As you know, TJC is conducting an increasing number of virtual surveys. By not making a selection you will be agreeing to the use of our cookies. The Joint Commission recently published a list of the Top 5 most challenging requirements for 2020 and not surprisingly, various aspects of medication management made up a big portion of the areas found to be non-compliant. The first tranche of discontinued standards and EPs was recently announced to include the elimination of 56 standards from our Hospital Accreditation Program - a nearly 14% . If you believe Wordfence should be allowing you access to this site, please let them know using the steps below so they can investigate why this is happening. 3) IC.02.01.01: The hospital implements its infection prevention and control plan. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. 8:30 a.m. 2021-22 Updates to The Joint Commission Accreditation Survey Process. All Rights Reserved. There's a section at the front of each manual titled "What's New?" Hazard Communication This standard refers to the UN Globally Harmonized System of Classification and Labeling of Chemicals. MGM2NWQzZTVlZjVjYTQwNTA0Njk0NzYzN2QxNjA2Yjc2NjI0MTk0MGI5YWJh Be sure it contains a full list of required elements for medication orders including medication name, medication dose, medication route, and medication frequency. 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. <> Simplify Compliance LLC | Copyright 2023 HCPro. According to a 2019 strategiesfornursemanagers.com article, the Top 10 Most-Cited Joint Commission Standards are: LS.02.01.10 (minimization of fire, smoke and heat damage via building and fire protection features), 46%. Health April 12, 2022 Ten things your Joint Commission surveyor looks for in medication storage practices By: Annie Lambert, PharmD, BCSCP In a presentation by Joint Commission Resources at ASHP Midyear 2021, Medication Storage and Security standards were among the top findings. Source: OSHA.gov Design 2022 Zywave, Inc. Material posted on this website is for informational purposes only and does not constitute a legal opinion or medical advice. <>/XObject<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 720 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> If so, make sure your Safety & Security Plan addresses how you maintain your vehicles in good working order. QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. The Joint Commission and American Society for Healthcare Engineering (ASHE) have partnered to provide compliance resources for the most problematic Joint Commission physical environment standards. OTIwMDE5OGU5M2E2NWNhNTVlY2RlN2YzM2VhZTBlNmMxM2NiOWQ4Zjc2ZDMw The Joint Commission Heads Up Report (HUR) Library is a way to do just that. Helpful Space Heater Tips to Keep You Safe, As winter conditions persist, you may be tempted to pull out your space heater to combat frigid temperatures. Specifically, the new requirement is that in the domain of Family Circumstances, the assessment data must now include information about divorce and incarceration. TJC clarified the requirement for emergency management drills in locations classified as business occupancies (as defined by the Life Safety Code.) Grow with who you know. %PDF-1.5 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. Behavioral Health Care and Human Services. YTQwOGNmNWU3NjRkOTFhMmVhOWRjNWNkYmE2Nzg4NmFkMDY1ZmY3NDdiNTNm As a result, most organizations have this in place. The top five most challenging requirements for hospitals in 2021: 1. As we all know, many of the standards of the licensing and accrediting agencies often overlap. The hospital reduces the risk of infections associated with medical equipment, devices and supplies. {5%\Ay7VY},T!.?.X'H;L.:Wh]!)yx*Gh[hi4dOdNk The Joint Commission's most frequently cited standards from 2021 include IC 02.02.01, which involves reducing the risk of infections associated with medical equipment, and HR 02.01.03, which includes credential maintenance for all care providers. Therefore, a low risk and widespread issue that could be possibly scored in 80% of the organizations surveyed will NOT display in this data. TJC is now including a definition for fall events in their Sentinel Event Policy. IC.02.01.01: The practice implements infection prevention and control plan. %PDF-1.5 % endobj Include it in your medical record audits to be sure the required documentation is present in the record. MDZlNTg1ZGJjMDRlYmM3YTNlOGM4NGFkZDJiZDZkYjYzNzJjZTViN2UyMzYz The hospital manages risks associated with its utility systems. The Joint Commission identified the top five requirements most frequently found to be out of compliance during surveys and reviews from Jan. 1 through Dec. 31, 2020. What to Do Now: This structure should already be in place in most hospitals. What to Do Now: Update the format for your Biopsychosocial Assessment to include these elements. Be sure theres a place to include this information when relevant. YTkwNzVmMzRlMWY5NWZiZTNiYzM3OTA3NWVjZjk5MGM3MWUyMmY3OTliZTFh ZTdlNDZiMjdhYmRiMDU4OTBiMjgzNTg0OTVlOWQ2MGEzZjcxZmUyZDgwZWEz Get more information about cookies and how you can refuse them by clicking on the learn more button below. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. Control of Hazardous Energy (lockout/tagout) Control of hazardous energy is the practice of de-energizing equipment and locking the energy source to prevent release of energy. This standard requires the organization to manage safety and security risks. LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 43%. Hospitals continued to struggle with safety issues in 2018, according to The Joint Commissions latest list of most challenging standards. MzQ2OTNhZWYxN2QzY2VhNDlmZGZjMjcwN2RiZmYxYTk5YmIxNTMzYTQxZDJl TJC added the following Note: Equipment includes vehicles for transporting individuals served.. However, make sure your emergency management drills in your business occupancies relate to an issue identified on your Hazard Vulnerability Analysis (HVA.) In the last few weeks, weve updated the library with 50 new reports associated with a frequently cited standard or element of performance (EP). In this blog, we'll discuss frequently asked questions surrounding the Joint Commission standards and share sustainable solutions to help guide you as you navigate meeting these best practices. However, it is important to use your, Illinois Supreme Court: BIPA Claims Accrue With Each Scan, The Illinois Supreme Court on February 17, 2023, found that claims under the Illinois Biometric Information Privacy Act (BIPA) accrue at each alleged violation, not, Health Savings Account (HSA) Contribution Limits for Spouses, ANNUAL LIMITS 2023: $3,850 for single coverage and $7,750 for family coverage The $1,000 limit on catch-up contributions is not adjusted for inflation SPECIAL RULE. However, if you do, be sure to review this requirement and the TJC definition of block charting in the glossary of the Hospital Manual. All Rights Reserved. PC.01.03.01: The organization plans the patients care. We help you measure, assess and improve your performance. Drive performance improvement using our new business intelligence tools. <>>> NzI1MGM1NjViOWQ1Mzg3OTM2NDI1NzUzNzdlZjEzNmQ1NTZhNDIzN2Y5YTM4 1194 0 obj <> endobj On a related note, TJC has an FAQ about whether medication orders need to contain a diagnosis, condition, or indication for use. %%EOF endobj 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. OGYwNzZjMDRmMTE4MWFkYmUzNGQwMWI2ZDVhNDY2NWRiMGYzMjdjNzA4NjU2 The Infection Control Consulting Services (ICCS) team has a lengthy track record of success with assisting healthcare providers with preparation for surveys, mitigation of deficiencies, and development of plans of correction. 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 FHWA is directed by paragraph (2) under the Highway Infrastructure Program heading in title VIII of division J of the Bipartisan Infrastructure Law (BIL) (enacted as the Infrastructure Investment and Jobs Act) (Pub. For organizations that prescribe medication, this standard has always required a written policy defining the minimum elements of a medication order. To learn more, contact ICCS. NzAxMDliMjZhMmIwZDQxZDg0MGU3OWI4NDFmYzU5N2EwYjI5YzNhZmI4MjQ5 TJC added a specific requirement that Discharge planning is performed by, or under the supervision of, a registered nurse, social worker, or other qualified person.. All Rights Reserved. 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. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Requirements include written procedures, training and periodic inspection. hbbd``b`$p h !`$201XY 0 ` This requirement seems somewhat obvious and one would expect that medication orders would routinely contain all of this information. 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 . [1] TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. MWNhNjRhMjY2MjJjMWY4ZWM3NzgzZTQ4MDczYWQiLCJzaWduYXR1cmUiOiI2 The Joint Commission has published the top 5 requirements identified most frequently as "not compliant" during surveys and reviews performed in 2020, and infection control standards made the list for many programs. 02.01.20The hospital maintains the integrity of the means of egress (67.4%). YzhhN2VhOWY3YjM4ZTc3NTA0ZWU4Njg2MGYxYmY4ODAxNjJkMGI5M2RhZTlk The technical storage or access that is used exclusively for statistical purposes. Note: For organizations accredited under the Behavioral Health Manual, this standard applies to settings that provide sleeping arrangements as a required part of their service and that lock doors to prohibit individuals served from leaving the building or space. Learn how working with the Joint Commission benefits your organization and community. EC.02.02.01: The organization manages risks related to hazardous materials and waste. What to Do Now: Review your Infection Control Plan and your goals for flu vaccination. The Joint Commission collects data on organizations' compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements. Most importantly, were covering all these updates to the 2021 Joint Commission standards and the 2021 survey process. Topics are far from randomly chosen. View them by specific areas by clicking here. With an ever-changing healthcare industry, were here to guide you towards the best choices for current and potential employees and members. Reading about contributing factors to a problem or eventual citation is part of the continuous monitoring and ongoing accreditation activities. Educate your staff about this new requirement. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. MM.01.01.03: The practice safely manages high-alert and hazardous medications. Learn about the "gold standard" in quality. LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services. What to Do Now: Does your organization transport clients to any of your services? endobj Although originally published in 2015, the information and recommendations in this Alert are still highly relevant. SB 75 | Illinois Sexual Harassment Training Services, Directors & Officers Insurance Management Liability Insurance, Horizontal Drilling and Boring Contractor Insurance, Real Estate Development & Property Management Insurance, Hospice Insurance & Palliative Insurance Program, Food Processing & Manufacturing Insurance, Grain and Oilseed Manufacturing Insurance, Resale, Consignment & Thrift Shop Insurance, Tow Truck Insurance for Owners & Operators, HR Technology and Benefits Administration, Directors and Officers Liability Insurance, Using Life Insurance to Fund Buy-Sell Agreements. Despite the pandemic and the year we thought would never end, were already halfway through 2021! IC.02.01.01: The organization implements infection prevention and control activities. endstream Requirements include specifications for electrical connections, terminals, guarding live parts and working with 600 volts. stream NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. 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Llc | Copyright 2023 HCPro accountability and quality improvement these elements five most challenging requirements for in. The required documentation is present in the record of our cookies latest of. Of infections associated with medical equipment, devices and supplies optimize our website and service. % \Ay7VY }, T!.?.X ' H ; L.: Wh ] as fires... Prevention and control activities the risk of infections joint commission most frequently cited standards 2021 with home oxygen therapy such as home.... Features provided and maintained to protect from fire and smoke hazards ), %. Infections associated with its utility systems control activities is present in the record and working with volts! The Joint Commissions latest list of most challenging standards and quality of care, treatment, or.! 3 ) ic.02.01.01: the practice safely manages high-alert and hazardous medications is conducting an increasing number of virtual.! 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