Joint Commission Addresses Implicit Bias in Healthcare

In the April 2016 issue of Quick Safety, The Joint Commission addresses implicit, or unconscious, bias in healthcare, and its impact on patient safety.

Fifteen years after the publication of two seminal reports from the Institute of Medicine (IOM) – Crossing the Quality Chasm: A New Health System for the 21^st Century and Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care – The Joint Commission highlights that racial and socioeconomic inequity persists in health care. In Crossing the Quality Chasm, the IOM stressed the importance of equity in care as one of the six pillars of quality health care, along with efficiency, effectiveness, safety, timeliness and patient-centeredness. Indeed, Unequal Treatment found that even with the same insurance and socioeconomic status, and when comorbidities, stage of presentation, and other confounders are controlled for, minorities often receive a lower quality of health care than do their white counterparts.

The Joint Commission identifies there is extensive evidence and research that finds

Joint Commission Releases Statement on Pain Management, Addresses Common Misconceptions

The Joint Commission has issued the following statement on pain management, and addressed common misconceptions regarding related Joint Commission requirements:

In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.

The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain. The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.

Our foundational standards are quite simple. They are:

• The hospital educates all licensed independent practitioners on assessing and managing pain.
• The hospital respects the patient’s right to pain management.
• The hospital assesses and manages the patient’s pain.

Requirements for what should be addressed in organizations’ policies include:

Joint Commission Addresses Informed Consent, Provides Recommendations

In the February 2016 issue of Quick Safety, The Joint Commission addresses patient informed consent, and how the consent process is “more than just getting a signature.”

The Joint Commission identifies “there are numerous challenges to implementing an effective informed consent process – that is, one in which the patient fully understands the health care treatment or surgical procedure they are agreeing to undergo. Even after signing a consent form, patients frequently do not understand the risks, benefits and alternatives involved in their course of treatment or surgical procedure – all of which are imperative for a patient to provide valid authorization.”

The process of obtaining informed consent is an essential aspect of patient-centered care and remains central to patient safety. The Joint Commission cites research that indicates an emphasis on obtaining the patient’s signature to document informed consent results in varying degrees of actual, effective communication between the clinician and the patient.

Further, communication issues are the most frequent root cause of serious adverse events reported to The Joint Commission’s Sentinel Event database. The Joint Commission’s Sentinel Event database includes 44 reports since 2010 of informed consent-related sentinel events; 32 of the reports were specifically related to wrong-site surgery, and five were related to operative or post-operative complication. Other reports were related to elopement, falls, medication errors, and suicide.

To improve informed consent processes, The Joint Commission identifies barriers that contribute to a lack of patient understanding about informed consent, and recommends safety actions healthcare organizations should consider to improve the informed consent process and enhance the safety of their patients. Detailed resources are also provided.

NAQC Issues 9 ‘Guiding Principles’ for Healthcare Providers to Engage Patients in Care

On July 12, 2012, The Nursing Alliance for Quality Care (NAQC) issued a list of guiding principles to help nurses and other health care providers engage patients in their care. The nine “Guiding Principles for Patient Engagement” call for a dynamic partnership among patients, their families, and caregivers that includes mutual responsibilities and accountabilities and shared decision-making.

“We hope that nursing organizations, nursing programs, medical schools, and others will use these principles to inform their members and students and integrate patient engagement into their programs and practices,” said Pamela Thompson, CEO of the AHA’s American Organization of Nurse Executives subsidiary and chair of the subcommittee that drafted the principles.

NAQC plans to discuss how to implement the principles with leading nursing organizations, patient advocates, and other provider groups, and to host a conference on the topic in November.

The NAQC “Guiding Principles of Patient Engagement” are available on the George Washington University Medical Center website at this link. The press release is available here.

Latest Joint Commission Speak Up™ Video Highlights Patient Rights

The Joint Commission has released its seventh episode in the animated Speak Up™ video series, “Speak Up:  Know Your Rights.” The new video features the characters Mira, Dr. Pierce, Nurse Amy and Armando as they depict the rights every patient should expect from their care givers. “Speak Up:  Know Your Rights” stresses that everyone has the right to:

• Be informed about the care they will receive;
• Make decisions about their care, including refusing care;
• Have their pain treated;
• Receive information about their care in their own language;
• Be provided with an up-to-date list of their current medications; and
• Be listened to and treated with courtesy and respect.

About The Joint Commission Speak Up™ Video Series:

Produced by The Joint Commission, Speak Up’s entertaining 60-second videos are intended as public service announcements. The series airs on The Joint Commission’s YouTube Channel, as well as other venues, and has received nearly 54,000 views on YouTube alone. This latest Speak Up video provides viewers with tips to help them better understand their rights as a patient. Previous videos in the series, the first of which debuted in March 2011, emphasize the importance of being comfortable speaking up and asking questions about your health care; preventing infection; managing and taking medication safely; preparing for, and what to ask during, doctor’s office appointments; encouraging children to feel confident asking questions about their health; and reducing the risk of falling.

The latest video, “Speak Up:  Know Your Rights,” is embedded below. This video, and the previous six videos in The Joint Commission Speak Up™ Video Series, are also available on The Joint Commission’s YouTube Channel at this link.

The Joint Commission News Release announcing the “Speak Up:  Know Your Rights” video is available at this link. For more information about Joint Commission’s Speak Up™ initiatives, visit the Speak Up™ page on The Joint Commission website.

CMS Publishes Final Rules Revising Hospital and CAHs Conditions of Participation; Eliminates Duplicative and Outdated Requirements to Promote Efficiency and Transparency for Hospitals, ASCs, ESRDs, Other Programs

On May 9, 2012, the Centers for Medicare and Medicaid Services (CMS) released pre-publication copies of two Final Rules designed to reduce the regulatory burdens related to the provision of healthcare and to “reflect the Centers for Medicare and Medicaid Services’ (CMS) commitment to the general principles of the President’s Executive Order 13563, released January 18, 2011, entitled “Improving Regulation and Regulatory Review.”

The first Final Rule (CMS-3244-F, Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation) intends to eliminate certain “burdensome” Medicare Conditions of Participation (CoPs) for hospitals and critical access hospitals (CAH).

The second Final Rule (CMS-9070-F, Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction) seeks to “eliminate duplicative, overlapping, outdated, and conflicting regulatory requirements for health care providers and suppliers, including hospitals, ambulatory surgical centers, end-stage renal disease facilities, durable medical equipment suppliers.” This Final Rule eliminates “outmoded” infection control and emergency equipment requirements previously applicable to ambulatory surgical centers (ASC) and National Fire Protection Association (NFPA) Life Safety Code requirements for all but high risk end stage renal disease (ESRD) facilities.

Both Final Rules where published in the May 16, 2012 Federal Register. CMS-3244-F, Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation, is available here. CMS-9070-F, Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction, is available here.

Both original Proposed Rules were published in the October 24, 2o11 Federal Register. CMS-3244-P, Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation, is available here.  CMS-9070-P, Medicare and Medicaid Program; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction, is available here.

Summary of Changes in the CMS Final Rule(s)

Governing Body Requirements

CMS proposed to allow a single governing body for hospitals in multi-hospital systems. In the Final Rule, CMS approved this revision and also added an additional requirement that at least one member of a hospital’s medical staff serve as a member of the multi-hospital system governing body in order to ensure communication and coordination between the system’s governing body and the medical staffs of the individual hospitals.

Patient’s Rights Requirements

CMS proposed to modify the reporting requirements when a patient death involves only the use of two-point wrist restraints and no use of seclusion. CMS finalized this proposed rule with minimal change, clarifying that hospitals need only to record in an internal log or other system soft wrist restraint-related deaths, and need not submit the information in the log to CMS or otherwise publicly release the information.

Medical Staff

CMS proposed to clarify that a hospital may grant privileges to both physicians and non-physicians to practice within their state scope of practice, regardless of whether they are also appointed to the medical staff. In the Final Rule, CMS removed the proposed concept of physicians and other clinicians being privileged to practice without appointment to the medical staff. Under the Final Rule, the medical staff may include other categories of non-physician clinicians. While the Final Rule falls short of requiring hospitals to place APRNs and other clinicians on the medical staff, the rule and its accompanying narrative does signal that CMS is supportive of APRNs, PAs, and other clinicians practicing to the full extent of their scope under state law.

Nursing Care Plan

CMS proposed to integrate the nursing care plan into the overall interdisciplinary care plan in those hospitals that use an interdisciplinary plan of care. The Final Rule permits either a stand-alone nursing care plan or one integrated into an interdisciplinary care plan.

Administration of Medications

The Final Rule allows hospitals to have an optional program for patients and support persons for self-administration of appropriate medications. The program must address the safe and accurate administration of specified medications, ensure a process for medication security, address self-administration training and supervision, and document medication self-administration.

Administration of blood transfusions and intravenous medications

The Final Rule eliminates the requirement for non-physician personnel to have special training in administering blood transfusions and intravenous medications. CMS also revised the requirement to clarify that those who administer blood transfusions and intravenous medications do so in accordance with state law and approved medical staff policies and procedures.

Orders by Other Practitioners

CMS proposed to allow all clinicians acting in accordance with state law and hospital privileges to provide orders for drugs and biologicals. The Final Rule allows for drugs and biologicals to be prepared and administered on the orders of non-physician practitioners provided such practitioners are acting pursuant to state law, hospital policy, and medical staff bylaws, rules and regulations. The non-physician practitioners may also document and sign these orders pursuant to state law and hospital policy.

Standing Orders

The Final Rule allows hospitals flexibility to use standing orders but adds a requirement for medical staff, nursing and pharmacy to approve written and electronic standing orders, order sets, and protocols. The rule also requires that orders and protocols be based on nationally recognized and evidence-based guidelines and recommendations.

Verbal Orders

The Final Rule eliminates the requirement for authentication of verbal orders within 48 hours and instead defers to applicable state law for authentication timeframes.

Infection Control Log

The Final Rule eliminates the obsolete requirement for a hospital to maintain an infection control log. Hospitals are already required to monitor infections and do so through various surveillance methods including electronic systems.

Outpatient Services Director

The Final Rule removes the requirement for a single director of outpatient services position, as many hospitals already have separate directors for individual outpatient departments and the single, overall director position may be duplicative and unnecessary.

Transplant Center Process Requirements

The Final Rule eliminates a duplicative requirement for an organ recovery team that is working for the transplant center to conduct a blood type and other vital data verification before organ recovery when the recipient is known, as the verification will continue to be completed at two other times in the transplant process.