Pg05 -Joint Commission Adds Accountability Measures for 2011- Four 2010 Non-accountability Measures Will Be RetiredREF: JCSC, PI]TJC has designated 22 new measures bringing the total to 44 Accountability Measures. As we predicted, these now apply specifically to Inpatient Psychiatric Services and six of the HBIPS (2a, 3a, 4-7). Four of six remaining non-accountability measures (relating to smoking cessation advice/counseling and antibiotics for pneumonia care) will be retired by 12/31/11. Review relevant HBIPS for the 85% compliance rate.
The Source (November Vol 9 #11)
Pg03 -Calculating Your Hospital's Composite Performance Rate for Accountability Measures[REF: JCSC, PI] Effective January 1, 2012, PI.02.01.03 will require “a composite performance rate of at least 85% on the ORYX accountability measures transmitted to The Joint Commission”. This half page explains how TJC (or you) will determine your score. Note compliance is/can not be determined or even affected by findings during survey, since only official submissions of Accountability Measures in your quarterly ORYX data are utilized. JCSC/PI should read the instructions and calculate your rate.
Clarification: 85 percent compliance rate requirement for accountability measures FYI: JCSC, PPR, Ldr. Apparently some have the misperception that failure to meet the 85% requirement (after Jan 2012) would cause their facility accreditation to be withheld. This is untrue. The consequence will be an RFI that “can be cleared anytime during the 18 months after the full survey by demonstrating acceptable performance through official quarterly ORYX data…” For more specific details refer to New hospital standard establishes 85 percent compliance rate for accountability measures in JC Online 6/29/1 or the JC Online 6/23/10 Special Edition on Accountability Measures.
Joint Commission is implementing new hospital performance measurement recognition program FYI: Ldr, PI
Starting this fall’s annual report on quality and safety TJC will begin recognizing Hospitals that have sustained high rates of performance on their accountability measures with special awards.
New! Additional accountability measures for 2011; four non-accountability measures to be retired FYI: PI
Four of the six non-accountability measures that are common to CMS and TJC are to be retired, effective with December 31, 2011 discharges. The four measures are three instances of Smoking Cessation Advice/Counseling (as listed under care for Heart Attack, Heart Failure and Pneumonia) and Initial Antibiotic Timing (under Pneumonia care) ). TJC still hopes to get CMS to consider retiring the two remaining non-accountability measures. For more background, see our review of Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified.
New hospital standard establishes 85 percent compliance rate for accountability measures FYI: JCSC, PI On January 1, 2012, performance expectations on accountability measures will be integrated into into accreditation standards. On that date, hospitals will be required to meet the new, direct impact requirement of standard PI.02.01.03, EP1 to achieve an 85% composite performance compliance rate for ORYX Accountability Measures (not the monthly ORYX performance measures). The composite rate is a single, calculated rate for all of your reported accountability measures. The details of that calculation is described in the article. It should be noted that after the effective date, failure to achieve the required composite rate will result in an RFI. How to address the RFI and consequences (including evaluation for Contingent Accreditation) for failing to meet the 85% rate are also described in the article.
Field review: proposed performance expectations for ORYX accountability measures[ALERT: JCSC, PI, MDx, RNx] There are still a few more days to provide feedback on the proposed performance expectations for the new accountability measures. For more information on the importance and relevance of this to state/psychiatric hospitals see: Field review: proposed performance expectations for ORYX accountability measures
Field review: proposed performance expectations for ORYX accountability measures[ALERT: JCSC, PI, MDx, RNx] In August of last year, we encouraged psychiatric hospitals to pay attention to Accountability Measures because TJC was already applying the accountability criteria to then current hospital core measures including hospital-based inpatient psychiatric services and was considering their integration into "accreditation requirements". TJC is now proposing a requirement "that would establish specific performance expectations (e.g., 85%) for the ORYX accountability measures for hospitals". Field review comments are being sought and will be accepted through February 22. You are strongly encouraged to participate. For quick additional background on Accountability Measures see our August review of Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified.
Pg01 -Joint Commission Annual Report Shows Big Improvements for Hospital Care FYI: JCSC, PI, Accountability measures are defined as "quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes". Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2010 focuses for the first time on these measures and shows that TJC-accredited hospitals are providing higher-quality, evidence-based care for heart attack, pneumonia, surgical care, and children’s asthma care. [PEARL] SPHCC facilities should pay attention because in 2009 six new performance measures, were introduced for inpatient psychiatric services. They include:
• Use of physical restraint
• Use of seclusion
• Multiple antipsychotic medications at discharge
• Multiple antipsychotic medications at discharge with justification
• Post-discharge continuing care plan created
• Post-discharge continuing care plan transmitted
Although these measures have not yet been evaluated against the accountability criteria it is likely that they will be. Again, we strongly suggest paying attention to this as TJC also intends to adopt these accountability measures for use in the ORYX program and is considering their integration into "accreditation requirements". For more background on Accountability Measure see also: Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified.
Pg01-Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified [REF:JCSC, PI, LDR, GB] The Joint Commission now has a new approach to performance measurement and it is based on something called accountability measures (AM). An accountability measure is described as an evidence-based quality measure for processes of care that are known to improve health outcomes for patients. TJC has defined 22 accountability measures (AM) and 6 non-accountability measures (NAM). The point of accountability measures is supposedly to help an organization focus its limited resources more effectively on those issues/measures that are most likely to actually improve health outcomes. Psychiatric hospitals should note that TJC is already applying the accountability criteria to current hospital core measures including hospital-based inpatient psychiatric services. We strongly suggest paying attention to this as TJC also intends to adopt these accountability measures for use in the ORYX program and is considering their integration into “accreditation requirements”. We would suggest this initiative is further confirmation of an unfolding PI direction and philosophy earlier evidenced in TJC’s evolution of the Center For Transforming Health Care, Robust Process ImprovementTMand revision of the Sentinel Event Policy described below. Take heed!
Key/Additional Details
The 22 accountability measures were based on their meeting a set of 4 criteria that were applied to a list of 28 Hospital Process of Care Measures(HPCM) utilized by CMS's Hospital Compare website.
The 28 HCPM are listed in a chart on page 9 of the article and consist of seven measures related to heart attack care, four measures related to heart failure care, six measures related to pneumonia care, eight measures related to surgical care improvement project and three measures related to asthma care (for children only).
Accountability measures (AM) are scored/weighed more heavily than non-accountability measures (NAM). Unsatisfactory performance on an AM would result in1.0 point (vs. 0.33 points for NAM) being assigned to a hospital’s related priority focus area (PFA) and clinical service group (CSG). Remember, PFAs and CSGs are part of the data used by TJC to determine the particular points of focus or emphasis for a survey.
JCO 6/23/10 (Special Issue for Hospitals) Focus on accountability measures: Helping hospitals meet future performance measurement expectations.
The article provides a general overview of the fact that TJC is categorizing its performance measures into accountability and non-accountability measures based on four critieria (research, proximity, accuracy and adverse effects.). These criteria are breifly explained ina sidebar. Clearly, TJC is announcing its movement toward more emphasis on the accountability measures and their integration into the Priority Focus Process and The Joint Commission’s Strategic Surveillance System (S3) Performance Risk Assessment.. The article also references resources such as the June 23, 2010 online issue of the New England Journal of Medicine that features an article, “Accountability Measures: Using Measurement to Promote Quality Improvement,” (HTML) (PDF) for which Mark R. Chassin, M.D., M.P.P, M.P.H., president of The Joint Commission, was the lead author. An audioconference on the topic is scheduled for 6/30/2010.
In the Nov 11, 2011 issue of Joint Commission Online, TJC announced a 4-month pilot of the new Intracycle Monitoring Process (IMP) that we encouraged psychiatric hospitals to sign up for. The pilot will begin as scheduled next month. Once it is fully implemented in January 2013, IMP will include ‘Touch Points’ at 12 and 24 months (post survey) and a Focused Standards Assessment (FSA) tool, which will replace the Periodic Performance Review (PPR) tool. During Touch Points, TJC may also engage organizations in more focused reviews of previously cited RFIs, program-specific risks, measurement data, and selected documents along with a discussion of TJC compliance tools that might be useful for your particular organization. See also TJC Intracycle Monitoring (IM) Process Pilot. TIP: 2013 is closer than you think, so keep you eye on this issue through our related review compilation, [RC(ap)_IntracycleMonitoring] that will also be posted on our first Hot Topic Blog, HT(ap)1201_Intracycle Monitoring.
Call for organizations to pilot test Intracycle Monitoring process FYI: JCSC, PI, Ldr. The June 29, 2011 issue of JC Online announced the fact that in 2013, the PPR would become the FSA (Focused Standards Assessment) as part of an initiative TJC calls the Intracycle Monitoring (IM) process. Under its new name, the PPR/FSA or self-assessment process will occur on approximately the 12 and 24th months after your triennial survey. These junctures are called ‘TouchPoints’. Unlike PPR submissions that require evaluation of all relevant standards, the concept of TouchPoint, instead focuses more selectively on higher risk issues and core measures. Pilot testing of the new approach is to occur between February and May of 2012. This article is a call for pilot volunteers. SPHCC would like to encourage psychiatric hospitals (especially those with a 12 or 24-month PPR due in the first half of 2012) to participate in the pilot so that the ultimate process is more user-friendly and relevant for our facilities. The pilot activities in 2012 would involve submitting a PPR on Feb 10th, converting this into an FSA submission by May 2nd and then taking advantage of TJC support and conference calls through the end of the pilot in June. Beyond this, the pilot is also an opportunity for getting a leg up on this new process and some free consultation by TJC (i.e., SIG, Account Executives, surveyors) regarding your areas of risk and some documents. For the simple application (6 blanks and 3 check boxes) or more detail, go to the PPR information page of your TJC Connect extranet. You might also listen to the first 10-15 minutes of the Oct 20, 2011 introductory Intracycle Monitoring Webinar. Pilot selections are to be finalized by the end of this month and Mr. Joe Misenko says they will accept applications until Thanksgiving, so please decide quickly.
Correction: PPR name remains during 2012 while FSA is piloted as part of new IM process FYI: JCSC, PPR, Ldr. Yes, as reported in JCO, 6/29/11, the PPR will be renamed the Focused Standards Assessment (FSA), but not until 2013. That will be part of implementing the new Intracycle Monitoring (IM) process. However, there is confirmation that starting 1/1/12 the PPR will not need to be submitted during the third year of accreditation
Now available: new APRs on Focused Standards Assessment
The FSA is part of what TJC calls "a broad initiative" known as the Intracycle Monitoring process (IMP). Although it is unlikely to be fully implemented until 2013, it is being desgined to focus on activities to "help identify risk points in health care organizations along with resources for addressing patient safety and quality problems". Pilot testing of the new IM process is to occur in 2012.
Patient-Centered Communication: Review Compilation for 1/2011-1/2012
Perspectives (PR) - December, Vol 32, # 1 Pg03 -
Update: Implementation of Patient-Centered Communication Standards FYI: JCSC, MDx, RNx, HR, PtAd,The phased Implementation plan for Patient-Centered Communication Standards that began in January of last year comes to completion on 7/1/12 when findings related to HR.01.02.01, EP 1; PC.02.01.21, (EPs 1 and 2); and RC.02.01.01, EP 28 are no longer excluded from affecting accreditation decisions. Additional guidance for effectively communicating and serving the Lesbian, Gay, Bisexual and Transgender (LGBT) community is also now available (see page 11 article review below).
Patient-centered communication standards go into effect July 2012 FYI: JCSC, HR, MDx, RNx. Just a reminder that beginning 7/1/12, surveyor findings related to all of the communication standards will affect accreditation.
5 Sure-Fire Methods Complying with RI.01.01.01 FYI: JCSC, PtAd, StEd, On 11/19/10, CMS issued a new condition of participation to ensure patient visitation rights (CMS-3228-F1106) that became effective on January 18 of this year. One of the key points of the ruling was to eliminate limitations and/or discrimination in visitation, particularly those based solely on sexual orientation and gender identity. These requirements are addressed by TJC in standard RI.01.01.01, EPs 28 and 29. These EP were first slated for implementation in a pilot phase and depending on feedback from the field were to be fully implemented in “early 2012”. In that context, this article provides suggestions for compliance with those two EPs. Much of the advice is based on TJC’s earlier work on improving communication, cultural competence and patient/family-oriented care. It is captured in the monogram, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (PDF)1106. Your are strongly encouraged to review the Roadmap if you have not already done so. If nothing else, pay particular attention to pages 61-63 in Appendix C that specifically address the revisions to EPs 28 and 29 and provide self-assessment guidelines. Then review your visitation policies, patient satisfaction data related to visitation and consider any needed refinements of patient orientation and staff training that might be useful to refine your level of compliance.
EOC News, March 2011, Vol15#3 Pg01 -
Talking to the World Treating Patients with Limited English Proficiency—During Emergencies and Every Day FYI: PtAd, RN, Ldr The context for this article is the new standards related to patient-centered communication and cultural competence and the fact that almost 20% of persons in the US over the age of 5 use a language other than English. Surveyors have begun evaluating these standards, but findings will not impact accreditation until after January 2012. The article provides insights and suggestions from the experience of a 4-hospital system in Broward County, Florida that had to communicate with an influx of limited English proficiency (LEP) patients after the January 2010 earthquake in Haiti. Tips include periodically surveying staff (especially licensed staff) to determine other languages they are capable of speaking. In addition to telephone language lines that many state hospitals subscribe to, the article also mentioned one provided by the Red Cross. Upon exploring this, we discovered that there are language banks provided by entities like the Red Cross or local governments that sometimes provide translation services free of charge. Check your local Red Cross chapter. Also be aware that should a disaster or other influx of LEP patients overwhelm your translation capabilities, that there is the option to contact the National Incident Management System (NIMS) for assistance in finding the needed services. See also: New R3 Report details rationale/research behind Joint Commission requirements and Update: Implementation Plan for Patient-Centered Communication Standards {Review/Full Article}
New R3 Report details rationale and research behind Joint Commission requirements[ALERT: JCSC] This new complimentary TJC newsletter is published as needed to provide rationale and references on new requirements that are more in-depth than that provided in the standards manuals. [REF: JCSC]The first release, R3Report Issue 1, focuses on Patient-centered communication standards for hospitals. TJC has begun surveying these requirements but they do not go into full effect until January 2011. Along with a bibliography, it provides rationale/references for the following selected standards: • PC.02.01.21 EPs 1 and 2 (Effective Communication) • RC.02.01.01 EP 28 (Collecting Race and Ethnicity Data), RI.01.01.01 EP 28 (Access to a Support Individual) and RI.01.01.01 EP 29 (Non-Discrimination in Care)
See also: Update: Implementation Plan for Patient-Centered Communication Standards {Review/Full Article} [Aug 2010 RTN]
