2016 JOINT COMMISSION UPDATE

1. 2016 JOINT COMMISSION UPDATE PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047

2. The Joint Commission 2016 Major Influences continue for 2016 • CMS Deeming Status • Competition • DNV ties to ISO • Now The Joint Commission moving to tie to ISO – not much action (high amount of turnover in TJC)

3. The Joint Commission 2016 Scoring for 2016 A’s and C’s only (C’s may go) EP’s 0, 1, 2 Timeline for Correcting • Criticality and Immediacy of Risk • 45 – 60 days

4. The Joint Commission 2016Standard Based Leadership Conditions Failures • Don’t just fail one (Governing Body) • Infection Control, Physical Plant and Surgical Services • About 95% fail two conditions

5. The Joint Commission 2016 • Sessions • Remain same right now • Opening Conference • Leadership (High Reliability) • Medication Management • Infection Prevention Control

6. The Joint Commission 2016 • Sessions cont'd • Data Management • Environment of Care (Big trouble) • Emergency Management • Competency • Credentials

7. The Joint Commission 2016 • Tracers – most significant • Cleaning, disinfectant and sterilization (1 ½-2 hrs in OR, Endo) from procuring, to storage, to distribution, to use

8. The Joint Commission 2016 • Evaluation of Physical Plant • Starts upon arrival • Specified OR time (1 ½-2 hrs) • Single document listhttp://www.jointcommission.org/life_safety_code_information_resources/

9. The Joint Commission 2016 • Diagnostic Imaging (July 2015) • Ask for policies to show compliance with new standards • Minimum qualifications for CT techs – still on hold

10. The Joint Commission 2016 Chapters (Alphabetized) • Accreditation Participation Requirement (APR) • Environment of Care (EC) • Emergency Management (EM) • Human Resources (HR) • Infection Prevention & Control (IC)

11. The Joint Commission 2016 Chapters cont'd • Information Management (IM) • Leadership (LD) • Life Safety (LS) • Medication Management (MM) • Medical Staff (MS) • National Patient Safety Goals (NPSG) • Nursing (NR) • Patient Safety Systems (PS)

12. The Joint Commission 2016 Chapters cont'd • Provision of Care (PC) • Performance Improvement (PI) • Record of Care, Treatment and Services (RC) • Rights and Responsibilities (RI) • Transplant Safety (TS) • Universal Protocol (UP) • Waived Testing (WT)

13. The Joint Commission 2016 • Most Significant Findings that will follow us into 2016 • NPSG – Labeling of meds • Anesthesia • Dating large volumes • Syringes including auto-injections

14. The Joint Commission 2016 • Most Significant Findings that will follow us into 2016 cont’d • Alarm Management – fully implemented • Rights/Responsibilities • Informed Consent • Advanced Directives

15. The Joint Commission 2016 • Most Significant Findings that will follow us into 2016 cont’d • Record of Care, Treatment and Services • Dating/timing • Post procedural Note • Immediate • Legibility

16. The Joint Commission 2016Provision of Care • Pain Assessment/Reassessment • ED triage • OP areas • Histories and Physicals • Ambulatory Problem List • Restraints • Moderate Sedation

17. The Joint Commission 2016Provision of Care • Anesthesia • Immediate Reassessment • Post anesthesia visit • Plan of Care • Individualized • Updated to current discharge plan • New diagnosis

18. The Joint Commission 2016Medication Management • Security • Anesthesia • Labor and Delivery • Emergency medications • Reason for medication

19. The Joint Commission 2016Medication Management • Titrated orders • Pitocin • Diprivan • High risk drug disposal • Compounding – Doctor’s office practices

20. The Joint Commission 2016Medication Management • Multidose vials • Fluids • Expired medications

21. The Joint Commission 2016Infection Control • Sterilization, High Level Disinfectant • Job descriptions • Competencies • Observe employees following manufacturer’s instructions • Brushes • Storage of sterile items

22. The Joint Commission 2016Infection Control • Sterilization, High Level Disinfectant cont’d • Contact time for cleaning • Temperature of chemicals • Standardized i.e. enzymatic soaks • Scopes hang freely • Semi-critical items – stored with impervious covers • Air quality

23. The Joint Commission 2016Transplant Safety • Bidirectional • Lot number of anything used with • Staff involved • FDA • Alarms

24. The Joint Commission 2016 Performance Improvement • Leadership findings • Complex organization

25. The Joint Commission 2016 Leadership • Contracts • Policies and Procedures • Failure to hold accountable

26. The Joint Commission 2016Environment of Care • Eyewashes • Ventilation systems • Oxygen storage • Egress • Relative humidity • Behavioral – ligature risk

27. The Joint Commission 2016Life Safety • Fire Doors • Smoke barriers • Penetrations • Fire proofing beams • Non-coded storage • Things hanging from sprinklers • Trash receptacles

28. The Joint Commission 2016Emergency Management • 96 hours sustainability • Drills/events

29. The Joint Commission 2016Human Resources • Doctor’s offices • Primary Source • Overstepping scope (compounding)

30. The Joint Commission 2016Information Management • Accurate Computer Information

31. The Joint Commission 2016Nursing • Over stepping scope • Oversight

32. The Joint Commission 2016Medical Staff Standards • OPPE • FPPE • Bylaw requirements • Radiology/Nuclear Qualifications

33. The Joint Commission 2016Waived Testing • Quality Controls

34. References • Joint Commission (2016). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2016 • AIA Academy Of Architecture for Health, United States. Dept of Health and Human Services. Guidelines for design and construction of hospital and healthcare facilities. American Institute of Architects Press, 2010(Facility Guidelines Institute – FGI)

35. References • Centers for Disease Control http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf Accessed: 10-27-2015 • http://www.jointcommission.org/sea_issue_52/ Accessed: 10-27-2015 • http://www.jointcommission.org/sea_issue_55/ Accessed: 10-27-2015 • http://www.jointcommission.org/life_safety_code_information_resources/ Accessed: 10-27-2015

36. Thank you jatkins@mckennaconsulting.com McKenna Consulting Post Office Box 3187 Charleston, WV 25332 304-988-1047