The March issue of The Joint Commission Perspectives contains an article on the latest change in the diagnostic imaging standards that have new requirements effective September 2016. Fortunately you have hopefully been reading and anticipating these for a long time as they have been in development and published by TJC on several occasions.
The lead article in the February issue of Perspectives addresses interim life safety code measures as required by. This standard is particularly important because EP 3 by itself is associated with an adverse outcome, accreditation with follow up survey, (AFS) if there is a failure to have an ILSM policy and evaluate life safety code deficiencies using that policy.
SGNA has two new clinical practice guidelines, one on reprocessing of flexible GI endoscopes and a second on infection prevention in the GI setting. These can be downloaded from SGNA using this link: https://www.sgna.org/Education/Standards-Practice-Guidelines
In the flexible scope document SGNA provides guidance on minimum cycle documentation including:
• procedure date and time
• patients name and MR #
• endoscopists name
• endoscope model and serial number or other identifier
• names of individuals who reprocessed the endoscope.
In The Joint Commission January 2016 Perspectives series entitled “Clarifications and Expectations” continues its discussion on Read more. They discuss EP’s 9, 10, 11, 12, 18 and 19. When reading these requirements, staff in either hospital quality or facilities might be tempted to say, “yea, we do that” and move on to something else. This one would be worth having a detailed discussion and analysis at a hospital wide meeting to verify actual compliance. Our recommendation is to use your “show me” technique, or your “how do we do that, where is it documented” methodology.
The December issue of TJC Perspectives reminds us that TJC has posted a draft set of standards for antimicrobial stewardship to their website. You can access proposed standards from their home page by clicking on the standards tab. The standards in general do not seem onerous, but there is an annual expectation for education for staff involved in ordering, dispensing or administration including all prescribing LIP’s.