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JOINT

COMMISSION
WHAT IS JOINT COMMISSION?
The Joint Commission evaluates and accredits more than
16,000 health care organizations and programs in the United
States.
An independent, not-for-profit organization, The Joint
Commission is the nation's predominant standards-setting
and accrediting body in health care.
Since 1951, The Joint Commission has maintained state-of-
the-art standards, that focus on improving the quality and
safety of care provided by health care organizations. The
Joint Commission's comprehensive process evaluates an
organization's compliance with these standards and other
accreditation or certification requirements.
Joint Commission accreditation and certification is recognized
nationwide as a symbol of quality that reflects an
organization's commitment to meeting certain performance
standards.

JOINT COMMISSION VISION

All people always experience the
safest, highest quality, best-value
health care across all settings.

SEAL OF APPROVAL
To earn and maintain the Joint Commission's Gold
Seal of Approval, an organization must undergo an
on-site survey by a Joint Commission survey team
at least every three years. Laboratories must be
surveyed every two years.
ACCREDITATION
All member health care organizations are subject to a
three-year accreditation cycle, while laboratories are
surveyed every two years. With respect to hospital
surveys, the organization does not make its findings
public.
Unannounced" means the organization does not
receive an advance notice of its survey date. The Joint
Commission began conducting unannounced surveys
on January 1, 2006. Surveys will occur 18 to 39 months
after the organization's previous unannounced survey.
Joint Commission accreditation and certification is
recognized nationwide as a symbol of quality that
reflects an organization's commitment to meeting certain
performance standards.


HOW DOES THE HOSPITAL DEFINE
QUALITY?
The following is a snapshot of some of the ways
QUALITY is defined.
1. Joint Commission and CMS Core Measures
2. Joint Commission Hospital National Patient Safety
Goals
3. Agency for Healthcare Research and Quality (AHRQ)
initiatives
4. University of Colorado Health Critical Success Factors
(aka Incentive Goals)
WHAT ARE CORE MEASURES?
Developed by The Joint Commission to improve the
quality of health care by implementing a national,
standardized performance measurement system.
The Core Measures were derived largely from a set
of quality indicators defined by the Centers for
Medicare and Medicaid Services (CMS).
They have been shown to reduce the risk of
complications, prevent recurrences and otherwise
treat the majority of patients who come to a hospital
for treatment of a condition or illness.
Core Measures help hospitals improve the quality
of patient care by focusing on the actual results of
care.

WHAT ARE CORE MEASURES
In November 2012 the Joint Commission
announced that it will expand performance
measurement requirements for accredited general
medical/surgical hospitals from four to six core
measure sets.
Under each category, key actions are listed that
represent the most widely accepted, research-
based care process for appropriate care in that
category.

CORE MEASURES 1-4:
MANDATORY REPORTING
Four of the six measure sets will be mandatory for
all general medical/surgical hospitals that serve
specific patient populations addressed by the
measure sets and related measures.
1. Acute myocardial infarction (AMI)
2. Heart failure
3. Pneumonia
4. Surgical Care Improvement Project
(SCIP)
THE 5
TH
AND 6
TH
CORE MEASURE:
PERINATAL CARE MEASURE (PCM) AND
ADDITIONAL CORE MEASURES
For hospitals with 1,100 or more births per year, the
PCM set will become the mandatory fifth measure set.
UCH began collecting this data on the effective date of
January 1, 2014.
The sixth measure set will be chosen by all general
medical/surgical hospitals from the approved
complement of core measure sets. These sets are
related to childrens asthma care, emergency
department care, hospital-based inpatient psychiatric
services, hospital outpatients, immunization, tobacco
treatment, stroke, substance use and venous
thromboembolism.
UCH has chosen to monitor emergency department
care, immunizations, tobacco treatment, stroke and
thromboembolism.


SURGICAL CARE IMPROVEMENT
PROJECT MEASURES (SCIP)
Prophylactic antibiotics
Administered 1 hour prior to incision
Consistent with current guidelines
Discontinued within 24 hours after anesthesia end time (48 hours for
cardiac surgery patients)
Appropriate surgical site hair removal
No hair removal with razors (clippers only)
Foley catheter removed on POD 1 or 2
Prevent CAUTI
Does not apply to certain urologic, gynecologic, or perineal procedures
Patients actively warmed during surgery or at least one
temperature greater than or equal to 36 C within 15 minutes after
anesthesia end time
Patients with intentional hypothermia are excluded
Patients on beta-blockers prior to admission continue beta-
blocker therapy during the perioperative period
Venous thromboembolism prophylaxis ordered anytime from
hospital arrival to 48 hour after anesthesia end time

NATIONAL PATIENT SAFETY
GOALS (NPSGS)
The purpose of the National Patient Safety Goals
are to improve patient safety.
The goals of each are to focus on problems in
health care safety and how to proactively solve said
problems.
2014 National Patient Safety Goals are:
1. Identify Patients Correctly
2. Improve Staff Communication
3. Use Medicines Safely
4. Use Alarms Safely
5. Prevent Infection
6. Identify Patient Safety Risks
7. Prevent Mistakes in Surgery

HOW TO COMPLY WITH NPSGS
Hospital National Patient Safety Goals
1. Use at least 2 ways to identify patients EVERY
TIME
2. Communication of Critical Lab Results to
providers
3. Take an accurate medication history from the
patient.
4. Hand washing
5. Identify which patients are most likely to try to
commit suicide.
6. Procedural pause to make sure the correct
patient, correct procedure, and correct laterality.

HOSPITAL CRITICAL SUCCESS FACTORS
1. Unassisted Falls/1000 days (Hospital Rate)
2. CLABSI/1000 Central Line Days (Hospital Rate)
3. CAUTI/1000 Catheter Days (Hospital Rate)
4. Pressure Ulcer/1000 discharges (Stage
III/IV/Unstageable)
5. CMS Core Measure Overall Roll-Up Score
6. Weighted Average of All HCAHPS Questions
HOW YOU CAN IMPACT QUALITY?
1. Unassisted Falls/1000 days (Hospital Rate): Have you assessed your patient for
falls?
2. CLABSI/1000 Central Line Days (Hospital Rate): If the patient has a central line
did you document on it?
3. CAUTI/1000 Catheter Days (Hospital Rate): Do you have an order for catheter
placement and documentation of reason for placement?
4. Pressure Ulcer/1000 discharges (Stage III/IV/Unstageable): Did your patient
have a pressure ulcer present on admission (POA)? And, if so, is it
documented as such?
5. CMS Core Measure Overall Roll-Up Score: This goes back to the Core
Measures discussed earlier.
6. Weighted Average of All HCAHPS Questions: Did you do your best to ensure
the patient has had all of their questions and concerns addressed prior to
surgery? Have you updated and involved the family at the bedside?
WHAT CAN YOU DO TO PREVENT
CLABSI AND CAUTI ?
Document patient has a central line.
Document central line teaching and give Care
Notes to patient/family.
Clean central lines using sterile technique.
Ensure that stat lock or leg strap is on patient
and documented in Epic.
Assess whether patient really needs a Foley.
Can it be discontinued in PACU?

AHRQ INITIATIVES
Prevent healthcare-associated infections (HAIs).
Accelerate patient safety improvement in hospitals.
Reduce harm associated with obstetrical care.
Improve safety and reduce medical liability.
Accelerate patient safety improvements in nursing
homes.

HOW YOU CAN IMPACT QUALITY
AHRQ Initiatives
Prevent healthcare-associated infections (HAIs):
Hand washing
Accelerate patient safety improvement in hospitals:
Scrub-the-Hub when administering medications
Reduce harm associated with obstetrical care:
Consulting Obstetrics for any patients for whom this is
appropriate
Improve safety and reduce medical liability:
Using 2 patient identifiers, obtaining proper consent
Accelerate patient safety improvements in nursing
homes:
This is not one we can directly impact in the pre/post/PACU
units, however, is mentioned for the purposes of developing
awareness.

CLEANING AGENTS: PURPLE TOP
Dry time - 2 minutes
Alcohol based
$3.92 per container;
$0.02 per wipe
Can kill 27 microorganisms
Shelf life of 24 months
Bactericidal, Tuberculocidal, Virucidal, Salamonella
Hard non-porous surfaces
Use to clean cables isolation cables, bladder
scanner, and equipment (except C. Difficile)
Do not flush down the toilet

CLEANING AGENTS: ORANGE TOP
Dry time - 4 minutes
Bleach based
$5.42 per container;
$0.07 per wipe
Can kill 50 microorganisms
Shelf life of 11 months
Bactericidal, Tuberculocidal, Virucidal, and
Fungicidal
Kills C. Difficile
Do not flush down the toilet
Use to clean any C. Difficile isolation cables and
equipment

CLEANING AGENTS: SILVER TOP
Dry time - 3 minutes
Quat based
$4.85 per container;
$0.07 per wipe
Can kill 44 microorganisms
Shelf life of 24 months
Bactericidal, Tuberculocidal, Virucidal
Fragrance, alcohol, bleach, acid, phenol, acetone, and
ammonia free
Meets CDC, OSHA and CMS Tag F441 guidelines
Use to clean chairs and stretchers
Do not flush down the toilet

HOW TO ACCESS OPIT
CLICK HOSPITAL REPORTS
CLICK UNIT SCORECARDS
CLICK AIP PACU
UNIT SCORE CARD
LISTS UNITS SCORE ON CRITICAL SUCCESS
FACTORS
I HAVE QUESTIONSWHO DO I CONTACT?
Quality Improvement Specialists
Sandy Godcharles at 8-6987 or
sandy.godcharles@uchealth.org
Jennifer Livingston at 8-6995 or
jennifer.livingston@uchealth.org
Janna Petrie at 8-6985 or
janna.petrie@uchealth.org
Lindsie Stephan at 8-6983
lindsie.stephan@uchealth.org