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Joint Commission Announces New Antimicrobial Stewardship Standard

This July 2016 issue of The Joint Commission Perspectives announces the 1/1/17 implementation date for the new antimicrobial stewardship standard, MM.09.01.01. There are 8 elements of performance, the first of which requires that leadership establish antimicrobial stewardship as a priority. Requirements like this are sometimes confusing on exactly how you go about doing this. The good news is TJC supplies a note with this EP stating 6 examples of how leadership can provide evidence of doing this. They include as examples:

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OBSERVATIONS FROM TJC SURVEYS THIS YEAR: EC.02.05.01, EP 15 and IC.02.02.01, EP 2

We are seeing a high degree of consistency occurring on hospital surveys this year in terms of frequently scored IC and EC standards. These two chapters of the accreditation manual are causing havoc on survey and we wanted to share these common findings with you, while still protecting the confidentiality of the hospitals hit by these issues.  Today I am going to discuss just two standards and two EP’s, EC.02.05.01, EP 15 and IC.02.02.01, EP 2. Both of these issues will score out at a COP level, thus inviting TJC back for a revisit in 45 days or less. The issues we are going to discuss next are appearing on more surveys we review than not, so preparing to prevent these same hits is important. Read more

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Life Safety and Environment of Care Updates from Joint Commission

The lead article in the June 2016 edition of Perspectives is about the adoption of the 2012 Life Safety Code which we have previously discussed. This article does mention 4 aspects that are different in the new code and these are:

1. Roller latches are only prohibited on doors to corridors, and rooms containing flammable or combustible materials.
2. By 2028 buildings taller than 75 feet will be required to install automatic sprinklers
3. Facilities must initiate a fire watch or evacuate if a fire sprinkler system is out of order for longer than 10 hours. (more flexible than the previous 4-hour requirement)
4. In new construction window sills must not be higher than 36 inches above the floor. Read more

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TJC Opens Door to Texting of Orders

The May issue of The Joint Commission Perspectives has an update on the subject of texting of orders to the hospital. Essentially TJC will eliminate their prohibition on this practice. However, before you announce this change be sure to share the article with IT leadership and note the new requirements for the security of the text message process. It is not as simple as just using any phone with text capability. The security requirements for the text message process must include:

*A secure sign on process
*Encrypted messaging
*Delivery and read receipts
*Date and time stamp
*Customized message retention timeframes
*Specified contact list for individuals authorized to receive and record orders

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Joint Commission Modifies Process for Preliminary Denial of Accreditation Decisions

The May 2016 issue of The Joint Commission Perspectives describes an important change in how they are handling preliminary denial of accreditation decisions, or PDA02. This is a particularly good news story, because TJC has found a way to not drive organizations all the way to a review hearing panel, providing they can quickly correct the issues found on survey. In the past a hospital that had a PDA02 decision had to submit their ESC, had to go through an ESC implementation verification survey, and had to then convince the Accreditation Committee not to uphold the PDA decision, and if not successful next go to a review hearing panel in Chicago to plead their case. This has become much simpler and less threatening.

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