At the end of March, we examined the most frequently cited Joint Commission (TJC) requirements of 2011. Now, let’s look at trends so far in 2012.
The first three months of 2012 TJC surveys are complete, and reports to Compass Clinical Consulting from clients and from the field draw a revealing and somewhat concerning picture.
Below are the discernible patterns and trends, along with a few thoughts about preparation.
Reflecting the frequently found concerns of 2011, Life Safety and Record of Care continue to be foci of surveys. The standards surrounding fire safety appear to be most troubling, though field reports of increased attention to emergency preparedness and hazardous risk assessment are also numerous.
A new emerging concern is the focus on competency verification and clinical supervision of nuclear medicine technicians, particularly related to the introduction of contrast media during diagnostic procedures. This concern is rumored to have been an emphasis during the annual surveyor conference presentation featuring CMS spokespersons, which may explain the increased attention from surveyors.
Finally, the hit parade of potential condition-level findings also continues. Areas of attention include restraint and seclusion, patient rights (particularly confidentiality), and pain assessment and management. Tracers on suicide risk assessment, vulnerability for abuse/neglect, and the progression through levels of care for patients admitted through the Emergency Department are also frequently reported activities.
Best practices in preparation should focus on ensuring that hospital policy and procedure are current and that practitioners are compliant with these policies and procedures. Tracing procedure compliance through a complex patient experience is the best way to discover areas of potential vulnerability.