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The Joint Commission accreditation survey visit: New processes for a new year

The Joint Commission (TJC) has extended Yale New Haven Hospital's accreditation until the hospital is re-surveyed in 2017. The survey is expected to occur sometime between Jan. 11 and April 11, most likely the fourth week in January or first couple weeks in February.

As of Jan. 1, 2017, TJC has changed its accreditation process, particularly how findings are recorded and responded to, and will be modeling its methodology more along the lines of the Centers for Medicare and Medicaid (CMS) certification surveys.

"We expect the new survey process to be stricter, the scoring different and outcomes and citations more numerous," said Thomas Balcezak, MD, YNHH chief medical officer. "It will be much tougher – but it will elevate our high reliability organization journey to an even higher level – meaning we will be better equipped than ever to prevent harm to patients, staff and visitors."

"The regulatory standards, for the most part, have not really changed – it's the methodology that has changed," added Victoria Dahl Vickers, director of Accreditation, Safety and Regulatory Affairs. At Yale New Haven, our top 15 high potential areas for risk of harm – which may also represent standards leading to federal CMS conditional-level citations – are:

  1. Universal protocol (pre-procedure verification, site marking, time-out)
  2. High-level disinfection /sterilization (pre-cleaning at point of use, proper transport/storage of scopes, probes and instruments, sterile pack inspection at point of use, sterile supplies)
  3. Scope of practice (provision of care, treatment and services are directed by MD/LIP; for example, what is being administered and documented is consistently aligned with the MD/LIP orders)
  4. Department-specific fire response plan (be able to articulate; know RACE and PASS)
  5. Basic infection prevention (hand hygiene, personal protective equipment, hair covered in OR and procedural areas; and low-level disinfection, cleaning multi-use equipment after each patient use)
  6. Means of egress remains unobstructed (nothing in stairwells; no blocking electrical panels, gas shutoff valves, fire extinguishers, doors, pull stations)
  7. Critical value reporting (nurse communicates laboratory critical results to MD/LIP ASAP and within 30 minutes)
  8. Two patient identifiers (confirmed before treatment or procedure; label specimens in the patient's presence at the bedside)
  9. Separation of clean and dirty areas and supplies (clean rooms [ORs, supply rooms] must have positive pressure airflow keeping germs out; dirty rooms [e.g., utility] must have negative pressure airflow keeping germs in)
  10. Procedural/OR care process documentation (informed consent, H&P, pre-sedation evaluation, brief operative note, operative notes, post anesthesia evaluation)
  11. Pain management AIR cycles (assessment, intervention and reassessment; sedation assessment with opioid administration)
  12. Fall risk prevention/screening and assessment (all patients must be screened and interventions implemented)
  13. Complete and accurate logs (emergency equipment, refrigerators, medication, food and specimen; warming cabinets, IV and dialysis fluids, eyewash stations and quality assurance logs)
  14. Oxygen tank management (clear separation of unused, full tanks and in-use tanks; tanks are secured in designated locations)
  15. Alarm management (review ventilator, telemetry and physiologic alarm settings upon application, change in caregiver and as clinically indicated; disable when no longer indicated)

"All eyes will be on Yale New Haven Hospital – as one of the first major hospitals in the country to go through this new Joint Commission accreditation process," said Dr. Balcezak. "We will need heightened awareness and attention to detail. We must apply what we already know 100 percent of the time."

To review TJC materials the YNHH Performance Management team has been sharing for the past few months, visit the YNHH intranet – go to "Departments," then "Accreditation, Safety and Regulatory Affairs," then "Survey Preparedness." A video on preparation for the visit is available on the YNHH employee intranet home page.