Joint Commission moves closer to CMS CoPs
Not up on the CoPs now? You better be soon
The Joint Commission has a lot going on these days. Besides issuing five sentinel event alerts in 2008 and the 2009 National Patient Safety Goals and standards, in January the organization released an addendum to its accreditation standards. In preparation for its application to the Centers for Medicare & Medicaid Services (CMS) for continued deeming authority for hospitals, The Joint Commission released a 46-page document as an addition to the earlier released 2009 standards.
As far as the 2009 standards, Ann Scott Blouin, executive vice president of accreditation and certification operations for The Joint Commission, says, "there are no substantive changes in the intent of the standards. They've been organized differently. That's probably the first thing that would be important for the quality improvement people to know and understand."
The 2009 standard changes are part of The Joint Commission's Standards Improvement Initiative to clarify and improve the wording and organization of its standards. As a result, in the 2009 standards, the emergency management standards, which were previously in the environment of care chapter, are now in a dedicated chapter on their own.
"The other thing you may be aware of is that there was something called life safety code that previously was not really explicated specifically in the elements of performance. It was referred to but kind of in one sentence," Blouin says. In response to customer feedback, The Joint Commission decided it would be better to have the life safety code more clearly delineated.
Other changes Blouin points to as part of the Standards Improvement Initiative are the availability of an electronic manual, in which users can utilize text searches to find specific sections or areas, and separating the standards and elements of performance into direct or indirect. The former would be standards or EPs "that specifically are linked without really many steps in between to patient safety and quality. They're typically things that relate to direct patient care and potentially harm if they're not done correctly, like infection control, managing medications, things like that," she says. Standards and EPs that require extra documentation vs. observation or discussion also are marked.
CoPs now in effect
In January, The Joint Commission was in the process of submitting its application to CMS to continue to have deeming authority. "That requirement requires us to have some explicit language around CMS' conditions of participation," Blouin says.
"We certainly want to be respectful of what the CoPs say. In the addendum, some of that was rewording some things, revising some things that already spoke to the CoPs but maybe not in the language CMS liked based on our feedback from them. And then there are others that they may tell us in March or April that they would like us to continue to change," Blouin says.
Although surveyors have already begun to accommodate these standards in their surveys, hospitals will not be scored on these latest additions until July 2009.
What you need to know
Will there really be a learning curve to accommodate the newly added standards? Kathleen Catalano, RN, JD, director of healthcare transformation support for Perot Systems Corp. in Plano, TX, says there shouldn't be. If you're already familiar with the CoPs, and you should be, there's nothing really different here, and The Joint Commission, she says, has outlined the most important ones in its recent addendum. Some changes she notes:
- verbal orders have to be cosigned or signed and signed and dated within 48 hours;
- additions to what is required within a progress note;
- under blood management, records must be kept for 10 years.
But Nancy McLean, RN, BSN, MHSA, senior consultant, Courtemanche & Associates, says, "We all know there were major changes to the Joint Commission requirements for 2009. Many of those changes went into effect Jan. 1. Hospitals that are scheduled for their tri-annual survey this year will have to demonstrate a 12-month record of compliance with all standards. If the survey for these hospitals occurs prior to December, they will have to be able to provide evidence that they have been in compliance since January 2009. This makes it easy to decide where to begin for preparedness; start with the newly added standards."
The Joint Commission on its web site published a "crosswalk," detailing chapter by chapter where standards were moved within the standards manual. "The last part of the crosswalk lists the additional standards that were required to be in place for 2009," McLean, says. "This is where the quality professional should begin."
Standards or elements on which McLean suggests you focus include:
- NPSG.01.01.01: Qualified and competent transfusionist, second person trained and competent in transfusion verification.
- NPSG.08.01.01: New documentation requirements on transfer of care and new requirement for short-term list of medications given to patients.
- NPSG.13.01.01: Requirements for patient education within 24 hours of admission on hand hygiene and respiratory precautions and for all surgical patients education on prevention of surgical site infections.
- Universal Protocol additions to the pre-verification and the time-out process and documentation.
- LD.02.04.01: Managing Conflict among leadership groups, hospital administration, medical staff and governance.
- LD.03.01.01: Managing conflict among those working in the hospital and developing a code of conduct that includes acceptable and unacceptable behaviors for those working in the hospital.
"Overall, The Joint Commission continues to adjust standards to maintain their compliance with changes in the law and regulations that the Centers for Medicare & Medicaid Services require hospitals implement," she says. "We see this in additions to the National Patient Safety Goals, which are a direct response to the present on admission complications selected for 2009.
"The important thing for the quality professional to focus on is the overall change in culture that the standards are leading us into — the change to a culture of safety and, to use a buzz word, 'transparency.' A culture where it is no longer accepted that a patient develop a pressure ulcer or surgical site infection as a complication of hospitalization," McLean says. "A culture that embraces evidence-based practice and has processes in place to address plans of care that veer from evidence-based medicine. Most importantly, a culture that includes the patient, and when appropriate, the patient's family as a partner in the provision of care. The requirement for education of the admitted patient on hand hygiene and respiratory precautions and the surgical patient on prevention of surgical site infections is an invitation to begin the culture change to one of patient partnering."
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