Patton Post – January 2024

New IC Standards:

Happy New Year to our readers! The year begins anew with opportunities and risks to keep up to date with regulatory changes and TJC has thrown down the gauntlet with the January issue of Perspectives containing many new standards changes becoming effective in July 2024. The new set of standards of most significance to our readers is likely the new IC chapter for hospitals.

When you read the Perspectives article you will note there is some “spin” that the chapter rewrite reduced the total number of EPs by 70%. While that is technically correct, don’t get your hopes up that this new chapter is in any way “easier.” The prior EP format contained many single concept, single requirement EPs, whereas the new chapter contains many compound EPs, with multiple bullet points, which still are requirements, but just part of a larger or multifaceted EP.

The new chapter is available for download now on the Joint Commission’s prepublication webpage and links are provided in the Perspectives article. TJC has also posted a Reference Guide that identifies the old standard and EP number along with the new standard and EP number.

As you review this reference, you will note that there are only three existing EPs that have no corresponding reference in the new chapter, meaning only three requirements may have actually “gone away”. The issues that don’t appear in the new IC chapter are IC.01.05.01, EP 2 and IC.03.01.01, EPs 1 and 7, which discuss the infection control plan and its required evaluation. This would appear to be a significant change if the requirements are actually gone, but we would suggest waiting for verification from TJC that it is genuinely gone and not still required from a PI perspective.

TJC indicated posting an IC Assessment Tool which we did find on the extranet near where you would look for your SAG. At first glance it looked like a mere reformatting of the new standards, but it is much more than that. It helps to identify hidden meanings and requirements that are not explicitly stated in the simplified or streamlined chapter. It also will help the infection control team in their preparation for issues they may be asked about by a surveyor, including infection prevention issues beyond just the IC chapter. There is a lot to study in this new tool.

The cross reference of 2023 – July 2024 infection control standards does identify five new standards concepts not clearly articulated in the old standards that are now explicitly in the July 2024 version. You will find these by looking in the column of Old IC (2023) Standards/EP and noting five items identified as NA, where there now is a specific standard and EP identified in the July 2024 version.

For example, there is a new clearly stated responsibility for IC oversight articulated for the governing body in the new IC.04.01.01.01 and IC.05.01.01. While you have seen this same responsibility scored for many years in the leadership chapter because the governing body is responsible for safe and effective implementation of all policies and procedures, it had not previously been as clear in the IC chapter.

Similarly, there are new requirements at IC.07.01.01, EPs 1 and 2 addressing preparedness for high consequence infectious diseases. This was less clear in the old IC chapter under IC.01.06.01, EP 3 using the term “emerging infections,” but was also previously referenced in the EM chapter under EM.11.01.01.

Another valuable addition is EP 3 of IC.04.01.01 which describes TJC’s hierarchy of controls that they have discussed in educational program for the past five years or more. Namely that hospitals follow law and regulation, then manufacturer’s instructions for use, then nationally recognized evidence-based guidelines in developing hospital policies and procedures. TJC also published one of its R3 reports on this new IC chapter, however the content is mostly a reprint of the standards, although there is also information on references, resources, and experts who participated in the development of the new IC chapter.

Be sure to share this revised chapter and R3 with your IC team as well as the extranet survey process tool and the cross reference of old to new standards. These revisions may take some time to be comfortable with from a compliance perspective.

New BH Workplace Violence Standards:

This month’s Perspectives also discusses new workplace violence prevention standards for behavioral health (BHC) programs as well as new requirements for certified community behavioral health clinics (CCBHC) also accredited using the BHC program. The workplace violence standards affect four (4) elements of performance in three chapters.

1. 02.01.01, EP 17: requires the development of an annual worksite analysis to help mitigate or remove safety and security hazards.
2. 04.01.01, EP 1: is refined to add data analysis for safety and security incidents as well as a requirement to report these incidents to the designated workplace violence prevention leader.
3. 03.01.01, EP 9: requires the identification of a workplace violence prevention leader and multidisciplinary team to analyze the incidents, implement a follow up process for victims and witnesses, provide counseling as needed and to report workplace violence to governance.
4. 01.05.01, EP 17: perhaps the most labor-intensive EP in the new standards set, which requires workplace violence prevention training at the time of hire, annually and whenever changes in the program occur. Training should include roles and responsibilities, prevention, recognition, reporting, and de-escalation.

As you prepare your implementation plan you will want to quickly identify your workplace violence prevention leader and team and instruct them to implement the policies and procedures for the work site analysis, prevention, reporting and training.

The CCBHC, or Certified Community Behavioral Health, program is somewhat new from SAMSHA and Joint Commission has developed a very extensive set of modifications to its standards to align with the SAMSHA requirements. Conceptually the program is designed to provide better, and more accessible community based behavioral health services. The new standards will only be effective for those BHC programs that are seeking to be certified as a CCBHC.

Revised EM Standards for AHC & OBS:

There is also a revised EM chapter for ambulatory care and office-based surgery accreditation, random EP modification to their post-acute certification for nursing care centers, and revised requirements for total hip and knee replacement certification. Small portions of our readership have these additional certifications or accreditation programs, and if you do you will need to download the revisions from the prepublication webpage at TJC. All revisions are effective July 1, 2024.

Pre-Anesthesia Assessments:

The January Consistent Interpretation column discusses PC.03.01.03 on pre-anesthesia assessments. EP 1, which describes the requirement to perform a pre-anesthesia assessment prior to high-risk procedures, moderate or deep sedation or anesthesia, had roughly a 20% noncompliance rate in hospital surveys last year. The guidance section from TJC’s internal CITE database, or scoring guidance to surveyors contains an interesting statement when is says, “An airway assessment and ASA classification are considered standard practice.”

While this is true, it is our understanding that the content requirement for the pre-anesthesia assessment was to be determined by the medical staff of the hospital. Most, but not all hospitals we visit do require both ASA classification and airway assessment. The noncompliance rate for EP 1 is fairly high and sometimes we find on consultations that staff just don’t know where to look to find the pre-anesthesia assessment as multiple software applications may be in use.

It is worth asking your anesthesia providers how and where they document the pre-anesthesia assessment and then test staff ability to locate the pre-anesthesia assessment when conducting your internal tracers.

The scoring data for EP 8, which requires the reassessment immediately prior to administering moderate or deep sedation, is surprisingly low at only 2.3% of hospitals being scored on this issue in the prior year. We say surprisingly low because we find the documentation of this is sometimes harder to find, or staff and providers believe the reassessment is not needed as the full assessment was conducted just shortly prior to the procedure. It is best to always think of this as a 2-step process and the second, or reassessment, step can be defined in policy as something simple such as documentation of the last set of vitals prior to induction.

EP 18, applicable to hospitals using TJC accreditation for deemed status, establishes the timeframe to conduct the pre-anesthesia assessment within 48 hours of the procedure and scoring data is very limited with less than 1% of organizations being scored noncompliant on this issue.

The Consistent Interpretation column also provides insight on scoring of PI.01.01.01, EP 5 which requires the hospital to collect data on adverse events related to using moderate or deep sedation/anesthesia. There were no hospitals scored deficient on this requirement in 2022. We would still suggest verifying that this data is being collected and some group is reviewing the data for improvement opportunities.

Medicare Deficiency Surveys:

TJC has been conducting Medicare Deficiency surveys in follow up to surveys which resulted in Medicare Conditions of Participation being scored noncompliant for many years now. In the past it has been our observation that most hospitals usually corrected the COP issue(s) and were scored compliant at a COP level on their first follow up survey.

Recently we have heard from multiple organizations that were not successful on either their first or second follow up and the consequences of this can be very problematic. A failure on the first Medicare deficiency survey results in a second follow up survey, within a very short timeframe and you absolutely, positively cannot fail that second survey.

The difficulties some organizations are having may be because TJC is applying a greater degree of scrutiny to these follow up surveys, or organizations are not implementing corrective actions quickly or thoroughly enough. As almost half of all deemed surveys result in one or more Medicare Conditions being scored noncompliant being prepared for your follow up survey is essential. More importantly if you are one of the organizations that is not successful on your first follow up survey, bear in mind you have entered very dangerous waters, and a redoubling of effort is needed to avoid serious ramifications on the second follow up survey.

Seeking consultative support after a second failure and missing potential standards clarification opportunities is too late to prevent the potential loss of accreditation. We urge readers to take this Medicare deficiency survey seriously and, if you have an opportunity to use consultative services, reach out as early as possible in the process while an opportunity to prevent disaster still exists.