Top Standards Compliance Data for First Half of 2016

Transcription

1 The Official Newsletter of The Joint Commission September 2016 Volume 36 Number 9 l l Top Standards Compliance Data for First Half of 2016 The Joint Commission regularly aggregates standards compliance data to pinpoint areas that present the greatest challenges to accredited organizations and certified programs. These data help The Joint Commission recognize trends and tailor education around challenging standards; National Patient Safety Goals (NPSGs); the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery ; and Accreditation or Certification Participation Requirements (APRs or CPRs). The bar graphs on pages 3 to 8 identify the Joint Commission requirements scored most frequently as not compliant during accreditation surveys and certification reviews from January 1, 2016, through June 30, (Data from for-cause surveys and for-cause reviews are not included.) While the principal text of the standards also appears in the bar graphs, the full content of each (including rationales, notes, and elements of performance) is included in the accreditation and certification manuals on E-dition and in print. The graphs display the 10 most frequently cited requirements for each program. Percentages indicate the number of organizations that received Requirements for Improvement (RFIs) for the standards shown. Please note that graphs for critical access hospitals, office-based surgery practices, and health care staffing services display more than 10 standards because several were tied in their percentage of RFIs. In addition, the graph for palliative care displays fewer than 10 standards because organizations achieved full compliance with the remaining standards. As a reminder, surveyors review compliance with all standards in manuals. These graphs are provided only to help organizations recognize potential trouble spots. Standards FAQs are located at standards_information/jcfaq.aspx; questions not addressed on this site may be directed to the Standards Interpretation Group via the online question form at sigsubmission/sigquestionform.aspx. P Contents 1 Top Standards Compliance Data for First Half of In Sight 2 Clarifications and Expectations Column on Hiatus 8 Revisions Announced for the System Accreditation Option 9 Notifying The Joint Commission About Organization Changes 11 Consistent Interpretation Continued on page 3

2 In Sight Executive Editor Katie Byrne Senior Project Manager Allison Reese Associate Director, Publications Helen M. Fry, MA Executive Director, Publications and Education Catherine Chopp Hinckley, MA, PhD Subscription Information: The Joint Commission Perspectives (ISSN ) is published monthly (12 issues per year) by Joint Commission Resources, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL Send address corrections to Joint Commission Perspectives, or Annual subscription rates for 2016: United States, Canada, and Mexico $319 for print and online, $299 for online only. Rest of the world $410 for print and online, $299 for online only. For airmail add $25. Back issues are $25 each (postage paid). Orders for single/ back copies receive a 20% discount. Site licenses and multiyear subscriptions are also available. To begin your subscription, jcrcustomerservice@pbd.com, call , or mail orders to Joint Commission Resources, Collections Center Drive, Chicago, IL Direct all inquiries to jcrcustomerservice@pbd.com or Copyright 2016 The Joint Commission This column lists developments and potential revisions that can affect accreditation and certification and tracks proposed changes before they are implemented. Items may drop off this list before the approval stage if they are rejected at some point in the process. APPROVED POLICIES l Revisions to the System Accreditation Option for ambulatory care and home care organizations (see article on page 8 of this issue) l Revisions to the Notifying The Joint Commission About Organization Changes policy for all accreditation programs and the Notifying The Joint Commission About Staffing Firm Changes for the health care staffing services certification program (see article on page 9 of this issue) CURRENTLY IN DEVELOPMENT STANDARDS l Proposed deletion of 51 additional elements of performance for hospitals as Phase II of the EP Review Project component of Project REFRESH l Proposed new Human Resources (HR) Standard HR , EP 37, for ambulatory care organizations that provide sleep study services l Proposed new and revised requirements for laboratories that address the following: molecular and genetic testing, clinical chemistry and toxicology, and aligning various requirements with Clinical Laboratory Improvement Amendments (CLIA) Interpretive Guidelines l Proposed revisions to clarify language of several requirements for behavioral health care organizations l Proposed revised and new requirements for Advanced Certification for Inpatient Diabetes Care in the disease-specific care program l Proposed expansion of the Integrated Care Certification program option for ambulatory care organizations, hospitals, and critical access hospitals to include home care and nursing care centers as partners along the post-acute care continuum l Proposed new Comprehensive Cardiac Center advanced certification option for accredited hospitals No part of this publication may be reproduced or transmitted in any form or by any means without written permission. Contact permissions@jcrinc.com for inquiries. Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes the materials under license from The Joint Commission. The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Visit us on the Web at Clarifications and Expectations Column on Hiatus The column Clarifications and Expectations, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Department of Engineering, The Joint Commission, is on hiatus. It is scheduled to return, with the 40th installment of the series, in the October 2016 issue of Perspectives. P 2 The Joint Commission Perspectives September 2016

3 Top Standards Compliance Data for First Half of 2016 (continued) Continued from page 1 Top Standards Compliance Data for First Half of 2016 Ambulatory Care 49% IC The organization reduces the risk of infections associated with medical equipment, devices, and supplies. 48% HR The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 39% MM The organization safely stores medications. 35% EC The organization inspects, tests, and maintains medical equipment. 34% EC The organization maintains fire safety equipment and fire safety building features. 31% EC The organization inspects, tests, and maintains emergency power systems. 29% EC The organization manages risks related to hazardous materials and waste. 29% MM The organization safely manages high-alert and hazardous medications. 28% MM The organization addresses the safe use of look-alike/sound-alike medications. 26% EC The organization manages risks associated with its utility systems. Note: The data determined for the ambulatory care program were derived from an average of 303 applicable surveys. Top Standards Compliance Data for First Half of 2016 Behavioral Health Care 44% CTS The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served. 30% HRM The organization verifies and evaluates staff qualifications. 30% NPSG Identify individuals at risk for suicide. 25% HRM Staff are competent to perform their job duties and responsibilities. 24% IC The organization facilitates staff receiving the influenza vaccination. 20% EC The organization establishes and maintains a safe, functional environment. 19% CTS % CTS For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products. For organizations providing care, treatment, or services in non 24-hour settings: The organization implements a written process requiring a physical health screening to determine the individual s need for a medical history and physical examination. 17% CTS The organization screens all individuals served for their nutritional status. 17% EC The organization maintains fire safety equipment and fire safety building features. Note: The data determined for the behavioral health care program were derived from an average of 474 applicable surveys. September 2016 The Joint Commission Perspectives 3

4 Top Standards Compliance Data for First Half of 2016 Critical Access Hospitals 73% IC The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 73% EC The critical access hospital maintains fire safety equipment and fire safety building features. 73% EC The critical access hospital manages risks associated with its utility systems. 59% EC The critical access establishes and maintains a safe, functional environment. 56% LS The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 49% LS The critical access hospital maintains the integrity of the means of egress. 46% EC The critical access hospital manages risks related to hazardous materials and waste. 39% EC The critical access hospital manages fire risks. 39% EC The critical access hospital inspects, tests, and maintains emergency power systems. 39% LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. 39% LS The critical access hospital provides and maintains systems for extinguishing fires. Note: The data determined for the critical access hospital program were derived from 41 applicable surveys. Top Standards Compliance Data for First Half of 2016 Disease-Specific Care Certification 28% DSDF.3 19% DSDF.2 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs. The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care. 17% DSDF.1 Practitioners are qualified and competent. 12% DSCT.5 The program initiates, maintains, and makes accessible a medical record for every patient. 10% DSSE.3 The program addresses the patient s education needs. 8% DSPR.1 The program defines its leadership roles. 7% DSPM.5 The program evaluates patient satisfaction with the quality of care. 6% DSDF.4 The program develops a plan of care that is based on the patient s assessed needs. 5% DSPR.5 The program determines the care, treatment, and services it provides. 4% DSPM.3 The program collects measurement data to evaluate processes and outcomes. Note: The data determined for the disease-specific care program were derived from 836 applicable surveys (not including those for Advanced Certification for Lung Volume Reduction Surgery or Advanced Certification for Ventricular Assist Device Destination Therapy). 4 The Joint Commission Perspectives September 2016

5 Top Standards Compliance Data for First Half of 2016 Health Care Staffing Services Certification 8% HSHR.1 The HCSS firm confirms that a person s qualifications are consistent with his or her assignment(s). 7% HSHR.6 The HCSS firm evaluates the performance of clinical staff. 4% HSLD.5 The services contracted for by the HCSS firm are provided to customers. 4% HSPM.3 The HCSS firm collects data to evaluate processes and outcomes. 3% CPR 5 The staffing firm submits performance measurement data to The Joint Commission on a routine basis. 3% HSPM.4 The HCSS firm analyzes its data. 2% HSLD.9 The HCSS firm addresses emergency management. 1% CPR 8 The staffing firm accurately represents its certification status and the facilities and services to which Joint Commission certification applies. 1% HSLD.1 The health care staffing services (HCSS) firm clearly defines its leadership roles. 1% HSLD.6 The HCSS firm is accessible to customers and staff. 1% HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information. 1% HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors. Note: The data determined for the health care staffing services program were derived from 101 applicable surveys. Top Standards Compliance Data for First Half of 2016 Home Care 41% PC The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. 36% PC The organization plans the patient s care. 29% IC The organization offers vaccination against influenza to licensed independent practitioners and staff. 28% IC The organization implements the infection prevention and control activities it has planned. 28% RC The patient record contains information that reflects the patient s care, treatment, or services. 27% HR The organization verifies staff qualifications. 27% HR Staff are competent to perform their responsibilities. 22% EM The organization evaluates the effectiveness of its Emergency Operations Plan. 20% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 16% PI The organization compiles and analyzes data. Note: The data determined for the home care program were derived from an average of 1,000 applicable surveys. September 2016 The Joint Commission Perspectives 5

6 Top Standards Compliance Data for First Half of 2016 Hospitals 66% EC The hospital establishes and maintains a safe, functional environment. 59% IC The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 56% EC The hospital manages risks associated with its utility systems. 50% LS The hospital maintains the integrity of the means of egress. 47% LS The hospital provides and maintains systems for extinguishing fires. 46% PC % LS % LS The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation. The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. 44% EC The hospital manages risks related to hazardous materials and waste. 44% RC The hospital maintains complete and accurate medical records for each individual patient. Note: The data determined for the hospital program were derived from 763 applicable surveys. Top Standards Compliance Data for First Half of 2016 Laboratory and Point-of-Care Testing 42% HR Staff are competent to perform their responsibilities. 34% QSA The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. 32% DC The laboratory report is complete and is in the patient s clinical record. 31% QSA The laboratory has a process for handling and testing proficiency testing samples. 30% LD The laboratory director, technical consultant, and/or technical supervisor are responsible for maintaining laboratory performance. 28% EC The laboratory inspects, tests, and maintains laboratory equipment. 28% QSA The laboratory performs calibration verification. 27% QSA % QSA The laboratory performs quality control testing to monitor the accuracy and precision of the analytic process. The laboratory participates in Centers for Medicare & Medicaid Services (CMS) approved proficiency testing programs for all regulated analytes. 27% QSA The laboratory maintains records of its participation in a proficiency testing program. Note: The data determined for the laboratory program were derived from an average of 383 applicable surveys. 6 The Joint Commission Perspectives September 2016

7 Top Standards Compliance Data for First Half of 2016 Nursing Care Centers 38% HR The organization permits licensed independent practitioners to provide care, treatment, and services. 21% MM The organization safely stores medications. 19% PC The organization assesses and manages the patient s or resident s pain. 17% WT Staff and licensed independent practitioners performing waived tests are competent. 16% PC The organization assesses and reassesses the patient or resident and his or her condition according to defined time frames. 13% HR The organization verifies staff qualifications. 13% EC The organization manages safety and security risks. 13% EC The organization establishes and maintains a safe, functional environment. 13% PC The organization plans the patient s or resident s care. 13% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Note: The data determined for the nursing care centers program were derived from 149 applicable surveys. Top Standards Compliance Data for First Half of 2016 Office-Based Surgery Practices 71% HR The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 53% IC The practice reduces the risk of infections associated with medical equipment, devices, and supplies. 41% EC The practice inspects, tests, and maintains medical equipment. 27% IC The practice identifies risks for acquiring and transmitting infections. 25% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 24% IC The practice offers vaccination against influenza to licensed independent practitioners and staff. 24% IC The practice plans for preventing and controlling infections. 24% MM The practice safely manages high-alert and hazardous medications. 20% MM The practice addresses the safe use of look-alike/sound-alike medications. 18% WT The practice maintains records for waived testing. 18% MM The practice safely stores medications. 18% NPSG Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: The data determined for the office-based surgery practices program were derived from an average of 51 applicable surveys. September 2016 The Joint Commission Perspectives 7

8 Top Standards Compliance Data for First Half of 2016 Palliative Care Certification 59% PCPC.4 The interdisciplinary program team assesses and reassesses the patient s needs. 28% PCPM.6 Program leaders are responsible for selecting, orienting, educating, and retaining staff. 19% PCPI.2 The program collects data to monitor its performance. 19% PCPI.3 The program analyzes and uses its data to identify opportunities for performance improvement. 16% PCPC.3 The program tailors care, treatment, and services to meet the patient s lifestyle, needs, and values. 13% PCPM.7 The program has an interdisciplinary team that includes health care professionals with the education and experience to provide the program s specialized care, treatment, and services that meet the needs of the patient and family. 9% PCIM.2 The program maintains complete and accurate medical records. 6% PCPC.2 The program communicates with patients and families and involves them in decision making. 3% PCPC.1 Patients and families know how to access and use the program s care, treatment, and services. Note: The data determined for the palliative care program were derived from 32 applicable surveys. Revisions Announced for the System Accreditation Option Policy Revisions Applicable to Ambulatory Care and Home Care Effective January 1, 2017, The Joint Commission has revised the System Accreditation Option for accredited ambulatory care and home care organizations. The System Accreditation Option involves awarding a single accreditation decision to a system an organization that has a corporate office or a main site, with multiple sites under the auspices of the main site. Surveying the system entails a visit to the main site and visits to a selected sample of sites within the system; the sites are selected based on the size of the system and the risk level of the services provided. The recent revisions involve changes to the sampling methodology and extension survey policy. Sampling Methodology The first revision reduces the number of sites that must be reviewed in order to provide a credible evaluation of the system and render an accreditation decision indicative of the performance of the entire system. The table in the column at right identifies the number of sites that are required to be reviewed, based on whether the services provided are high risk or low risk. Please note that this methodology does not apply to ambulatory care sites providing surgery, general sedation, or moderate sedation. Any ambulatory care system site that Sampling for System Surveys by Size Note: All ambulatory care sites that provide general anesthesia, moderate sedation, or surgery are considered high risk and will be sampled at a rate of 100%. High-Risk Sites Low-Risk Sites Number of Sites in System Survey Volume 75 or fewer All sites up to or more 25% of sites up to a maximum of 30 sites Number of Sites in System Survey Volume 200 or fewer All sites up to or more 10% of sites up to a maximum of 30 sites Continued on page 10 8 The Joint Commission Perspectives September 2016

9 Notifying The Joint Commission About Organization Changes Effective October 1, 2016, for all accreditation programs, The Joint Commission has updated its policy regarding notification of changes within accredited organizations. The Notifying The Joint Commission About Organization Changes policy appears in The Accreditation Process (ACC) chapter of the Comprehensive Accreditation Manuals.* Historically, the policy required organizations to notify The Joint Commission within 30 days after a significant change occurred. However, because certain changes may result in the need for on-site survey activity, the policy now requires organizations to provide written notification to The Joint * The similar policy Notifying The Joint Commission About Staffing Firm Changes in the Health Care Staffing Services Certification Manual will also be updated to reflect the revisions. Commission when the change is initially contemplated that is, when leadership within the organization has approved moving forward with the proposed change and identified a time frame for implementing that change. Advance notice of a potential change allows organizations and The Joint Commission to evaluate whether there is any impact from an accreditation standpoint, including the need and timing for any on-site survey activity. Once the change has officially occurred, the organization should update its electronic application for accreditation (E-App) within 30 days. The policy revisions (shown below; new text is underlined and deleted text has strikethrough) will be included in the fall 2016 E-dition update and the 2017 manuals. Questions may be directed to an organization s assigned account executive. P Official Publication of Joint Commission Requirements Revisions to Policy Regarding Notification of Changes Applicable to All Accreditation Programs Effective October 1, 2016 Notifying The Joint Commission About Organization Changes Accreditation is neither automatically transferred nor continued if significant changes occur within [an organization]. Organizations must notify The Joint Commission promptly, in writing, when an additional service is contemplated* so any potential impact to accreditation can be determined. Medicare-certified organizations must also notify the Medicare Administrator Contractor promptly, in writing, when an additional service is contemplated. When significant changes occur, the [organization] must notify The Joint Commission in writing or through its Joint Commission Connect site not more than 30 calendar days after such change is made. The [organization] must also notify The Joint Commission in writing or in its E-App if it opens or closes any units or services. Once the change has actually occurred, the E-App must be updated to reflect the change as well. Changes Affecting E-App Information At any time during the accreditation process, an organization may undergo a change that modifies the information reported in its E-App (see APR in the APR chapter). The [organization] must update its E-App within 30 calendar days after such a change is made. Organizations must notify The * An organization is considered to have contemplated a change when leadership within the organization has approved moving forward with the proposed change and identified a time frame for implementing that change. Joint Commission promptly, in writing, when an additional service or location is contemplated so any potential impact to accreditation can be determined. Medicare-certified organizations must notify the Medicare Administrator Contractor promptly, in writing, when an additional service is contemplated. Once the change has actually occurred, the organization must update its E-App within 30 calendar days. Information that must be reported includes any of the following: l A change in ownership l A change in location l A significant increase or decrease in the volume of services or individuals served l The addition of a new type of health service, program, or site of care l The deletion of an existing health service, program, or site of care l The acquisition of a new component l The deletion of an existing component The Joint Commission may conduct an additional survey at a later date if its surveyor or survey team arrives at the [organization] and discovers that a change was not reported. The Joint Commission may also survey any unreported services and sites addressed by its standards during the survey as appropriate. The Joint Commission makes the final accreditation decision for the [organization] only after surveying all or an appropriate sample of all services, programs, and sites provided by the [organization] for which The Joint Commission has standards. Information reported in the E-App is subject to The Joint Commission s Information Accuracy and Truthfulness Policy. September 2016 The Joint Commission Perspectives 9

10 Revisions Announced for the System Accreditation Option (continued) Continued from page 8 Sampling for System Surveys by Risk Ambulatory Health Care Note: All sites that provide general anesthesia, moderate sedation, or surgery are considered high risk and will be sampled at a rate of 100%. High-Risk Services Low-Risk Services l Cardiac catheterization and cardiology l Chiropractic medicine l Dentistry l Endocardiography l Endoscopy l ENT procedures l Freestanding ER l Gynecology and obstetrics l Hematology l Infusion therapy l Interventional radiological procedures l In vitro fertilization l Kidney care/dialysis l Lithotripsy l Mohs surgical procedures l Nuclear medicine l Oncology l Ophthalmic surgery l Oral maxillofacial surgery l Orthopedic surgery l Pain management (invasive) l Plastic surgery l Podiatric surgery l Radiation oncology l Short stay observation/ recovery/infirmary l Telehealth surgical l Urgent care l Urological procedures l Urology l Vascular medicine l Allergy l Alternative medicine l Anesthesia practice that provides only local anesthesia l Audiology l Cardiac practice (noninvasive) l Computed tomography l Computed tomography angiography l Convenient care l Dermatology l Diagnostic imaging l Direct primary care l Family practice l Gastroenterology l General practice l Internal medicine l Mammography l Magnetic resonance angiography l Magnetic resonance imaging l Nuclear cardiology l Neurology l Occupational/worksite health l Optometry practice l Orthopedic medicine l Orthotic/prosthetics l Otolaryngology l Pain management (noninvasive) l Pediatric medicine l Positron emission tomography l Pharmacy dispensary l Podiatry l Pulmonary medicine l Rheumatology l Sleep diagnostics l Ultrasound provides surgery, general sedation, or moderate sedation must be surveyed. For lists of the types of sites determined to be high risk and low risk, please see both tables on this page. Extension Surveys The second revision addresses the fact that, over time, systems may add more sites or expand their scope of services. These changes necessitate a determination of the point at which a system s size and scope have changed sufficiently enough to warrant an additional survey. For systems providing what are considered high-risk services, The Joint Commission will review the composition of the system at two intervals (9 and 18 months) in the system s three-year accreditation cycle to determine whether an extension survey of the system is warranted. For systems providing what are considered low-risk services, the system will be reviewed at the midpoint in its accreditation cycle. These revisions will be included in the fall 2016 E-dition update and the 2017 Comprehensive Accreditation Manuals for the ambulatory care and home care programs. Questions regarding the System Accreditation Option may be directed to an organization s assigned account executive. P Sampling for System Surveys by Risk Home Care High-Risk Services l Apnea monitors l Biomedical vents maintenance l Compounding pharmacy l Freestanding ambulatory infusion Low-Risk Services l Clinical consulting pharmacy l Clinical respiratory l DMEPOS in-home, facility-based, mail-order l HME l Home health/pcss skilled; PT, OT, ST, medical social, aides l Hospice in-home, facility-based (freestanding and segregated units) l Long-term care pharmacy (SNF or VA setting) l Warehouse storage only l Warehouse clean/ repair/test 10 The Joint Commission Perspectives September 2016

11 Consistent Interpretation Joint Commission Surveyors Observations on PC , EP 1 The bimonthly Consistent Interpretation column is designed to support standards compliance efforts. Each column draws from a de-identified database containing surveyors observations as well as guidance from the Standards Interpretation Group on how to interpret the observations on an element of performance (EP) in the Comprehensive Accreditation Manual for Hospitals. This installation (the fifth in the series) highlights Provision of Care, Treatment, and Services (PC) Standard PC , EP 1. Note: Interpretations are subject to change to allow for unique and/or unforeseen circumstances. P Provision of Care, Treatment, and Services (PC) Standard PC : The hospital assesses and reassesses its patients. EP 1: The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. Patient information is collected according to these requirements. (See also RC , EP 2)* Note 1: In defining the scope and content of the information it collects, the organization may want to consider information that it can obtain, with the patient s consent, from the patient s family and the patient s other care providers, as well as information conveyed on any medical jewelry. Note 2: Assessment and reassessment information includes the patient s perception of the effectiveness of, and any side effects related to, his or her medication(s). Surveyor Observations Guidance/Interpretation The organization had not defined, in writing, the scope and content of the information it requires for assessments and reassessments including the minimum required elements for preanesthesia and postanesthesia assessments. Surveyors observed that both the physician and nursing assessments and reassessments were not always completed per the organization s own requirements. In some instances, physicians had not completed evaluation forms, protocols, or order fill-in the blanks. It was also observed that for one nuclear medicine patient, no breastfeeding status had been documented even though this was required by organization requirements. The minimum required elements should be consistent with evidence-based guidelines from organizations such as the American Society of Anesthesiologists and the Centers for Disease Control and Prevention. Surveyors should conduct their evaluation according to the organization s defined requirements. For failure to implement assessment of the defined minimum required elements, surveyors should cite the following: l Standard PC , EP 1, for preanesthesia assessments ( Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital conducts a presedation or preanesthesia patient assessment. [See also RC , EP 2] ) l Standard PC , EP 7, if the individual completing the postanesthesia assessment is not qualified to administer anesthesia or if the assessment is not completed within 48 hours ( For hospitals that use Joint Commission accreditation for deemed status purposes: A postanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services. ) l Standard PC , EP 8, if required elements are missing from the postanesthesia assessment ( For hospitals that use Joint Commission accreditation for deemed status purposes: The postanesthesia evaluation for anesthesia recovery is completed in accordance with law and regulation and policies and procedures that have been approved by the medical staff. ) For failure to complete all required history and physicals (H&Ps) and for failure to update elements, see Medical Staff (MS) Standard MS , EP 5: The medical staff complies with the medical staff bylaws, rules and regulations, and policies. * This language was announced in the August 2016 Perspectives, Project REFRESH: Survey of PC , page 11. September 2016 The Joint Commission Perspectives 11

12 The Official Newsletter of The Joint Commission Volume 36, Number 9, September 2016 Send address corrections to: The Joint Commission Perspectives or Interim Quality Director Services Stay on track during challenging times Whether you have a position vacancy or just need additional staff to manage an increased workload, let our Interim Quality Director Services help you achieve and maintain high performance in delivering quality, patient-focused care. For more information on our Interim Quality Director Services, please visit jcrinc.com/consulting. Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services, publications and software to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit for more information. JCP09