2017 CAMH. What s New July 2017 Release Effective as Noted

Transcription

1 Comprehensive Accreditation Manual for What s New July 2017 Release as Noted This What s New section is intended to help get you up to speed regarding the substantive changes that have been made to the since its previous update. Major changes to reuirements, accreditation policies and procedures, and other important information in this update include the following: n Reordered and streamlined The Accreditation Process (ACC) chapter to reduce redundancy, improve information flow, and enrich customer understanding n Updated the decision rules for 2017 in the ACC chapter n Revised The Joint Commission Quality Report (QR) chapter to reflect changes in ORYX reporting, as The Joint Commission no longer reuires measure set reporting Please refer to the table that begins on the following page for more details about this update. Revisions to content within this update are highlighted using shaded text within the replacement pages., July 2017 i E-dition, Release

2 Title Page and Contents Page Updated title page and contents page immediately Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) Table 1. Acronyms Used in This Manual: Updated table Use the Standards to Improve Care, Treatment, or Services: Updated the list of challenging standards Stimulate Improvement: Updated guidance for standards uestions Reuesting Permission to Copy Content from the Manual: Removed the mailing address for copy reuests but retained the e- mail address Minor editorial revisions Patient Safety Systems (PS) Changed high-volume to high-freuency when referring to areas organizations should prioritize when conducting a proactive risk assessment Appendix: RI , EP 5: Added cross-references to RI , EPs 2 and 3 Minor editorial revisions Accreditation Reuirements Accreditation Participation Reuirements (APR) APR , EP 1: Added language to Note 1 clarifying the participation of surveyor management staff in the survey process; moved language about survey fees into new Note 2 ii, July 2017 E-dition, Release

3 Environment of Care (EC) EC : Added Note 2 for deemed-status hospitals reuiring compliance with the 2012 edition of NFPA 99: Health Care Facilities Code; added Note 3 with a link to further information on waiver and euivalency reuests EC , EP 19: Updated NFPA reference to 2012 EC , EP 4: Revised Note 3 by reuiring a 100% completion rate for scheduled maintenance activities for non-highrisk medical euipment in an alternative euipment maintenance (AEM) program inventory and adding that AEM freuency is determined by the hospital EC , EP 2: Added language to Note 3 stating that AEM freuency is determined by the organization EC , EP 14: Changed compliance reuirement for deemedstatus hospitals in Note from Life Safety Code to Health Care Facilities Code EC , EP 6: Revised Note by reuiring a 100% completion rate for scheduled maintenance activities for non-high-risk utility systems components in an AEM program inventory and adding that AEM freuency is determined by the hospital EC , EP 7: Changed compliance reuirement for deemedstatus hospitals in Note from Life Safety Code to Health Care Facilities Code EC , EP 7: Changed compliance reuirement for deemedstatus hospitals in Note from Life Safety Code to Health Care Facilities Code Emergency Management (EM) EM , EP 15: Removed cross-references to EC , EP 1 and EC , EP 3, July 2017 iii E-dition, Release

4 Human Resources (HR) HR , EP 1: Added cross-reference to HR , EP 19 HR , EPs 1 3: Added cross-reference to HR , EP 19 HR , EPs 1 and 2: Added cross-reference to HR , EP 19 HR , EP 1: Deleted cross-references to EC , EPs 1 and 3 HR , EP 2: Deleted cross-reference to EC , EP 10 Infection Prevention and Control (IC) No changes Information Management (IM) No changes Leadership (LD) LD , EP 5: Added cross-reference to MM , EP 1 LD , EP 6: Specified that accountability is for the uality of care provided to patients LD : Changed to reflect that close calls is the term usually used instead of near misses in the Introduction and EP 3 Life Safety (LS) LS , EP 1: Added Note reuiring that deemed-status hospitals comply with the 2012 Life Safety Code LS , EP 4: Replaced Notes 3 and 4 with new Note 3 that provides a link to further information on waiver and euivalency reuests iv, July 2017 E-dition, Release

5 LS , EP 1: Added LS , EP 15 to list of reuirements evaluated in the hospital s written interim life safety measure (ILSM) policy LS , EP 15: Added EP reuiring hospital policy to allow the use of other ILSMs not addressed in EPs 2 14 LS , EP 5: Added Note 2 for deemed-status hospitals on meeting applicable provisions of the Life Safety Code TIA 12-1 LS , EP 1: Added Note for deemed-status hospitals on meeting applicable provisions of the Life Safety Code TIA 12-4 LS , EP 4: Added Note for deemed-status hospitals on meeting applicable provisions of the Life Safety Code TIA 12-2 LS , EP 4: Added Note for deemed-status hospitals on meeting applicable provisions of the Life Safety Code TIA 12-1 Clarified that the following standards apply to AHCO classification reuirements for hospitals and added language about provisions that must be met by AHCO application: LS LS LS LS LS LS LS LS Medication Management (MM) MM , EP 8: Added documentation icon Medical Staff (MS) MS , EP 1: Added cross-references to LD , EPs 4 and 23 in bulleted item regarding evidence of internal review of practitioner s performance of privileges, July 2017 v E-dition, Release

6 National Patient Safety Goals (NPSG) No changes Nursing (NR) No changes Provision of Care, Treatment, and Services (PC) No changes Performance Improvement (PI) No changes Record of Care, Treatment, and Services (RC) No changes Rights and Responsibilities of the Individual (RI) RI , EP 5: Added cross-references to RI , EPs 2 and 3 Transplant Safety (TS) No changes Waived Testing (WT) No changes Accreditation Process Information The Accreditation Process (ACC) Removed all references to Contingent Accreditation (CONT) as this decision rule category has been eliminated Notices: Moved paragraph about Joint Commission Connect as the primary means of communication from the end of the chapter to the beginning Eligibility Reuirements for Initial Surveys: Incorporated language from the now-deleted Initial Surveys section to eliminate redundancy of content Tailored Survey Policy: Clarified that laboratory services are among the components to which this policy applies vi, July 2017 E-dition, Release

7 Inclusion of Physician Practices in Survey: Deleted parenthetical limiting provider-based practices to those that are not freestanding and added Note clarifying that an organization s inclusion of physician practices is optional Multiorganization Option: Deleted paragraph regarding the survey team leaders maintenance of team continuity and compilation of information for corporate summation Contracted Services: Clarified that laboratory services provided under contract are included in the evaluation of contractually provided care, treatment, and services Accrediting in Accordance with CMS Certification Numbers: Clarified that the Centers for Medicare & Medicaid Services (CMS) reuires each Joint Commission accredited hospital with its own CMS Certification Number (CCN) to demonstrate full compliance with all applicable Joint Commission standards Information That Is Publicly Disclosed on Reuest: Deleted language restricting the availability of an organization s accreditation history to the past seven years Process for Responding to a Complaint: Changed time frames for responding to complaints from calendar days to business days An Organization s Secure Joint Commission Connect Site: Updated to reflect that Joint Commission Connect is the primary means of communication between The Joint Commission and accredited organizations Accreditation Contract and Business Associate Agreement: Deleted language about contracts availability (via the extranet) for printing/ approval and governmental organizations ability to enter into uniue contracts with The Joint Commission Annual and Survey Fees: Updated to reflect that failure to pay overdue amounts will result in a loss of accreditation with no opportunity for appeal or reinstatement During the Survey: Incorporated language about embedding standards into routine operations from the now-deleted section The On-Site Survey, July 2017 vii E-dition, Release

8 Survey Notification (formerly Unannounced Surveys ): Renamed, reorganized, and revised section by adding information about notifying organizations of unannounced, announced, and shortnotice survey events Patient Flow Tracer: Removed section (but kept description of tracer in Table 2. Hospital-Specific Tracer Applicability and Objectives) Survey Agenda: Changed the web address in the footnote to connect to the 2017 Survey Activity Guide Immediate Threat to Health or Safety: Made the following changes: Updated time frame within which The Joint Commission will notify CMS of an immediate threat (in deemed status scenarios) from 24 hours to 2 business days of confirming it Revised to reflect that resolution of an immediate threat may change accreditation status from Preliminary Denial of Accreditation (PDA) to a time-limited PDA and Accreditation with Follow-Up Survey (AFS) Figure 2. Process flow for Immediate Threat to Health or Safety (ITHS) situations at organizations seeking reaccreditation: Deleted references to Contingent Accreditation and replaced Accreditation Committee with executive leadership Figure 3. Survey Analysis for Evaluating Risk (SAFER) matrix: Updated matrix to include descriptors How Accreditation Decisions Are Made: Made the following changes: Revised to reflect that organizations recommended for a PDA02 decision are reuired to submit a Plan of Correction (instead of an ESC) within 10 business days and to have a validation survey within 60 days Updated to reflect that resolution of an Immediate Threat to Health or Safety situation may result in a change from PDA to AFS viii, July 2017 E-dition, Release

9 The Accreditation Decision Process: Added bullet point stating that organizations recommended for a PDA02 decision are reuired to submit a Plan of Correction (instead of an ESC) within 10 business days and to have a validation survey within 60 days Central Office Review of Summary Reports: Deleted section to eliminate redundancy of content Decision Categories for Organizations Seeking Accreditation Renewal: Streamlined description of AFS Deleted Contingent Accreditation and noted that there are now four possible categories for reaccreditation surveys Figure 4. Continuum of survey activity outcomes for organizations seeking renewal of accreditation: Deleted Contingent Accreditation Decision Outcomes for Organizations Seeking Initial Accreditation: Clarified that organizations found out of compliance with Joint Commission reuirements during their initial survey may voluntarily withdraw from the accreditation process with no decision rendered if they have not yet submitted their ESC in the allotted time Figure 5. SAFER matrix placement and reuired follow-up activities: Streamlined figure for readability Corrective ESC: Revised to reflect that organizations recommended for a PDA02 decision are reuired to submit a Plan of Correction (instead of an ESC) within 10 business days and to have a validation survey within 60 days The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation: Deleted section to eliminate obsolete and redundant content Figure 6. Process flow for a Preliminary Denial of Accreditation (PDA) decision: Deleted figure Figure 7. Process flow for a Contingent Accreditation (CONT) decision: Deleted figure Top Performer on Key Quality Measures: Deleted section, July 2017 ix E-dition, Release

10 Focused Standards Assessment (FSA): Clarified content and updated to reflect that the FSA tool now includes the SAFER methodology Clarification Validation Survey (CVS): Deleted section On-site Follow-up Survey for a Condition-level Deficiency: Clarified that these surveys occur according to CMS regulations Decision Rules for Organizations Seeking Initial Accreditation: Moved section and reordered the decision rule categories Decision Rules for Organizations Seeking Reaccreditation: Made the following changes: Moved section and reordered the decision rule categories Revised decision rule AFS10 to reflect that surveyors no longer evaluate the Plan for Improvement Added AFS11 on Immediate Threat to Health and Safety abatement surveys and AFS12 on fraud and abuse Eliminated Contingent Accreditation decision rule category Replaced former decision rule PDA06 regarding Contingent Accreditation with new PDA06 regarding organizations with an AFS decision that fail to resolve all RFIs after two opportunities to submit ESCs Added PDA09 for deemed-status organizations that fail their second Medicare follow-up survey as a result of a one or more Conditions of Participation scored as a Condition-level deficiency Added PDA10 for organizations with patients at risk due to possible fraud or abuse Removed failure to resolve Contingent Accreditation status as a cause for Denial of Accreditation (DA) decision rule DA02 Added failure to submit a Plan of Correction as a cause for decision rule DA04 Added DA05 regarding organizations in the sustaining improvement program that fail to participate in Joint Commission intervention x, July 2017 E-dition, Release

11 Process for Organizations That Meet Decision Rule PDA02: Made the following changes: Renamed section (formerly titled Preliminary Denial of Accreditation Due to Patterns, Trends, or Repeat Findings ) Relocated section (formerly included as part of The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation section) Revised to reflect the new process for organizations that receive a PDA02 decision (including the reuired submission of a Plan of Correction within 10 business days followed by a validation survey within 60 calendar days) Added new Figure 6. PDA02 decision process flow Process for Organizations That Meet Decision Rule PDA04: Made the following changes: Renamed section (formerly titled Preliminary Denial of Accreditation for Organizations Without Proper License, Certificate, or Permit ) Relocated section (formerly included as part of The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation section) Streamlined content and removed reference to Contingent Accreditation Review and Appeal Procedures: Made the following changes: Deleted former Figure 8. Process flow for the appeal of a Preliminary Denial of Accreditation decision Deleted several sections to reflect elimination of Contingent Accreditation decision category and streamlined content to eliminate redundancies Minor editorial revisions Standards Applicability Grid (SAG) LS , EP 15: Added EP with applicability to all five services (Acute, Long Term Acute Care, Psychiatric, Surgical Specialty, and Swing Beds services), July 2017 xi E-dition, Release

12 Sentinel Events (SE) Removed near miss throughout chapter, in deference to the more accurate term close call Clarified throughout chapter that action plans must be corrective Updated references to Board of Commissioners and Accreditation Committee with executive leadership throughout the chapter to align with the current process at The Joint Commission Definition of Sentinel Event: Expanded footnote concerning an unintended foreign object to define the term after surgery Added language to distinguish patient safety events from sentinel events and added a reference to the Patient Safety Systems (PS) chapter Oversight of the Sentinel Policy: Deleted reference to aggregating de-identified data; changed Sentinel Event Hotline to Office of Quality and Patient Safety Survey Process: Added language to clarify that surveyors are not authorized to review root cause analysis documents and determine credibility, thoroughness, or acceptability Specified that surveyors can only apply the related standards and elements of performance to assess performance improvement practices Added specific standards references Minor editorial revisions xii, July 2017 E-dition, Release

13 The Joint Commission Quality Report (QR) Introduction: Clarified reporting is of ORYX chart-abstracted performance measure information What Will My Quality Report Contain?: Revised the title of Figure 1 to Legend of National Patient Safety Goal Quality Indicator Symbols and updated crossreferences Revised Quality Indicators section on National Quality Improvement Goals to reflect changes to ORYX chart-abstracted performance measure reporting reuirements Information Released by The Joint Commission: Removed information about the display of measure set information (as The Joint Commission no longer reuires measure set reporting) and revised the description of how individual measures are displayed, including through the use of comparative symbols (plus, minus, check, or star) Guidelines for Publication: Revised guidelines to reflect revised reporting reuirements including the use of comparative symbols Minor editorial revisions Performance Measurement and the ORYX Initiative (PM) Revised the term performance measure data to chart-abstracted performance measure data to align with the revised reporting reuirements Deleted the term measure set to align with the revised reporting reuirements Current Reuirements for : Revised the entire section to align with the recent elimination of measure set reporting Reuirements for Small : Revised the entire section to clarify the measurement reporting reuired by small hospitals, July 2017 xiii E-dition, Release

14 Reuirements for Psychiatric : Eliminated the exemption of psychiatric hospital s with an average daily census of 10 or fewer inpatients from reporting data Use of Performance Measure Data: Updated contact information for general ORYX reuirement ueries Minor editorial revisions Reuired Written Documentation (RWD) Added MM , EP 8 Early Survey Policy (ESP) No changes Primary Care Medical Home Certification Option (PCMH) No changes Appendix A: Medicare Reuirements for (AXA) No changes Appendix B: Special Conditions of Participation for Psychiatric (AXB) No changes Glossary Revised the following terms: accreditation decisions (in particular, revised Limited, Temporary Accreditation, Accreditation with Follow-up Survey, and Preliminary Denial of Accreditation and deleted Contingent Accreditation) appeal process designated euivalent source Evidence of Standards Compliance (ESC) report Focused Standards Assessment (FSA) xiv, July 2017 E-dition, Release

15 Plan of Action (POA) Reuirement for Improvement (RFI) Review Hearing Panel Minor editorial revisions, July 2017 xv E-dition, Release