Tag Archives: Performance Improvement

Joint Commission Publishes Most Challenging Primary Care Medical Home Requirements

The Joint Commission has published its list of most challenging Primary Care Medical Home (PCMH) requirements for 2014 – 2015. The included requirements generated findings in at least 10% of organizations surveyed by the agency during that time frame.

Five (5) EPs under the Provision of Care, Treatment, and Services (PC) chapter, two (2) EPs under the Performance Improvement (PI) chapter, two (2) EPs under the Rights and Responsibilities of the Patient (RI) chapter, and one (1) EP under the Record of Care, Treatment, and Services (RC) chapter. Both PC.02.04.01 EP 4 and RI.01.04.03 EP 7 are new to the most challenging requirements list; the remaining eight (8) EPs appeared on the previous list. Continue reading →

Joint Commission Deletes 131 Hospital Requirements

The Joint Commission, as part of the first phase of its initiative to streamline standards and elements of performance (EPs), has announced the deletion of 131 requirements from its Hospital Accreditation Program (HAP).

The initiative, now called Project REFRESH, is a multi-phased project designed to improve The Joint Commission accreditation and certification process. According to The Joint Commission, the review project was initiated, in part, as a response to customer feedback regarding the complexity of Joint Commission standards. The Joint Commission also recognizes that the concepts of some standards, considered groundbreaking when they were introduced years ago, have now become part of organizations’ routine operations. Therefore, while it is important to continue following the practices that hospitals find to be useful, it is no longer necessary to include them in standards. Removing such requirements allows a greater focus on the most important contemporary quality and safety issues. Continue reading →

Joint Commission Announces Phased Accreditation Improvement Project, Deletes Hospital Requirements

It appears 2016 will be a busy year for Joint Commission accredited organizations.

Earlier this quarter, the Joint Commission surveyed accredited hospitals about the value of specific elements of performance (EPs) in the Comprehensive Accreditation Manual for Hospitals (CAMH), indicated it intended to eliminate a number of EPs.

Then, Joint Commission employees started discussing with industry leaders potential changes to scoring categories, including the elimination of ‘A’ and ‘C’ categories and the ‘Risk’ category, and the introduction of a new scoring algorithm.

Now, the accrediting body has quietly announced it is officially reviewing its requirements, indicating this is the ‘start’ of ‘improving The Joint Commission accreditation process.’

Downplaying the apparent scope of the project, The Joint Commission announced this week it Continue reading →

Joint Commission Publishes New Diagnostic Imaging Requirements

The Joint Commission has finalized new and revised elements of performance (EPs) for accredited hospitals that provide diagnostic imaging services. This set of standards was previously announced in December 2013 and would have gone into effect in July 2014. However, The Joint Commission determined that further research and additional revisions were needed.

The Revised Requirements for Diagnostic Imaging Services incorporate recommendations from imaging experts, professional associations, and accredited organizations about areas that must be evaluated to ensure the safe delivery of diagnostic imaging services.

Revisions include 12 new EPs and 1 revised EP under the Environment of Care (EC) chapter, 2 new EPs under the Human Resources (HR) chapter, 1 new EP under the Medication Management (MM) chapter, 5 new EPs, 1 revised EP, and 2 deleted EPs under the Provision of Care, Treatment, and Services (PC) chapter, and 3 new EPs under the Performance Improvement (PI) chapter. The proposed requirement that addressed minimum qualifications for technologists performing diagnostic computed tomography (CT) exams remains on hold pending additional research.

The new and revised Requirements for Diagnostic Imaging Services for accredited hospitals are effective July 1, 2015.

Standard EP Status
EC.02.01.01 14 New
EC.02.01.01 16 New
EC.02.02.01 17 New
EC.02.04.01 10 New
EC.02.04.03 15 New
EC.02.04.03 17 Revised
EC.02.04.03 19 New
EC.02.04.03 20 New
EC.02.04.03 21 New
EC.02.04.03 22 New
EC.02.04.03 23 New
EC.02.06.05 4 New
EC.02.06.05 6 New
HR.01.05.03 14 New
HR.01.05.03 25 New
MM.06.01.01 13 New
PC.01.02.15 5 Revised
PC.01.02.15 6 Deleted
PC.01.02.15 7 Deleted
PC.01.02.15 10 New
PC.01.02.15 12 New
PC.01.03.01 25 New
PC.01.03.01 26 New
PI.01.01.01 41 New
PI.01.01.01 42 New
PI.02.01.01 6 New

Joint Commission Publishes Proposed Revisions to Diagnostic Imaging Standards, Seeks Input

On September 11, 2014, The Joint Commission published Proposed Revisions to Diagnostic Imaging Services Requirements for the Hospital Accreditation Program, and is seeking input from the field.

Earlier this year, The Joint Commission postponed the July 1, 2014 implementation of the “first phase” of new and revised diagnostic imaging requirements for accredited hospitals, critical access hospitals, and ambulatory care organizations that provide diagnostic imaging services, identifying that further research was needed to ensure the new standards sufficiently supported improvements in quality and safety.

The Joint Commission announced it would instead implement a single, comprehensive set of revised diagnostic imaging requirements. Though no new implementation date was announced, the comprehensive set of revised requirements is expected no later than July 2015.

As part of its ongoing research, The Joint Commission is seeking input on proposed standards revisions that address the following areas:

  • Minimum qualifications for radiologic and nuclear medicine technologists that perform computed tomography (CT) exams.
  • Orientation of technologists on safe practices related to the provision of diagnostic imaging
  • Documentation of CT radiation dose

Since the proposed standards changes focus on highly technical areas, The Joint Commission “strongly encourage [organizations] to solicit feedback from clinicians and radiology staff with expertise in diagnostic imaging.”

The proposed changes revise Human Resources (HR) standards HR.01.02.05, EP 19, HR.01.05.03, EP 14, and HR.01.05.03, EP 25, and create HR.01.02.05, EP 21; revise Provision of Care, Treatment, and Services (PC) standard PC.01.02.15, EP 5, and delete PC.01.02.15 EPs 6 and 7; and create Performance Improvement (PI) standard PI.02.01.01, EP 15. (See chart below)

Comments on the proposed revisions are being accepted by The Joint Commission until October 24, 2014.

Proposed Revisions to Diagnostic Imaging Services Requirements – Hospital Accreditation Program​

Standard EP Status
HR.01.02.05 19 Revised
HR.01.02.05 21 New
HR.01.04.01 24 Revised and moved from HR.01.05.03, EP 14
HR.01.04.01 25 Revised and moved from HR.01.05.03, EP 25
HR.01.05.03 14 Revised and moved to HR.01.04.01, EP 24
HR.01.05.03 25 Revised and moved to HR.01.04.01, EP 25
PC.01.02.15 5 Revised
PC.01.02.15 6 Deleted
PC.01.02.15 7 Deleted
PI.02.01.01 15 New

Joint Commission Delays Implementation of New and Revised Diagnostic Imaging Requirements; Targets July 2015

On May 15, 2014, The Joint Commission published a revised timeline for implementation of new and revised diagnostic imaging standards, postponing the identified July 1, 2014 implementation of the “first phase” of the new and revised diagnostic imaging requirements, and announcing it will instead implement a single, comprehensive set of new and revised requirements in favor of the two phase approach originally planned for 2014 and 2015. The complete Joint Commission announcement is included below.

Prepublication – Diagnostic Imaging Services Requirements: Update; Delayed Implementation
Revised Timeline for Implementation of New and Revised Diagnostic Imaging Standards

In January 2014, The Joint Commission published new and revised requirements that address risks associated with diagnostic imaging for accredited hospitals and other organizations that provide diagnostic imaging services. The changes were intended to be effective July 1, 2014, with additional changes to be phased in by 2015 (see “Standards Changes for Organizations Providing Imaging Services,” Joint Commission Perspectives, January 2014).

Since that time, we have received significant feedback from key stakeholders both praising the overall effort, and raising concerns about several critical standards. This feedback sheds light on issues that may not have been either identified or sufficiently evaluated during the standards development process. Some of these issues highlighted complexities that require us to engage in further research in order to ensure that the new standards best promote the improvement of quality and safety.

Therefore, The Joint Commission is postponing the July 1, 2014 implementation of the revised diagnostic imaging requirements.

The 2014 Update 1 to the Comprehensive Accreditation Manual for hospitals, critical access hospitals, and ambulatory care will be delayed until early July for customers who purchased the print updates so that The Joint Commission can revert the imaging standards. The goal is to implement the revised standards by July 2015, which will allow for the release of a comprehensive set of requirements, rather than partial sets over 2014 and 2015. When we finalize the 2015 diagnostic imaging requirements, it is expected that the majority of the 2014 proposed requirements will be implemented as currently written. A prepublication version of the final requirements will be posted on our website six months in advance of any identified implementation date.

In order to finalize a single set of standards in 2015, we are collecting additional information about several critical areas of radiation safety. The critical areas include:

  • Documentation of the radiation dose.
  • Annual equipment performance evaluations by a medical physicist or Magnetic Resonance scientist.
  • Minimum qualifications for radiologic technologists who perform computerized tomography (CT) exams (These requirements were to have become effective July 1, 2015. Since this subject is covered in the now postponed revised requirements, this date is also no longer effective)
  • Requirements that align with the State of California’s CT law.

We value and appreciate the feedback received from imaging professionals, our accredited organizations, and other key stakeholders. The decision to postpone the implementation of these requirements is based on our goal of advancing imaging quality and safety.

AHRQ Releases Final Podcast in ‘Quality Indicators Toolkit for Hospitals’ Series, Free Toolkit Still Available, First 5 Podcasts Archived

The Agency for Healthcare Research and Quality (AHRQ) has released the last two audio interviews in a series focused on the use of quality improvement tools in the AHRQ Quality Indicators TM Toolkit for Hospitals. The toolkit is a free resource to guide hospitals through the process of using the AHRQ Inpatient Quality Indicators (IQIs) and Patient Safety Indicators (PSIs) to improve care.

  • Implementing Changes to Improve Performance on the IQI or PSI Measures:  Joseph Jensen, MD, from the University of Arkansas for Medical Sciences Medical Center talks about the process of implementing changes in the hospital to improve performance on the IQIs and PSIs.
  • Achieving Sustainable Improvements: Martha Radford, MD, from NYU Langone Medical Center offers advice on planning for the sustainability of a hospital’s improvements to the AHRQ QIs.

Download these interviews at http://www.ahrq.gov/qual/qitoolkitinterviews. (Audio file and transcript are available.)

The first 5 podcasts are also available:

  • Getting Started with the AHRQ QI Toolkit
  • Analyzing Your IQI and PSI Rates
  • Using the Documentation and Coding Tool
  • Identifying Your Improvement Priorities
  • Analyzing Your Barriers and Strategy Options

Download the AHRQ Quality Indicators TM Toolkit for Hospitals at: http://www.ahrq.gov/qual/qitoolkit

Access the slide presentations and an audio recording from an introductory webinar about the Toolkit at: http://www.ahrq.gov/qual/qitoolkit/webinar0215/index.html

More information on the AHRQ Quality Indicators is available at: http://www.qualityindicators.ahrq.gov/

Credit: AHRQ