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Joint Commission EC/LS Changes

The October 2016 issue of The Joint Commission Perspectives has a must read for your facilities leadership team in its Clarifications and Expectations column. Here George Mills summarizes all the changes brought about by eliminating the regular PFI, the elimination of clarifications for delayed handling of required documents in the survey process, ILSM documentation, time limited waivers and equivalencies.  There are many new acronyms to learn too with TLW, time limited waivers, SPFI, survey related plans for improvement, and SCD for scheduled completion date. Read more

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Joint Commission’s New “SAFER™ Matrix”

The lead article in the October 2016 issue of Perspectives discusses the new SAFER Matrix and the many changes planned for 2017. As you will recall from earlier articles on the SAFER Matrix each finding will be color-coded one of 4 colors by order of significance and scope. The lowest level findings will be bright yellow, or lemon colored. The somewhat moderate level findings will be a pale yellow/orange sort of like French’s mustard. The next highest ranking is a darker golden/orange color, somewhat like Guldens spicy mustard. Lastly there is a red color for the highest significance and most widespread scope. (Dare we say the color of ketchup?) The way in which these different levels will be handled during the ESC is different also, with the 2 highest levels requiring:

Leadership involvement

Preventative analysis

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Summary of Hospital Sentinel Event Statistics for 2016

The August 2016 issue of The Joint Commission Perspectives summarizes the sentinel event statistics for the first half of 2016. The top 5 most common sentinel events identified so far in 2016 are:

1. Unintended retention of a foreign object
2. Falls
3. Wrong patient, site or procedure
4. Suicide
5. Delay in treatment.

Each of these 5 issues also has a recent reference from TJC either as a Sentinel Event Alert, a Quick Safety Newsletter or Targeted Solutions reference. We would encourage all of our readers to look at the references and discuss their own risks and what might be done to reduce them. Read more

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Joint Commission: Changes to the Statement of Conditions Process

Statement of Condition Changes
The August 2016 issue of Perspectives had articles on changes to the Statement of Condition, eliminating long duration plans for improvement to self identified life safety code deficiencies. This was widely reported in everyone’s newsletters and list serves and directly by TJC, but bottom line do you know how your organization dealt with this? The Clarifications and Expectations article in August went into specifics on how to manage through this change and as is customary, TJC came up with several new acronyms you will want to familiarize yourself with including TLW for “time limited waiver,” and SPFI for “survey related plan for improvement,” and SCD for “scheduled completion date.” Read more

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Blurred Lines of Distinction: Standing Orders, Protocols, Order Sets, Favorites

Many clients have asked Patton Healthcare Consultants to help them clarify the blurry lines of distinction between the terms standing orders, protocols, “favorites,” and order sets. The CMS interpretive guidelines make it clear that CMS’s intent is to establish a vetting or review process involving medical, nursing and pharmacy leadership for any “standing order” which would authorize a nurse to take action prior to the order from a practitioner. While the regulation uses the terms interchangeably, the interpretive guidelines specifically state: “Not all pre-printed and electronic order sets are considered a type of ‘standing order’ covered by this regulation.

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