Joint Commission update: Survey follow-up continues while Universal Protocol changes planned for 2010
Follow-up monitoring of multidisciplinary compliance with The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS) and EMORY HEALTHCARE (EHC) Medical Staff Bylaws requirement that all handwritten medical record entries be dated and timed began in December. Monthly monitoring of related Emory University Hospital Midtown (EUHM) staff performance is underway as part of the compliance action required following findings from the October 2009 TJC survey. Greater than 90 percent compliance is necessary in order to ensure the hospital successfully clears this requirement for improvement. Initial baseline results show marked improvement over previous performance, especially by the medical staff, but we are still falling short of our required benchmark. Thanks to those who are currently "taking the time to note time" when making entries such as history and physical reports, assessments, progress notes, orders, procedure-related notes, discharge instructions and consents. For those who have not yet joined in this organization-wide effort, please try to remember to time and date all handwritten medical record entries. Timing of all record entries is now the national standard and is no longer optional for any clinician.
On another topic, TJC has responded to feedback received from accredited organizations throughout the country regarding last year's implementation of standard UP.01.01.01, the Universal Protocol/Time Out/Call-to-Order requirements. As a result, several of the most difficult mandated practices related to the Universal Protocol for prevention of wrong site, patient or procedure surgery/invasive procedures have been modified. These changes include redefinition of the types of clinicians who can perform site marking, expansion of the locations in which the pre-procedure verification and/or consent process can take place and clarification regarding how the patient should be involved in the Time Out/Call-to-Order process. The Universal Protocol Oversight Subcommittee is in the process of revising EHC's policy to reflect the changes to the standard and subsequently will present the revised policy for review/approval by the organizational OR and Medical Executive Committees. In the meantime, clinicians must continue to comply with the present policy. Stay tuned for further information on related changes and formal implementation of the revised policy.
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.
