Joint Commission Requirements Research Articles

SU‐E‐I‐65: The Joint Commission's Requirements for Annual Diagnostic Physics Testing of Nuclear Medicine Equipment, and a Clinically Relevant Methodology for Testing Low‐Contrast Resolution

Purpose:To introduce the Joint Commission's requirements for annual diagnostic physics testing of all nuclear medicine equipment, effective 7/1/2014, and to highlight an acceptable methodology for testing lowcontrast resolution of the nuclear medicine imaging system.Methods:The Joint Commission's required diagnostic physics evaluations are to be conducted for all of the image types produced clinically by each scanner. Other accrediting bodies, such as the ACR and the IAC, have similar imaging metrics, but do not emphasize testing low‐contrast resolution as it relates clinically. The proposed method for testing low contrast resolution introduces quantitative metrics that are clinically relevant. The acquisition protocol and calculation of contrast levels will utilize a modified version of the protocol defined in AAPM Report #52.Results:Using the Rose criterion for lesion detection with a SNRpixel = 4.335 and a CNRlesion = 4, the minimum contrast levels for 25.4 mm and 31.8 mm cold spheres were calculated to be 0.317 and 0.283, respectively. These contrast levels are the minimum threshold that must be attained to guard against false positive lesion detection.Conclusion:Low contrast resolution, or detectability, can be properly tested in a manner that is clinically relevant by measuring the contrast level of cold spheres within a Jaszczak phantom using pixel values within ROI's placed in the background and cold sphere regions. The measured contrast levels are then compared to a minimum threshold calculated using the Rose criterion and a CNRlesion = 4. The measured contrast levels must either meet or exceed this minimum threshold to prove acceptable lesion detectability.This research and development activity was performed by the authors while employed at West Physics Consulting, LLC. It is presented with the consent of West Physics, which has authorized the dissemination of the information and/or techniques described in the work.

Clinical Anesthesia, 7e

Clinical Anesthesia, 7e

EFLU: Electronic Collection and Tracking of Employed and Non-employed Healthcare Worker Influenza Vaccination in a Large Healthcare System

The 2012-2013 influenza season is the fourth year of the HCA influenza patient safety program which includes healthcare worker (HCW) vaccination. New this year are Joint Commission (TJC) and National Healthcare Safety Network (NHSN) requirements for reporting vaccine decisions of nonemployee populations, including physicians, dependent healthcare practitioners, vendors, contractors, student and volunteers. In prior years, HCA tracked employees (over 190,000) in an enterprise wide payroll system for summary enterprise reporting. Non-employees were tracked locally at the facilities, but not at the enterprise level. Employee tracking depended on manual processes using paper consent and declination forms prior to database entry. Improvement goals were to convert to electronic capture of decisions for both employees and non-employees, and to streamline the data entry and quality of data.

Providing Cultural Competent Care

Our Adult Blood and Marrow Transplant Program at a tertiary health care center is a leader in clinical care and bio-medical research. Patient centered care is the fundamental framework of our organization. Many patients from diverse cultural backgrounds from across our nation and the world travel here, seeking our care. With this growth in diversity, it is critical that as health care providers we understand their particular needs. It is also in our best interest to provide care that is culturally competent. The “Advancing effective communication, cultural competence, and patient and family centered care: A Roadmap for Hospitals” article, published in August 2010, provides recommendations to help hospitals address unique patient needs and comply with existing joint commission requirements. Firstly, our organization purchased a Culture Vision database to help health care providers learn about specific cultures. Then, our ABMT unit took steps to embrace culturally competent care by integrating a cultural knowledge. The nursing staff completed an assessment of their own healthcare beliefs and practices, and existing cultural knowledge. Then, we enlisted the help of nursing staff from different cultural backgrounds to share their experience in the context of their culture's perception of illness, pain, healing, attitudes toward authority figures, use of nonverbal and verbal communication and its interpretations, spiritual and death practices, and the role of family within the specific group. Unit based nursing grand rounds during staff meetings included presentations from staff members of Latino, African, Caribbean, Native American, and Arabic background. Our focus of presenting unbiased information about the potential cultural behavior of patient's, resulted in tearing down barriers and providing optimal patient care. More importantly, this project helped members of the nursing staff become more aware of our own traditions and motivated us to recognize, respect, and take into account beliefs and practices of our patients. It is no surprise, that health care providers who understand their patients’ cultural values, beliefs and practices are more likely to have positive interactions with their patients and provide them with culturally acceptable care. When we embrace other cultures, we learn to understand, accept and respect differences while fostering trusting relationships with our patients and their family members.

Full-scale regional exercises

Man-made (9/11) and natural (Hurricane Katrina) disasters have enlightened the medical community regarding the importance of disaster preparedness. In response to Joint Commission requirements, medical centers should have established protocols in place to respond to such events. We examined a full-scale regional exercise (FSRE) to identify gaps in logistics and operations during a simulated mass casualty incident. A multiagency, multijurisdictional, multidisciplinary exercise (FSRE) included 16 area hospitals and one American College of Surgeons-verified Level I trauma center (TC). The scenario simulated a train derailment and chemical spill 20 miles from the TC using 281 moulaged volunteers. Third-party contracted evaluators assessed each hospital in five areas: communications, command structure, decontamination, staffing, and patient tracking. Further analysis examined logistic and operational deficiencies. None of the 16 hospitals were compliant in all five areas. Mean hospital compliance was 1.9 (± 0.9 SD) areas. One hospital, unable to participate because of an air conditioner outage, was deemed 0% compliant. The most common deficiency was communications (15 of 16 hospitals [94%]; State Medical Asset Resource Tracking Tool system deficiencies, lack of working knowledge of Voice Interoperability Plan for Emergency Responders radio system) followed by deficient decontamination in 12 (75%). Other deficiencies included inadequate staffing based on predetermined protocols in 10 hospitals (63%), suboptimal command structure in 9 (56%), and patient tracking deficiencies in 5 (31%). An additional 11 operational and 5 logistic failures were identified. The TC showed an appropriate command structure but was deficient in four of five categories, with understaffing and a decontamination leak into the emergency department, which required diversion of 70 patients. Communication remains a significant gap in the mass casualty scenario 10 years after 9/11. Our findings demonstrate that tabletop exercises are inadequate to expose operational and logistic gaps in disaster response. FSREs should be routinely performed to adequately prepare for catastrophic events.

Ask George

In this column, BI&T features questions and answers between AAMI members and Joint Commission expert George Mills. Become part of the discussion and ask questions about those subjects that matter to you the most.You can submit your Joint Commission question at this link: www.aami.org/htmcconnect/askgeorge.html. Or to join AAMI's Joint Commission e-forum, which is open to all AAMI members, visit www.aami.org/communities/discussion.html. Some of the questions and answers may have been edited for space, style, and clarity.My last Joint Commission inspector wanted me to rate all my medical devices for infection control risks. Is this specified in the standards? Are there some examples of this rating that I can use?Although inclusion of potential risk associated with infection control makes sense, this is not required in the Elements of Performance that address developing your medical equipment inventory (EC.02.04.01 EP 1 and EP2). EP 2 states: “The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorization by physical risk associated with use (including all life-support equipment) and equipment incident history.”The recent issues surrounding scopes make a good argument for including infection control in the categorization process, but, again, it is not required for medical equipment. Note: EC.02.05.01 EP 2 is similar for utilities systems and does include the line: “. . . utility systems based on risks for infection, occupant needs, and systems critical to patient care (including life-support equipment).”Is The Joint Commission's expectation that we track individual endoscopes or just keep a total number inventory? I'm hearing two different things. Also, how is “endoscope” being defined? Does this include all urology and laparoscopic scopes?The intent is to provide another concerned department with a look at the process that those responsible for cleaning and storing scopes use. I am not as concerned with serial numbers—although risk managers may be for tracking possible adverse events—as bringing another department to take a fresh look at the process to ensure handling and storing does not create opportunities for cross-contamination. Joint Commission surveyors have seen scopes that were cleaned and stored in cabinets that were too short, causing the end of the scope to actually rest and drain onto a towel that is shared with another scope.To answer the question, if you have five scopes on the inventory and one is sent out to the supplier and a different scope is provided, the inventory is still five. The risk manager or your own policies may require more detailed information.A surveyor just wrote up one of our facilities for having a piece of lifesupport equipment coded as “could not locate (CNL).” Of course, the preventive maintenance is overdue and the surveyor told the facility that CNL was no excuse and that life-support equipment must be inspected 100% of the time. Is this surveyor making an incorrect assumption or did the surveyor not understand that sometimes items go missing?This is hard to answer, as I was not there to hear the discussion. Generally, if you have a policy stating how you manage “could not locate” items as they affect life-support equipment and associated completion rates, and show that to the surveyor, the result should be acceptance of your process—unless the process is determined to be lacking. If the policy is not acceptable, ask the surveyor to explain why.Is it a department's responsibility to make its equipment available to biomedical equipment technicians (BMETs) for preventive maintenance inspection purposes? Or do BMETs have to search for the equipment due for scheduled inspection?This is driven by your policy. Ideally, users and maintainers should have a common goal of working together to ensure that scheduled activities can be done in a timely manner for the benefit of the patients.Is there a standard requiring that the expiration date on the refill cartridges of hand-sanitizer dispenser be visible through a wall dispenser window?Nothing to that effect in the Joint Commission requirements, but it sounds like a good practice to consider.

The Roundup

The Roundup

Validating Patient Safety in the Endoscopy Unit Using The Joint Commission Standards

Patient safety has gained increasing interest and importance in the endoscopy suite. To maintain standards in patient identification, confidentiality, medication safety, and specimen handling while still meeting The Joint Commission or other agency requirements, all employees must be part of this process. This article demonstrates ways to accomplish this goal, using audits of safety standards that increase staff involvement. A sample audit tool is provided, along with methods to help all employees feel empowered to meet standards and report any patient safety issues.

Evidence for Increasing Diversity in Graduate Medical Education: The Competence of Underrepresented Minority Residents Measured by an Intern Objective Structured Clinical Examination

Some have commented that the limited number of underrepresented minorities (URMs) in United States' residency programs is due to a lack of qualified candidates. At the University of Michigan, an objective structured clinical examination is administered to incoming residents at the beginning of training to determine baseline competence. In this study we wanted to determine if competence differed for underrepresented minorities when compared to non-URM residents. The postgraduate orientation assessment, a 10-station examination, was developed that focused specifically on the knowledge and skills needed in the first 6 to 18weeks of training. Stations assessed competence in informed consent, aseptic technique, evidence-based medicine, diagnostic images, critical laboratory values, cross-cultural communication, and Joint Commission requirements such as surgical fire safety, pain assessment, and management. We used various assessment measures including standardized patients, computer-based testing, and multiple-choice questions. Our study found no significant differences in overall mean scores between URM residents and all other residents for the 5years during which we administered the examination, except for 2002. This stands in contrast to the consistently worse performances of URM students on USMLE Step 1 and Step 2 Clinical Knowledge. Also, URM residents did not perform better or worse than their non-URM colleagues on standardized patient stations during the course of 5years during which the examination was administered. The postgraduate orientation assessment provides residency program directors with a standard format to measure initial clinical skills. When compared to incoming non-URM residents from a variety of medical schools, URM residents perform as well as other trainees. Our results may aid in the recruitment efforts of URM medical students into academic residency programs such as those at the University of Michigan.

The Joint Commission Practice Performance Evaluation: A Primer for Radiologists

As health care quality continues to move into the limelight, so do physicians. The new Joint Commission requirements (Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation) mandate continuous data-based evaluation and monitoring of physician practice performance. This task could be seen as cumbersome, but it may provide opportunities to develop quality improvement programs that demonstrate the value provided by hospital-based radiologists.

Louisiana's Approach to Criminal Background Checks of Nursing Students

In recent years, growing concern for patient safety has led to additional requirements for health-care personnel. Prominent among these requirements is a criminal background check on all persons who provide patient care, including students. In many cases, contractual agreements between nursing education programs and health-care institutions compel faculty and students who need hands-on clinical experience to meet these requirements. But who is responsible for conducting background checks—nursing education programs, health-care institutions, or the state board of nursing? With the current focus on student privacy rights, increased Joint Commission requirements, and complex jurisdiction over nursing student regulation, this is an appropriate time to examine regulation of students on their enrollment in nursing programs and throughout the progression of their clinical course sequence. Louisiana is the only U.S. state or territory with the authority to regulate nursing students. This article discusses the issues surrounding criminal background checks of nursing students, using Louisiana as a model.

A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure

A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure

A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure.

Review question/objective: The objective is to identify the best available evidence on effectiveness of nurse coordinated transitioning of care between hospital and home on all hospital readmission rates in hospitalized adult patients with heart failure. Inclusion criteria: Types of participants: This review will consider studies that include adult patients, 18 years of age or older, hospitalised with heart failure being discharged to home. Types of intervention(s)/phenomena of interest: This review will consider studies that evaluate all models of nurse coordinated transitioning of care from hospital to home, limited to inpatient care coupled with post-discharge home-based and/or telephone education and support by a nurse. Types of outcomes: This review will consider studies that include the following outcome measures: all hospital readmission rates with a focus on 30 day readmissions.

Medical Equipment Management Manual

Author: Robert H. Stiefel, MS, CCE, Publisher: AAMI, ISBN: 1-57020-350-4, Publication date: 2009, Pages: 111, Price: List: $135/AAMI member, discount: $85Audience: The seventh edition of AAMI's Medical Equipment Management Manual by Robert H. Stiefel was released this spring. This manual is useful for those who are responsible for the design and/or implementation of a medical equipment management program in preparation for The Joint Commission's accreditation survey. It is written as a reference that allows the new medical equipment manager to read it from cover to cover and emerge with a thorough understanding of the standards, while also serving as a reference for the more seasoned medical equipment manager. Medical equipment managers will appreciate the discussion of the evolution of the accreditation process and in the accreditation standards included in the manual.Features: The manual includes the standards pertinent to medical equipment management, contained in The Joint Commission's Comprehensive Accreditation Manual for Hospitals. In addition, standards related to human resources, infection prevention and control, information management, and leadership are given the same level of attention.As it is written from a historical perspective, the manual explains how standards have evolved. It contains a helpful “Crosswalk” comparing 2009 standards to those from 2008. A discussion of the history of The Joint Commission's formation and work culminates in a detailed explanation of the most recent Standards Improvement Initiative, launched in August 2006, and the resulting changes.The intent of each standard is discussed, as well as its pertinence to the overall medical equipment management cycle of Plan/Assess, Evaluate/Select, Acquire, Install/Implement, Use, Maintain, and Replace. Suggestions on writing a medical equipment management plan are made and examples of policies that will support the plan are provided, as are multiple sample documents.The survey process and scoring methodology are explained in detail. The scoring section is perhaps the most difficult portion to understand as it represents a process that has developed incrementally and changed with the standards. Recommendations are made regarding documentation to be prepared in advance and presented during the survey process. An overview of the survey process as it relates to the overall organization is also explained. For example, the exit interview and the rendering of an accreditation decision are described as well as the required process for responding to identified deficiencies.Several appendices supplement the text. The glossary is a helpful tool as The Joint Commission survey process is full of acronyms that are used throughout the manual. A listing of other accrediting agencies is included with a short description of each.Assessment: The manual is a very comprehensive treatment of the subject matter and the reader emerges with broad knowledge of The Joint Commission requirements as they pertain to medical equipment management and related standards. The reader will take away the knowledge that there is some latitude in designing a program to meet the standards. However, the example documentation and methodologies described are quite conservative and even dated in their approach, most likely because this is written as a tutorial document. For example, the author favors an all-inclusive medical equipment inventory but recognizes that a risk-based inventory is sufficient. An exhibit of suggested fields for inclusion in that equipment inventory is offered but doesn't illustrate the more contemporary needs of such things as software version, applicable anti-virus software, and operating system. Discussion of the historical development of standards is intertwined with discussion of current standards, making it difficult at times for the reader to focus on the current requirements. This is most evident in the discussion of survey scoring methodologies. While this approach is very interesting for the seasoned medical equipment manager, people new to that role may need more time to study the text for comprehension. Having invested that additional time, however, understanding the historical perspective may better prepare the new medical equipment manager to understand the evolution of his or her own program.

Recommendations for the Implementation of Joint Commission Guidelines for Labeling Medications

Recommendations for the Implementation of Joint Commission Guidelines for Labeling Medications

Surgical Time Outs in a Combat Zone

AORN supports the Joint Commission's requirements and guidelines to promote correct site surgery, including preoperative verification, site marking, and conducting and documenting a surgical time out. This article highlights the success of a well-implemented surgical time out policy and procedure at a two-bed combat support hospital in northern Iraq. Policy implementation, training, documentation, and quality management chart checks prevented any incidence of wrong site surgery through the completion of more than 900 procedures on more than 400 patients during a 15-month period.

Standards in Practical Use. . . What You Need to Know About EQ56

Since its initial release in 1999, ANSI/AAMI EQ56, Recommended Practice for a Medical Equipment Management Program has set the bar for the minimum requirements of a successful medical equipment management program. EQ56 was reaffirmed in December 2008, and the committee is discussing when to start working on a revision. With changes to Joint Commission requirements planned for 2009, EQ56 remains a valuable tool for any biomed shop or clinical engineering department. Get the facts on EQ56 below.Everyone involved in healthcare medical equipment management, regardless of whether they are in-house or contracted. This includes not only those directly involved with the day-to-day operations of the department, but—in some ways more importantly—also the administrators overseeing the medical equipment management program. These could include the chief operating officer (COO), chief information officer (CIO), chief nursing officer (CNO), and even the chief executive officer (CEO).EQ56 sets the minimum standards about how to set up a program, including space, training, tools, and performance. It also provides you with the tools to measure your level of compliance.Always, but especially before a hospital's administration compares options for their medical equipment management program, be it a department or contracted service. Also, EQ56 helps hospitals provide and measure a minimum level of service. While the Joint Commission has not adopted this standard, it will help you maintain a level of readiness for accreditation surveys. (Incidentally, three current and former Joint Commission senior engineers in the Standards Interpretation Group—George Mills, Dean Samet, and Ode Keil—have been involved with this standard at one time or another.)Every healthcare facility.The ultimate goal of EQ56 is to provide better patient safety by defining the minimum requirements for the maintenance of medical equipment. It accomplishes this by defining the minimum space, training, and tools for the maintenance providers. An underlying principle of the document is that efficient and well-trained technology managers who are equipped with the tools required to work safely and efficiently can concentrate on keeping equipment properly maintained without cutting corners. This, in turn, provides better, safer care (through the medical equipment) for the patients.The most important thing to do with EQ56 is ensure that the administrators throughout the reporting structure know what it is. You might purchase a copy for your administrator to keep in his or her office, or you might just make sure that they know you have it. The next thing you need to do is make sure that they know what is in it and how it applies to them.Finally, keep administrators apprised of your compliance with EQ56. You may want to add it to the scorecard section in your annual or quarterly report—simply include a line that says that your department meets or exceeds AAMI/ANSI EQ56.It is important that you keep this standard in the forefront of administrators' thinking. This can be essential if administration ever wants to look at changing their medical equipment situation by outsourcing or bringing it in-house. By knowing that there is a standard, administrators can apply it to the proposals they are considering and keep a level playing field, comparing apples to apples.If you are a well-functioning department, and if, due to budget constraints or other reasons, it is decided to attempt to cut maintenance costs, your administrator needs to have the facts readily at hand when looking at your operations. If your department is struggling with any of the standard's covered items, you should use it to help get that needed resource, be it tools, training, etc.

Planning a Mass Vaccination Exercise Using Influenza Vaccine in Grand Forks, North Dakota

ISSUE: Communities and healthcare organizations are preparing for bioterrorism and biological events. Plans include mass distribution of pharmaceuticals. The 2005 Joint Commission requirements include preparation to respond to epidemics or infections that can overwhelm organizational resources. PROJECT: A North Dakota Department of Health grant allowed the Northeast Biological Planning Coalition to adapt the Greater Grand Forks (GF) community's mass vaccination plan to an exercise administering free influenza vaccine to the public. Participating agencies included: GF Public Health, Altru Health System, Alerus Center, United Way, GF County Sheriff's Department, University of North Dakota, City of GF Public Information Office, GF Fire Department, GF Air Force Base, GF Police Department, GF County Social Services, UND Family Practice, Red Cross, and the Regional Bioterrorism Coordinator. The exercise was named MAXVAX. The Center for Disease Control and Prevention's (CDC) Smallpox Response Plan and Guideline was used to calculate the number of vaccinees and workers needed to simulate the scenario of immunizing 70,000 people in 10 days. The MAXVAX goal was to give 1750 people influenza vaccine in 4 hours. The venue was the 447,000-sq.-ft. Alerus Center. One-hundred-twenty volunteers were identified. A media campaign invited the public to be vaccinated. RESULTS: Although final plans were in place, the event was cancelled on short notice due to the unexpected shortage of flu vaccine in December 2003. LESSONS LEARNED: An exercise will identify weaknesses in written bioterrorism plans. Weaknesses that we identified include: event communication plans, volunteer management, security, and accommodating persons with special needs and homebound persons. Implementation of community emergency plans requires cooperation between many agencies.

The Joint Commission's requirements for evaluating contracted home care services.

Contracted services have gained greater emphasis in the home care standards and survey process over the past several years, especially as they relate to the quality and safety of the services provided. This column reviews 2004-2005 standard LD.3.50, its applicable elements of performance, and discusses the Joint Commission's requirements for evaluating the care and services provided by contracted providers.

Pain management: the global connection.

Understanding pain and the cultural perceptions patients and staff hold about it is crucial to developing a pain management program that complies with Joint Commission requirements.