We attended the annual TJC Hospital Executives Briefings and CMS Update in New York City earlier this month. It was chock full of information on the latest TJC and CMS compliance issues. It was also a glimpse into what some of the key TJC focus areas will be in 2015. The following are highlights from the conference with more info to follow as these new requirements unfold.

News Item # 1: New Patient Safety Systems chapter coming in 2015

A new chapter will be added to the Hospital Accreditation Manual in 2015. It is titled the Patient Safety Systems chapter. This new chapter will not contain any new standards or requirements per se. Rather, it will describe how existing Joint Commission requirements can be applied to enhance patient safety. Here’s an outline of the chapter:

• Becoming a Learning Organization
• The Role of Leaders in creating a Fair and Just Safety Culture
• Data Use and Reporting Systems
• A Proactive Approach to Preventing Harm
• Encouraging Patient Activation (helping patients become more actively involved in their own care)

It was clear from the presentation that while there are no new requirements in this new chapter, its content will be a focus of surveys in 2015 with surveyors zeroing in on leadership’s role in this area.

News Item # 2: Revised Sentinel Event Policy coming in 2015

TJC has rewritten its Sentinel Event Policy. Some of the key changes are as follows:

• The policy defines Sentinel Events as just one category of Patient Safety Events. A Patient Safety Event is an event, incident, or condition that could have resulted or did result in harm to a patient. Patient Safety Events also include adverse events, close calls (or near misses), hazardous (or unsafe conditions), and no-harm events.
• The types of follow-up activities that TJC may require have been expanded. These typically include submitting Measures of Success (MOS) related to the sentinel event or other documentation of sustained improvement.
• A new term “Comprehensive Systematic Analysis” is used (for identifying the causal and contributory factors) with Root Cause Analysis identified as the most common example.

News Item # 3: Top Hospital Standards Compliance Issues for First Half of 2014

One of the favorite sessions at this conference is listening to the details of the current top standards compliance issues. While the Top Ten compliance issues were also published in the September 2014 issue of TJC Perspectives, Executive Briefings goes twice as deep and identifies the Top Twenty compliance issues. This is particularly helpful since eight of the Top Ten compliance issues for hospitals are in the areas of Environment of Care or Life Safety. So, here’s a summary of the non-EOC/Life Safety issues that fall into the Top Twenty and how we see these playing out in psychiatric hospitals:

Infection Control Chapter

Reducing risk of infections associated with medical equipment (IC.02.02.01); 50% of hospitals cited. Issues are:

• Lack of staff training re disinfection of medical equipment
• Failure to follow procedures
• Inadequate supervision

Record of Care Chapter

Complete and accurate medical records (RC.01.01.01); 49% of hospitals cited. Issues are:

• Timing and dating of entries
• Lack of information to promote continuity of care (Lack of alignment between assessments and treatment plans is frequently cited.)

Medication Management Chapter

Safe medication storage (MM.03.01.01); 32% of hospitals cited. Issues are:

• Medication storage area not secure
• Expired medications
• Opened multi-dose vials not labeled with 28 day expiration date

Unclear medication orders (MM.04.01.01); 24% of hospitals cited. Issues are:

• Unclear medication orders (e.g. PO/IM or 1-2 tablets every 4 hours)

Pharmacy review of medication orders (MM.05.01.01); 20% of hospital cited. Most common issue is no review for therapeutic duplication:

• Multiple PRNs without clear guidelines when one is to be selected over another
• Multiple pain medications
• Multiple benzodiazepines for anxiety

Provision of Care Chapter

Treatment Planning (PC.01.03.01); 29% of hospitals cited. Issues are:

• Problems identified in assessment not address in treatment plans (e.g. medical issues)
• Lack of revision to tx plans based on progress or lack of progress

Pre and Post Anesthesia Assessment (for hospitals doing ECT) (PC.03.01.03); 24% of hospitals cited. Most common issue is that the assessment does not contain all the TJC required components.

Leadership Chapter

Management of programs and services (LD.04.01.05); 22% of hospitals cited. Most commonly cited issue is “Staff are held accountable for their responsibilities.” Surveyors cite this when they conclude that leadership has allowed non-compliance to exist without correction.

We recommend that you incorporate review of these “Hot Spots” into your Continuous Readiness Program. Include these topics in your medical record audits, your tracers, and consider conducting a time limited study on a particular topic to see if it’s a trouble spot for your organization.