaccine Mandate Conundrum, ICCS Infection Prevention & Control Newsletter: April 2021, Joint Commission Infection Control Standards Among the Most Challenging in 2020. The organization identified the top five requirements for which hospitals were most frequently out of compliance, based on surveys and reviews from Jan. 1 through Dec. 31. xZ[o6~7A*wRE@v VGuVj; /w)%Nm!-;\) |a1`XV,~32dq2{~g~:\i7aW[@ThDp\ghR&`Epy1y~=C 1:~% YQ kN'j$QFfau@4 JjJUKlon3L0~4PdgJ;oeCTK.ayDjXN=[Fl/-Uoto\,Vg\Ce"/dV^WIDKfhN2EkIF#EPkeghmKYj1 !NW.0?WWAP:B*GFF"U4P YThkZDgwODNlMjhiODQ0YjhkNzliODliYjM1YWEyY2NhMTBlOGRmODU0YTQz 1194 0 obj <> endobj The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. 2. To identify trends on challenging requirements, The Joint Commission collects data on organizations' compliance with standards, national patient safety goals and accreditation, and certification participation requirements. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Taking Care of the Basics. 02.01.30The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%). Include it in your medical record audits to be sure assessments include this information. Ionizing radiation This standard refers to the exposure of ionizing radiation, exposure in airborne radioactive materials. The most recent statistics from OSHA reveal the top standards cited in the fiscal year 2021 for the hospital industry. HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services. Listed below are those most frequently identified for each program: Ambulatory Health Care Find the exact resources you need to succeed in your accreditation journey. MWI0NmI2NmMzNDAzNmE0OGEzY2FjOTk4M2EyODJmYjk4N2MyODQxYmNiNTA5 EC.02.05.01: The organization manages risks associated with its utility systems. Copyright © 2015-2023 Barrins & Associates, an HBS Company. MWVjYjQyNWNlZTNhM2U3MmRlYzVlOWI1MjYwMjgwZWZjOTUwY2UyNzZmNjBi We specialize in personal and flexible strategies to support multiemployer (Taft-Hartley) health, retirement and insurance needs. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. This standard requires the organization to manage safety and security risks. Learn about the development and implementation of standardized performance measures. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. If you receive an incident report for a fall, review it against this definition. 02.02.01The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70,9%). Requirements of this standard include hazard evaluation, entry-permit systems, employee training, and emergency response plans. Your access to this site was blocked by Wordfence, a security provider, who protects sites from malicious activity. Bloodborne Pathogens This standard refers to the prevention of occupational exposure to blood or other potentially infectious materials. <>/XObject<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 720 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 3) IC.02.01.01: The hospital implements its infection prevention and control plan. An infection control standard took the second spot: 2) IC.02.01.01: The organization implements its infection prevention and control plan. The Joint Commission is a registered trademark of the Joint Commission enterprise. Joint Commission 2021 Standards: E-dition All these standards changes are included in the E-dition January 2021 Update 2 to the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services. View our May issue of the Patton Post for further detail on each above EP or contact us for further clarification! ZjBiNTFhMzY5OTM4NmJkYjY3MjdhMDA4ZTE1MTRmY2E0MDVmMzQ0MWE5N2Y0 It is the oldest and largest standard-setting and accrediting body in healthcare. All Rights Reserved. 02.01.20The hospital maintains the integrity of the means of egress (67.4%). QVLP`[%sm}5*. COVID-19 health care This standard refers to the requirements for health care services or health care support services during the COVID-19 pandemic. What to Do Now: This requirement for spare sprinkler heads is in the 2012 edition of the Life Safety Code which TJC adopted in 2016. This top 10 list comprises establishments that provide medical, diagnostic and treatment services that include physician, nursing and other health services to inpatients and the specialized accommodation services required by . Youll get all the details and some very useful resources related to these new requirements. NzAxMDliMjZhMmIwZDQxZDg0MGU3OWI4NDFmYzU5N2EwYjI5YzNhZmI4MjQ5 Its comprehensive blend of news, strategies, and toolsstraight from The Joint Commissionmakes The Source a monthly must-read that you'll want to keep close at hand throughout the year. The Joint Commission (TJC) is an independent, not-for-profit organization created in 1951 that accredits more than 20,000 US health care programs and organizations. Privacy Policy. See how our expertise and rigorous standards can help organizations like yours. MjdjNDgyYTAwMTAwODQ4NDBjMWFmNmE1NDI0ZTQ2MTkzYjk3MzA2NmZjNTZh MDZlNTg1ZGJjMDRlYmM3YTNlOGM4NGFkZDJiZDZkYjYzNzJjZTViN2UyMzYz 02.05.05The hospital inspects, tests, and maintains utility systems (64.7%). Just click on that tab and select New/Changed EPs as of selected effective date.. MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. Its been around for a while. MGI4ODFlN2JkYWUzNDA0YmQ1NjY4NWQ4YWY3OTk1ZTEwNmMzNjkyOGY4ZDA3 For an update on that front, check out our recent post Virtual Joint Commission Surveys: Get Prepared. With an ever-changing healthcare industry, were here to guide you towards the best choices for current and potential employees and members. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. MzY2YTNhMTZmY2VlYTFkNGY1MzVjNDJmNDNiMzNmYzZkNDJjOTdjOTExMGQ4 Requirements of this standard include a written program, selection of respirators, medical evaluations, fit testing, safe operating procedures and training. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. <> Stay updated on the latest trends and compliance regulations in your industry. Be sure it contains a full list of required elements for medication orders including medication name, medication dose, medication route, and medication frequency. 2) IC.02.01.01: The organization implements infection prevention and control activities. Learn about the priorities that drive us and how we are helping propel health care forward. For organizations that prescribe medication, this standard has always required a written policy defining the minimum elements of a medication order. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. YmUwYWJkNDg2MDZiZDIwZDU4ZmZhODg0YzNjNmRlNGQ5NjUxMjZkOGU2YTFj NPSG.15.01.01, EP 1 (requires the suicide risk assessment of the physical environment), IC.02.02.01, EP 2 (establishes requirements for high level disinfection and sterilization), IC.02.01.01, EP 1 (a very basic requirement to implement your infection prevention practices), MM.06.01.01, EP 3 (establishes requirements for medication administration and the necessary staff verifications prior to administration; titration issues are now scored here), EC.02.05.01, EP 15 (deals with air pressure relationships in critical spaces such as operating rooms, sterile compounding, or central sterile supply areas), EC.02.06.01, EP 1 (another catch all EP where just about any defect in the environment from torn furniture to suicide hazards have been scored), EC.02.02.01, EP 5 (requires the organization to minimize risks associated with hazardous chemicals), NPSG.15.01.01, EP 5 (one of the new requirements added a couple of years ago which requires adherence to written policies and procedures in the care of patients at risk for suicide), NPSG.15.01.01, EP 4 (requires documentation of the overall risk for suicide and the plan to mitigate that risk), IC.02.02.01, EP 4 (establishes infection prevention requirements for safe storage of medical equipment, devices, and supplies). It includes updates to the survey process and any changes to the content of the survey sessions. As a result, there are several language changes in the 2021 manual that reflect this new title. %%EOF 2020's Most Challenging Joint Commission Standard December 7, 2021 opens in a new window Printable PDF A Quarterly Publication by Danielle Donovan Winter 2021 Each year, The Joint Commission (TJC) releases their findings on the requirements most frequently identified as "not compliant" during surveys of various accreditation programs. ZTVmZDU5Y2EzN2NjYTc3YTQ3NmU4OGRjZTQzYWI3YmUzNzFhYWUzYzI5OWVj TJC clarified the requirement for the availability of spare sprinkler heads. NzI1MGM1NjViOWQ1Mzg3OTM2NDI1NzUzNzdlZjEzNmQ1NTZhNDIzN2Y5YTM4 Find evidence-based sources on preventing infections in clinical settings. YTkwNzVmMzRlMWY5NWZiZTNiYzM3OTA3NWVjZjk5MGM3MWUyMmY3OTliZTFh What to Do Now: This structure should already be in place in most hospitals. contains information that reflects the patients care, treatment, or services. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. EC.02.06.01: The hospital establishes and maintains a safe, functional environment. [1] TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. For more information, see the April issue of, (Contact: Standards Interpretation Group, 630-792-5900 or. See also the TJC FAQ on titration orders. The program is implemented through the use of Clinical Practice Guidelines (CPG's) selected to meet the patient's needs (DSDF.3) 2. We apply insight and experience to drive more value and deliver better outcomes from your benefit programs. EC.02.05.01: The critical access hospital manages risks associated with its utility systems. PC.01.03.01: The organization plans the patients care. In compliance with the Essentials of the Accreditation Council for Continuing Medical Education and the Standards for Commercial . ZmQ5OWRiYmQwZDZjMmZhZjU4ZmU0YzQ5NjMxNjVhODkzYWE3MTAwNDJmZDFi Educate your staff about this new requirement. View them by specific areas by clicking here. MjVjMTVjY2MzMmZmOGUxOWU0Yjg1NmY4M2I4YTE0Yzk4YjAyNGU2ZDE1YjRm The following are changes contained only in the 2021 Hospital Manual: TJC added a new requirement for discharge plans of Medicare patients. This is a popup dialog that overlays the main content of the page. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. @A@!q@ q!'8'p\~W=GzQ~UmYstsUz:_Q}V `G3xRyWu=p3 T?P*B :k.Tf. Drive performance improvement using our new business intelligence tools. Requirements include exposure control, training and compliance, vaccination evaluations and follow-up, hazard communication and recordkeeping. All rights reserved. These went into effect in September, 2020. Include it in your medical record audits to be sure the required documentation is present in the record. Infection control standards took the first and third spots: 1) IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. All Rights Reserved. These two-page reports span eight accreditation programs. So, the Joint Commission SAFER matrix provides a snazzier, more customer-friendly packaging of survey results. Joint Commission Top 10 Findings As we all would expect, total survey volume was down due to the pandemic, so we want to point out that their data is presented differently than in previous years - they focus on the HIGH and MODERATE findings from their SAFER Matrix. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). We can make a difference on your journey to provide consistently excellent care for each and every patient. Its our way of keeping frequently cited standards on your organizations radar to help avoid a finding. Why would this matter to us? All these standards changes are included in the E-dition January 2021 Update 2 to the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services. 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