Joint Commission Hospital Executive Briefings Update

Joint Commission Hospital Executive Briefings Update

With fresh content and some new faces, the latest Joint Commission Hospital Executive Briefing seemed to be approached with a renewed sense of purpose. At the forefront of the presentations, speakers offered practical tips and tools on the topics of infection control, environment of care, medication management, and suicide prevention – the four identified high-risk areas in TJC’s 411 on Survey Enhancements.

Infection Control Update

For the past couple of years, the hospital executive briefings on infection control have shifted away from focusing on hospital acquired surgical site infections and high-level disinfection sterilization. Instead, presentations focused on environmental causes of infections and seemed to ask whether hospitals are making patients sicker. During this presentation we learned that in 2017 the Centers for Medicare and Medicaid Services (CMS) released a memo requiring healthcare facilities to reduce the risk of Legionella in their water systems. The speaker indicated that there is more Legionella pneumophia present in the environment and that when hospitals test the quality of their water, nine out of ten will test positive for Legionella.

Risk assessments were advocated by CMS and TJC to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Waterborne pathogens can be found in the water systems including shower heads, faucets, ice machines, water baths, decorative fountains, and cooling towers. The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the Centers for Disease Control and Prevention (CDC) offer several resources including standards and toolkits for water management, physical controls related to temperature management, disinfectant levels, inspections and testing for pathogens to help hospitals reduce Legionella.

We learned that high-risk patients who are exposed to mold have higher fatality rates. Surfaces that stay wet for longer than 72 hours are potential sources of mold. Ceiling tiles can become breeding grounds for mold if faulty overhead plumbing leaks onto ceiling tiles. Hospitals were cautioned to conduct risk assessments for any work that generates dust including construction, vacuuming, or even watering plants. The speaker cautioned that many of the infection control risk assessments (ICRAs) fail to include multiple construction phase projects, may not include all of the elements specified by the Facilities Guidelines Institute (FGI) or the CDC publication on Guidelines for Environmental Infection Control in Healthcare Facilities, or do not include the Infection Preventionist.

It’s important that staff use personal protective equipment (PPE) not only for their safety, but to protect their families as well as their patients. Employers should enforce correct procedures when staff are donning and doffing PPE. The CDC has an excellent resource for putting on and removing PPE that could easily be used for competency assessments.

IC. 02.04.01 EP 5 requires that hospitals (1) set incremental flu vaccine goals for staff and providers and (2) show progress towards attaining 90% compliance by 2020. Hospitals are not required to be at 90% but must be able to show progress towards meeting this goal.

Environment of Care and Life Safety Update

Data from hospitals surveyed in 2018 revealed that the five most frequently cited immediate threat to health and safety (ITHS) findings concerned:

  1. A lack of a mitigation plan to address ligature risks
  2. Failure to adopt evidence-based guidelines for high-level disinfection sterilization
  3. Failure to follow manufacturer instructions for use
  4. A lack of training and competency related to high-level disinfection and sterilization
  5. Failure to conduct suicide risk assessments.

One resource available to hospitals is TJC’s Physical Environment portal which provides guidance on compliance with the top cited environment of care (EC) and life safety standards. Additionally, the speaker shared that EC rounds are excellent tools to monitor unsafe practices and mitigate identified risks. Earlier this year, TJC published a Fire Drill Matrix which organizations can use to help ensure that fire drills are conducted randomly.

Coming in 2020, the e-application will ask for building square footage as exact measurements instead of ranges. Facilities staff can expect Life Safety surveyors to focus on pre-construction assessments, lab, dust, rust, and damaged equipment. Any space where a patient could go (e.g., retail restaurants/gift shops, pharmacy) will be subject to Life Safety inspections.

Suicide/Ligature Risk Update

The Joint Commission has provided a suicide-prevention portal to assist organizational compliance with this national patient safety goal. Early identification of patients is a key suicide prevention strategy. Screening identifies individuals that require further mental health/suicide safety assessment. Organizations should choose an evidence-based tool to screen patients that are at risk of harming themselves or others. Hospitals are expected to implement a patient screening and risk assessment strategy that is appropriate to the patient population (i.e. pediatric population versus adult population). Organizations are cautioned not to use evidence-based screening tools designed for depression to screen patients for suicidal ideation. Organizations should never alter the evidence-based tool that they choose.

In all areas designated for the treatment of psychiatric patients, organizations should conduct an environmental risk assessment annually or when changes in the environment occur. Environmental risk assessments must be appropriate to each unit and should consider the possibility that the unit may sometimes care for patients at risk for threat of harm to self or others. TJC strongly cautioned attendees not to place staffing restrictions on the environmental risk assessment. If a patient is not in a ligature resistant environment the mitigation strategy must be a 1:1 with continuous visual observation.

Medication Management Update

Complex medication orders such as titration orders, therapeutic duplication, and range orders continue to be frequently scored items in part due to lack of clear orders and misconceptions. Pharmacy staff must review orders and have a procedure in place to clarify orders that do not match the organization’s policy. Policies can be utilized and implemented to guide direction when orders are unclear. In addition to the elements required for a complete medication order, titration orders should include the starting dose (rate), the titration amount, titration frequency, the maximum dose (expressed as a rate), and the clinical endpoint.

When more than one medication is ordered for the same indication (therapeutic duplication), it’s difficult for pharmacists to know whether this was an intentional act or oversight by the provider. The standard states that all orders must be reviewed for therapeutic duplication. The organization should have a policy on clarifying these orders and addressing how nursing will know that the therapeutic duplication is intended. Organizations should leverage the use of the electronic medical record to ensure these orders are clear on the medication administration record.

A common misconception is that TJC prohibits range orders and that orders must then be split in the medication administration record. However, this practice carries the risk of administering more medication than was intended, so organizations should carefully develop consistent practices for implementing range orders. TJC will be providing several resources to accredited organizations to assist in addressing complex medication orders.

In September, the United States Pharmacopeia (USP) announced that in accordance with its bylaws, the effective date for implementation of the standards for general chapters <795> (Pharmaceutical Compounding – Nonsterile Preparations), <797> (Pharmaceutical Compounding – Sterile Preparations), and <825> (Radiopharmaceuticals – Preparation, Compounding, Dispensing, and Repackaging) had been postponed from the original date of 12/1/2019. The new general chapter <800> (Hazardous Drugs Handling in Healthcare Settings) will be informational only and will not be applicable until the appeals process is complete.

Even though the implementation dates have been postponed while an appeal is pending, the USP encourages utilization of <800> in the interest of advancing public health. In order to be proactive, TJC is encouraging organizations to complete a risk assessment to determine the NIOSH category for all medications. If a medication is NIOSH Category 1 <800> requirements for receiving, compounding, and storage must be met. If medications fall in NIOSH Category 2 and 3 the level of implementation should be determined by a risk assessment.

Medication compounding continues to focus on four areas that include personnel, product, environment, and leadership. Coming soon: TJC will make a sterile compounding portal available to its customers and provide a self-assessment and gap analysis tool.

Currently Trending

Surveyors are focusing on food and nutrition storage (outdated/expired food, lack of cleanliness, improper storage temperatures, and equipment failures) (PC.02.02.03 EP11). Resuscitation equipment is coming under surveillance as cart checks are not performed in the frequency required by hospital policy, medications and/or supplies are expired, the manufacturer’s instructions for use are not followed in checking emergency equipment, open electrode packs are not dated, and staff are unable to demonstrate how to test defibrillators (PC.02.01.11 EP 2). Although code drills are not required, many organizations find them useful in assessing staff competencies. Hospitals are encouraged to standardize their cart checklist.

Presedation assessment standard PC.03.01.03 EP 1 is most frequently cited when performing moderate sedation procedures or electroconvulsive treatments as being incomplete or not timed. To comply with the standard hospitals are urged to reduce variation when sedation is performed in multiple procedural areas, provide staff education, and conduct routine monitors to ensure all required elements for completing the pre-anesthesia assessment are documented. Changes to the Medical Staff chapter includes sharing of information between organizations that are CMS certified. Organizations should keep in mind that primary source verification must be done at the organization and cannot be shared information. Organizations can use information from other CMS certified organizations for FPPE and OPPE to supplement their information, especially in the case of low volume providers; however, the organization still must collect organization-specific data.

TiER1 Healthcare can help!

To discuss how TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment, call (800) 241-0142 or email for a consultation.


Read More from These Authors

Suicidal Ideation and Patient Safety – Tabitha Garbart

Does Your Moderate Sedation Program Measure Up? – Tabitha Garbart

What’s the Difference between TJC and CMS Survey Preparation? – Victoria Fennel

Share your email address to get our best performance content delivered to your inbox via our eNewsletter.

Subscribe T1HC Newsletter:

Keep reading