This standard may also be cited if organizations fail to follow: Following the Infection Prevention & Control Hierarchywill help ensure that the activities your organization implements are compliant with regulations, Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfCs) where applicable, and MIFU. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Learn about the "gold standard" in quality. Privacy Policy. The technical storage or access that is used exclusively for anonymous statistical purposes. The table below identifies the Top 5 Joint Commission requirements identified most frequently as "not compliant" during surveys and reviews from Jan. 1 through Dec. 31, 2021. Learn about the priorities that drive us and how we are helping propel health care forward. Top 5 most challenging requirements for 2021 The Joint Commission collects data on organizations' compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements. TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. This portal will provide information to reduce findings of non-compliance. Drive performance improvement using our new business intelligence tools. The key to success would appear to be not letting budgets or staffing shortages get in the way of ensuring that each patient identified to be at high risk to have the required 1:1 supervision. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. View a larger depiction of the infographic here: January 2021 memo from Johns Hopkins Bloomberg School of Public Health. Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Utility Systems - EC.02.05.01 - Clinical Impact, Means of Egress - LS.02.01.20 - Clinical Impact, Built Environment - EC.02.06.01 - Clinical Impact, Fire Protection - EC.02.03.05 - Clinical Impact, General Requirements - LS.02.01.10 - Clinical Impact, Protection - LS.02.01.30 - Clinical Impact, Automated Suppression - LS.02.01.35 - Clinical Impact. The table below identifies the Top 5 Joint Commission requirements identified most frequently as not compliant during surveys and reviews from Jan. 1 through Dec. 31, 2021. We have reproduced that link again for your use. Medical Gas Room Signage, COVID-19 Test Positivity Rates The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. Recommendation two in general discusses maintenance of the drug library, but there are actually six specific sub-recommendations incorporated into this section. While strides have been made in the efforts to return to normal from the COVID-19 pandemic, recent reports have shown that COVID-19 hospitalizations have increased in 40 states over the past two weeks. Jennifer Cowel, RN MHSA Learn about the development and implementation of standardized performance measures. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Top Compliance Challenges for Ambulatory Care Organizations in 2021, manufacturers instructions for use (MIFU) and/or processes, instruments used for surgery and/or procedures. The U.S. Department of Health and Human Services also has tracked a 59% increase in COVID-19 cases over a two-week period, as of Friday, May 6. The Joint Commission asks that healthcare workers and organization staff continue to remain masked while interacting with our surveyors and reviewers. The second element of performance scored very often in the high and moderate risk category is IC.02.02.01, EP 2, which establishes requirements for high level disinfection and sterilization. As with all ITM activities, documentation of these tasks must be current, accurate and made available to Joint Commission staff when requested on survey. MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. The Joint Commission (TJC) is an independent, not-for-profit organization created in 1951 that accredits more than 20,000 US health care programs and organizations. If this rate continues in the second half of the year, total sentinel event reports will likely surpass the 1,197 sentinel events reported in 2021, which represented the highest annual level seen since the accrediting body started publicly reporting them in 2007. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA There is also a link to the OSHA guidance that was issued during the height of the pandemic in April 2020 that had discussed reprocessing of respirators. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. The LS and EC requirements have not changed significantly in recent years and yet hospitals continue to fall short with meeting compliance in these areas. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. Herman McKenzie is currently the director, Department of Engineering in the Standards Interpretation Group at The Joint Commission. We can make a difference on your journey to provide consistently excellent care for each and every patient. He was part of the team that opened the first new hospital in Illinois in over 25 years. The accrediting body received 832 reports of sentinel events in the first six months of 2022, 90 percent of which healthcare organizations voluntarily reported. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs. EC.02.05.01: The critical access hospital manages risks associated with its utility systems. Home > Resources > News & Multimedia > News Releases > Cookie Policy. Get more information about cookies and how you can refuse them by clicking on the learn more button below. In 2020, 809 total events were reported. Leave a Reply Cancel reply. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. MM.06.01.01: The critical access hospital safely administers medications. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions.