Though surveyors review all aspects of a facility during a review, they target specific areas involving patient care. For 2020 and 2021, there is a focus on infection prevention and control, emergency management, provision of care, Swing beds, and Life Safety.  Much of what the Joint Commission requires for certification and deemed status follow the Conditions of Participation from CMS. Hospitals who receive deemed status through Joint Commission are not required to have a certification survey by CMS to participate in Medicare reimbursement.  

This webinar will cover several Joint Commission hot topics for 2021. It will cover the new changes in the September 2020 and January 2021 Joint Commission standards. It will discuss the Joint Commission requirements for advance directives, contract management, grievances, informed consent, and more.

Webinar Objectives

• Recall that the Joint Commission has two sections in the manual that address the issue of informed consent
• Discuss that the Joint Commission requires hospitals to have an informed consent policy
• Describe that Joint Commission has contract management standards and that the hospital should evaluate every contract to ensure the performance indicators are met 
• Remember that Joint Commission requires hospitals to provide patients with written information on admission on advance directives
• Recall that TJC states that patients and families have a right to have a complaint reviewed and it must be done timely
• Discuss that TJC has changed to the hospital standards in July and September of 2020

Webinar Agenda

Contract Management LD.04.03.09

• Contract standard and the EPs
• Same level of care
• Updates
• Hospital leader responsibility for contracted services
• Safety and quality requirements
• Limited applicability to patient care services
• Consults and referrals not subject to requirements.
• Staff competence
• Credentialing/privileging 
• Performance improvement requirements
• Ideas on how to review contracts
• Credentialing and privileging
• Nature and scope of services 
• Leadership approval of contracts
• Monitoring the performance of contracts
• Contracts with other accredited organizations
• Communicating expectations in writing
• Contracts that do not meet expectations
• Continuity of patient care maintained if contract terminated
• Contract lab services

Joint Commission Informed Consent Standards

• RI.01.03.01 and the revised EPs and recuperation
• Remember state law requirements
• Written policy requirements
• Surgery and procedures requiring consent must be specified
• Consent as a process
• Risks benefits, and side effects
• Elements not required by CMS
• Exceptions to policy
• Emergency surgery
• Consent on chart required before surgery
• Consent for photography
• TJC tracer on consent

Joint Commission Advance Directives RI.01.05.01 and RC.02.02.01

• End of life care
• Written policy and procedure
• Tracer
• Advance directives and outpatients
• Providing patients with information about Ads
• Honoring advance directives
• Organ donation wishes
• Medical records to contain copy of AFs
• Recommendations for compliance

Joint Commission Complaints RI.01.07.01

• Patient and family right to have reviewed
• Need complaint resolution process
• Board responsible and delegation
• Acknowledging receipt of a complaint
• Written notice of decision
• Information in patient rights of who will handle complaints
• QIO and process for resolving complaints

Standards for September 2020 Through July 2021

• Environment of care
• Emergency management
• Infection Prevention and Control
• Provision of care
• History and physicals
• Swing bed changes
• Discharges and transfers
• Infection control
• QAPI
• Self-administered medications
• Record retention
• Organ donation

Who Should Attend

• CEO
• Compliance Officer
• Chief Medical Officer (CMO)
• Chief Nursing Officer (CNO)
• Chief Operating Officer (COO)
• Joint Commission Coordinator
• Nurse Educator
• Nurses
• Nurse Supervisors
• Nurse Managers
• Hospital Legal Counsel
• Risk Manager
• Board Members
• Physicians
• Medical Staff Coordinator
• Patient Safety Officer
• Senior Leadership
• Chief Risk Officer
• QAPI director
• Discharge Planners
• HIM director
• Director of Anesthesia
• OR nurse director
• Patient Advocates
• Ethics Committee
• Director of Registration
• HIPAA Privacy Officer
• Quality Improvement Staff
• Others responsible for compliance with meeting Joint Commission standards
• Persons responsible for rewriting policy and procedure.