Download The Joint Commission A PRIMER FOR STUDENTS AND DMS

Diagnostic Medical Sonography Program
The Joint Commission:
A primer for Students
Harry H. Holdorf
PhD, MPA, RDMS (Ab, OB/Gyn, BR) RVT, LRT(AS)
Objectives:
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Identify the purpose of Joint Commission
Describe areas that impact health
services
Identify resources for Joint Commission
reviews
Review Joint Commission Standards for
Medical Imaging
Mission Statement:
"The mission of The Joint Commission is
to continuously improve the safety and
quality of care provided to the public
through the provision of health care
accreditation and related services that
support performance improvement in
health care organizations."
What is the Joint Commission?
An independent, not-for-profit organization, The
Joint Commission accredits and certifies
nearly 21,000 health care organizations and
programs in the United States. Joint
Commission accreditation and certification is
recognized nationwide as a symbol of quality
that reflects an organization’s commitment to
meeting certain performance standards.
Vision Statement
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All people always experience the safest,
highest quality, best-value health care
across all settings
Background
History:
• Founded in 1951
• Nonprofit organization
• Establishes standards to: address a facility’s
level of performance in areas such as patient
rights, patient treatment, and infection control.
Fun Facts
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The Joint Commission was founded as
the Joint Commission on Accreditation of
Hospitals (JCAH) in 1951.
Ernest Codman was an early 20Th
century health care leader who proposed
the “End result system of hospital
standardization.”
One more fun fact
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The Joint Commission on Accreditation
of Hospitals surveyed 5 hospitals in
1953.
Purpose: Assure standards of care
Benefits of Joint Commission accreditation and
certification
• “Strengthens community confidence in the quality and safety of care,
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treatment and services
Provides a competitive edge in the marketplace
Improves risk management and risk reduction
Provides education on good practices to improve business
operations
Provides professional advice and counsel, enhancing staff education
Enhances staff recruitment and development
Recognized by select insurers and other third parties
May fulfill regulatory requirements in select states” JCAHO web
Functions
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Conducts on site evaluations of facilities
“Accreditation Surveys”
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Issues a certificate of accreditation valid for
3 years
In 2006 moved to ‘unannounced surveys’ to
encourage a system of continuous quality
improvement rather than preparation
focused specifically on a site visit
Scope
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Accredited 4365 hospitals in 2015; Total
>20,000 organizations and programs
• Types of hospitals general, psychiatric,
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children’s, rehabilitation
Others: Managed care networks, Preferred
Provider Organization (PPOs), home care
systems, long-term care, Subacute care,
behavioral health facilities (mental health,
mental retardation and chemical
dependency), ambulatory care centers,
clinical laboratories
Outcome of an accreditation
review
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Accreditation with full standards
compliance
Accreditation with recommendations for
improvement
Provisional accreditation
Conditional accreditation
Preliminary accreditation
Not accredited
Another fun fact
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The American Dental Association was
NOT a founding member of the original
Joint Commission on Accreditation of
Hospitals.
Quality Report
Summary of Quality Information
Children's Hospital and Regional Medical Center
Org ID: 9614
4800 Sand Point Way, Northeast
Seattle, WA 98105
(206)987-6000
www.seattlechildrens.org
Accreditation Decision:
Accredited
Decision Effective Date: April 09, 2005
This organization is in full compliance with all applicable standards.
Special Quality Awards
2006 The Medal of Honor for Organ Donation
Quality Report
Summary of Quality Information
Overlake Health Care Association
Org ID: 9573; 1035 116th Avenue Northeast; Bellevue, WA 98004; (425)688-5000
Accreditation Decision:
Conditional Accreditation Decision Effective Date:
January 27,
2007
This organization is not in full compliance with all applicable standards.
Requirements for Improvement
Hospital - The hospital complies with applicable law and regulation.
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Staff qualifications are consistent with his or her job responsibilities.
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The hospital manages its hazardous materials and waste risks.
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Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®.
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The hospital maintains fire-safety equipment and building features.
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The hospital maintains, tests, and inspects its medical gas and vacuum systems.
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Medications are properly and safely stored.
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Pain is assessed in all patients.
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Operative or other procedures and/or the administration of moderate or deep sedation or anesthesia are planned.
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Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals.
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Based on risks, the hospital establishes priorities and sets goals for preventing the development of health careassociated infections within the hospital.
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Implement a standardized approach to 'hand-off' communications, including an opportunity to ask and respond to
questions.
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Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and
off the sterile field.
Why become accredited?
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Required by Centers for Medicare and
Medicaid Services for reimbursement
Required by insurance companies
Required for state licensure
Good for public relations and marketing
Specific standards that impact
health care services
Assessment (Performance Evaluation)
Care, service, treatment, and rehabilitation
Performance improvement (PI).
Care Process and Model
Provision of Care
 Assessment
 Planning of Care
 Provision of Care
Health Care Process and Model
Joint Commission
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PC.4.10
Monitor effectiveness of care
 PC.5.60
Match internal & external
resources
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PC.15.10
Process for discharge & transfer
needs
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PC.15.20
Transfer or discharge based on
assessed needs
Other Joint Commission
Standards
Joint Commission
PI = Performance Improvement
 PI.1.10
The organization collects data to monitor its
performance.
 PI.2.10
Data are systematically aggregated and analyzed
Other Joint Commission
Standards
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PI.2.20
Undesirable patterns or trends in performance are
analyzed
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PI.3.10
Information from data analysis is used to make
changes that improve performance
American Dietetic Association
Example:
The organization has a process for
preparing and /or distributing food and nutrition products
appropriate to the care, treatment, and services
provided
• Food and nutrition products are provided for the patient as appropriate to
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care, treatment, and services
Food and nutrition products are stored and prepared under proper
conditions of sanitation, temperature, light, moisture, ventilation and
security
Individuals’ cultural, religious or ethnic food preferences are honored
when possible unless contraindicated
Substitutes of equal nutritional value are offered when patients refuse
the food served
Responsibilities are assigned for all activities involved in safely and
accurately providing food and nutrition products
Foods brought in by patients are stored appropriately (applicable only to
HAP)
Patient communal dining areas are adequately supervised (applicable
only to LTC).
American Dietetic Association
Sentinel Events
Something that causes serious injury or death.
A sentinel event is a patient safety event (not
primarily related to the natural course of the
patient’s illness or underlying condition) that
reaches a patient and results in the following:
Death
Permanent harm
Severe temporary harm
Joint Commission Web Accessed
Joint Commission Web Accessed
The Joint Commission
National Patient Safety Goals
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The Goals and Requirements are programspecific
Patient Identification
Goal: Improve the accuracy of patient
identification.
Requirement: Use at least two patient
identifiers when providing care, treatment or
services.
Applies to: Ambulatory Care, Assisted Living, Behavioral Health Care, Critical
Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term
Care, Office-Based Surgery
Patient Identification
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Requirement: Prior to the start of any
invasive procedure, conduct a final verification
process, (such as a “time out,”) to confirm the
correct patient, procedure and site, using
active—not passive—communication
techniques.
Applies to: Assisted Living, Home Care, Lab, Long Term
Care
Improve Communication
Goal: Improve the effectiveness of
communication among caregivers.
Requirement: For verbal or telephone
orders or for telephonic reporting of critical
test results, verify the complete order or test
result by having the person receiving the
information record and "read-back" the
complete order or test result.
Improve Communication
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Requirement: Standardize a list of
abbreviations, acronyms, symbols, and dose
designations that are not to be used
throughout the organization.
Applies to: Ambulatory Care, Assisted Living, Behavioral
Health Care, Critical Access Hospital, Disease-Specific
Care, Home Care, Hospital, Lab, Long Term Care,
Office-Based Surgery
Improve Communication
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Requirement: Measure, assess, and if
appropriate, take action to improve the
timeliness of reporting, and the timeliness of
receipt by the responsible licensed caregiver,
of critical tests and critical results and values.
Applies to: Ambulatory Care, Behavioral Health Care,
Critical Access Hospital, Disease-Specific Care, Home
Care, Hospital, Lab, Long Term Care, Office-Based
Surgery
Improve Communication
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Requirement: Implement a standardized
approach to “hand off” communications,
including an opportunity to ask and respond to
questions.
Applies to: Ambulatory Care, Assisted Living, Behavioral
Health Care, Critical Access Hospital, Disease-Specific
Care, Home Care, Hospital, Lab, Long Term Care,
Office-Based Surgery
Medication Safety
Goal: Improve the safety of using medications.
Requirement: Identify and, at a minimum,
annually review a list of look-alike/soundalike drugs used by the organization, and
take action to prevent errors involving the
interchange of these drugs.
Applies to: Ambulatory Care, Behavioral Health Care,
Critical Access Hospital, Home Care, Hospital, Long
Term Care, Office-Based Surgery
Medication Safety
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Requirement: Label all medications,
medication containers (for example, syringes,
medicine cups, basins), or other solutions on
and off the sterile field.
Applies to: Ambulatory Care, Critical Access Hospital,
Hospital, Office-Based Surgery
Health Care-Associated Infections
Goal: Reduce the risk of health careassociated infections.
Requirement: Comply with current World
Health Organization (WHO) Hand Hygiene
Guidelines or Centers for Disease Control
and Prevention (CDC) hand hygiene
guidelines.
Reconcile Medications
Goal: Accurately and completely reconcile
medications across the continuum of care.
Reconcile Medications
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Requirement: A complete list of the patient’s
medications is communicated to the next provider
of service when a patient is referred or transferred
to another setting, service, practitioner or level of
care within or outside the organization. The
complete list of medications is also provided to the
patient on discharge from the facility.
Applies to: Ambulatory Care, Assisted Living, Behavioral
Health Care, Critical Access Hospital, Disease-Specific
Care, Home Care, Hospital, Long Term Care, OfficeBased Surgery
Patient Involvement
Goal: Encourage patients’ active involvement
in their own care as a patient safety strategy.
Requirement: Define and communicate the
means for patients and their families to
report concerns about safety and encourage
them to do so.
Pressure Ulcers
Goal: Prevent health care-associated
pressure ulcers (decubitus ulcers).
Requirement: Assess and periodically
reassess each resident’s risk for developing
a pressure ulcer (decubitus ulcer) and take
action to address any identified risks.
Applies to: Long Term Care
Joint Commission and
Ultrasound Services
Standards for Diagnostic
Imaging facilities:
The Standard itself is a statement that defines the performance
expectations and/or structures or processes that must be in place
in order for an organization to provide safe, high-quality care.
A center is evaluated as either “compliant” or “not compliant” with a
standard.
Accreditation decisions are based on simple counts of the
standards scored “not compliant.”
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Elements of performance (EPs) are specific performance expectations
and/or structures
or processes that must be in place. The scoring of EP compliance
determines a center’s
overall compliance with a standard. EPs are evaluated on the following
scale:
0 - Insufficient compliance
1 - Partial compliance
2 - Satisfactory compliance
NA - Not applicable
QA in Ultrasound: Environment
of Care
Environment of Care (EC)
The goal is to promote a safe, functional, and supportive environment
within the organization so that quality and safety are preserved.
The environment of care is made up of the following three basic elements:
• The building or space, including how it is arranged and special features
that protect patients, visitors and staff
• Equipment used to support patient care or to safely operate the building
or space
• People, including those who work within the organization, patients, and
anyone else who enters the environment, all of whom have a role in
minimizing risks.
Elements of Performance
Elements of Performance for EC.02.04.03
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1 Before initial use of medical equipment on the medical equipment inventory, the
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organization performs safety, operational, and functional checks. (See also EC.02.04.01,
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EP 2)
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2 The organization inspects, tests, and maintains all life support equipment. These
activities are documented. (See also EC.02.04.01, EPs 3 and 4)
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3 The organization inspects, tests, and maintains non-life support equipment identified on
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the medical equipment inventory. These activities are documented. (See also EC.02.04.01,
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EPs 2-4)
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4 The organization conducts performance testing of and maintains all sterilizers. These
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activities are documented. (See also IC.02.02.01, EP 2)
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5 The organization performs equipment maintenance and chemical and biological testing of
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water used in hemodialysis. These activities are documented.
Emergency Ultrasound
Emergency Services
(Ultrasound)
As part of its Emergency Management Plan, the organization prepares for how it
will manage patients during emergencies
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The fundamental goal of emergency management planning is to protect life and
prevent disability.
The manner in which care, treatment or services are provided may vary by type
of emergency.
However, certain activities are so fundamental to patient safety (this can include
decisions to modify or discontinue services, make referrals, or transport
patients) that the organization should take a proactive approach in considering
how they might be accomplished.
Human Resources: Certification,
competency: Ethics…
Human Resources
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The contribution that human resources management makes to an
organization’s ability to
provide safe, quality care cannot be overestimated.
The standards and elements of performance address the
organization’s
responsibility to establish and verify staff qualifications, orient staff, and
provide staff with
the training they need to support the care, treatment, or services the
organization provides.
Once staff is on the job, human resources must provide for the
assessment of staff
competence and performance.
Human Resources
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All staff that provide patient care,
treatment or services posses a current
license, certification, or registration, as
required with law and regulation.
Human Resources
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Staff who provide patient care, treatment, or services practice within
the scope of their license, certification, or registration and as required
by law and regulation.
Staff oversee the supervision of students when they provide patient
care, treatment, or services as part of their training.
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The organization defines the competencies it requires of its staff who provide patient care,
treatment, or services.
An individual with the education background, experience, or knowledge related to the
skills being reviewed assesses competence.
Note: When a suitable individual cannot be found to assess staff competence, the
organization can utilize an outside individual for this task. Alternatively, the organization
may consult the competency guidelines from an appropriate professional organization to
make its assessment.
Staff competence is initially assessed and documented as part of orientation.
Staff competence is assessed and documented once every three years or more frequently
as required by organization policy or in accordance with law and regulation.
The organization takes action when a staff member’s competence does not meet
expectations.
Infection Control
Infection Prevention and Control
To help reduce the possibility of acquiring and transmitting an infection, ambulatory
care
centers should establish a systematic infection prevention and control program.
The processes are applicable to all infections or potential sources of infection that
an ambulatory health care practitioner might encounter, including a sudden influx of
potentially infectious patients.
These standards address activities of planning, implementation, and evaluation and
are based
on the following conditions necessary to establish and operate an effective infection
prevention and control program. Every ambulatory care center, regardless of its
size or the
services it provides, should:
Infection Prevention and Control
Recognize that its infection prevention and control program plays a major role in its
efforts to improve patient safety and quality of care
• Demonstrate leadership’s commitment to infection prevention and control
• See that staff collaborate with each other when designing and implementing the
infection prevention and control program
• Regularly assess its infection prevention and control program by using an approach
that consists of surveillance, data collection, analysis, and trend identification
• Coordinate its program with the larger community
• Take into account that the potential exists for an infection outbreak so extensive that
it overwhelms the ambulatory care center’s resources
Information (Data) Management
Information Management
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Every episode of care generates health information that must be managed systematically
by the organization.
All data and information used by the organization is categorized, filed, and
maintained.
Health information should be accessed by authorized users who will use health
information to provide safe, quality care.
Unauthorized access can be limited by the adoption of policies that address the privacy,
security, and integrity of health information
Medical Imaging Leadership
Leadership
The safety and quality of care, treatment, or services depend on many factors including the
following:
A culture that fosters safety as a priority for everyone who works in the
organization
• The planning and provision of services that meet the needs of patients
• The availability of resources—human, financial, and physical—for providing
care, treatment, or services
• The existence of competent staff and other care providers
• Ongoing evaluation of and improvement in performance
Patient’s Rights…
Rights and Responsibilities of
the Individual
When the organization recognizes and respects patient rights, it is
providing an important
aspect of care that has been shown to encourage patients to become
more informed and
involved in their care.
Recognizing and respecting patient rights directly impact the provision of
care.
Care, treatment, or services should also be carefully planned and
provided with regard to the patient’s personal values, beliefs, and
preferences.
Rights and Responsibilities of
the Individual
The standards address the following processes and activities as they
relate to
patient rights:
 • Informing patients of their rights
 • Helping patients understand and exercise their rights
 • Respecting patients’ values, beliefs, and preferences
 • Informing patients of their responsibilities regarding their care,
treatment, or services.