Joint Commission news
The Joint Commission news: EUHM fully accredited, EUH Stroke Program recertified, Lab Surveys under way and new Universal Protocol changes effective June 1
After successfully meeting all post-survey performance goals, The Joint Commission (TJC) awarded Emory University Hospital Midtown (EUHM) the highest level of accreditation status, in accordance with the date of the organization’s original survey October 20, 2009. The accreditation decision and cycle are valid up to 39 months from the original survey date, but the hospital is eligible for an unannounced on-site survey 18 months after its last accreditation visit (April 2011). Thanks to all physicians and staff who worked tirelessly to ensure we met all post-survey compliance requirements, particularly timing of handwritten medical record entries. In the future, all EMORY HEALTHCARE (EHC) facilities are vulnerable to citation for non compliance to this requirement due to strict enforcement by TJC.
Congratulations go to members of Emory University Hospital’s (EUH) multidisciplinary Stroke Program for achieving full re-accreditation with surveyor commendation following the survey March 29. The surveyor praised the program, noting “patient care was seamless” and EUH had “one of the best programs in the country.” TJC re-evaluates the Stroke Program for continued certification every two years.
The biennial survey of the Laboratory Program at all EHC facilities is under way. On-site surveys of the hospital facilities are expected to be completed by June 30, while the survey of The Emory Clinic’s lab is due for completion by the end of September.
As noted in our last TJC update, TJC modified several practices related to the Universal Protocol for prevention of wrong site, patient or procedure surgery/invasive procedures for 2010; these practices have now been approved for implementation by all facility Medical Staff Executive Committees/Boards, effective June 1, 2010. To review the revised organizational policy and detailed information about these changes, visit the TJC section of the EHC intranet (under the Clinical Resources tab) and select Staff Education Materials. We will also communicate these revisions through a special edition of the organizational TJC e-newsletter, which we will forward to all practitioners. Key changes to the Universal Protocol include:
Expansion of individuals who can mark the surgical/procedural site
The physician/licensed independent practitioner (LIP) ultimately accountable for the procedure may now delegate site marking to individuals who are:
- familiar with the patient and will be present for the procedure, and
- either residents or fellows being supervised by the above accountable practitioner for that procedure, or
- PAs or advanced practice RNs performing duties under supervisory agreement with the above accountable practitioner.
Expansion of individuals who can perform the Time Out/Call to Order
The physician/licensed independent practitioner (LIP ultimately accountable for the procedure may now delegate performance of the Time Out/Call to Order to individuals who are:
- familiar with the patient, will be present for performance of the procedure and are deemed competent to perform the Time Out by the primary attending practitioner and
- either residents or fellows being supervised by the above accountable practitioner for that procedure, or
- PAs or advanced practice RNs performing duties under supervisory agreement with the above accountable practitioner.
– The above noted staff may now perform the Time Out/Call to Order even though they may not hold specific privileges to perform the procedure.
– Removal of exact stipulations dictating which pre-op departments/areas must verify patient identity.
– Addition of primary attending surgeon or proceduralist as a person who can initiate the Time Out.
For questions or further information about TJC issues, please contact Amy Nally, RN, MS, CIC, CPHQ, Director, Clinical Performance Improvement – Accreditation Support Services, Office of Quality at 404-712-4545 or amy.nally@emoryhealthcare.org.
