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The Joint Commission Announces 4 Medical Staff Survey Focus Areas

News  |  By Credentialing Resource Center  
   November 07, 2017

Cultures of safety and ligature risks for behaviorial health units are in the accreditor's compliance crosshairs, according to a recent presentation for medical staff professionals.

The following article was originally published on the Credentialing Resource Center, October 24, 2017.

Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation Program (HFAP), and National Committee for Quality Assurance (NCQA) took the stage at the 2017 NAMSS Educational Conference & Exhibition to share what they have learned from this year's accreditation surveys and to tell audience members what standards changes they need to be aware of.

The Joint Commission announced four areas of focus:

  1. The SAFER Matrix: Implemented in January 2017, this matrix has nine boxes that measure the likelihood to harm a patient on one axis and scope of occurrence (limited, pattern, widespread) on the other.
  2. Antimicrobial Stewardship: The CDC reported that 20-50% of antibiotics were prescribed unnecessarily or inappropriately. Medical staffs must reduce their antimicrobial use and have a medical staff process to demonstrate an effective use of antibiotics or antimicrobials in their organizations.
  3. Ligature Risks for Behavioral Health Care Units: Due to the increasing rise of inpatient suicides (1,200–1,500 each year) 70% of which are by hanging, ligature risks are no longer acceptable in areas specified for the treatment of behavioral healthcare patients with suicide risk.
  4. Culture of Safety: Leaders must ensure a culture of safety and identify areas to improve culture of safety. Staff must be comfortable and able to report issues of safety to leadership. This is already a standard under leadership and will become a medical staff standard in 2018.

According to Louis Goolsby, MD, FACOG, FACHE, the most common citations from the medical staff chapter still come from MS.01.01.01, specifically EP3 (specific requirements and associated details are included in the medical staff bylaws) and EP5 (the medical staff complies with the medical staff bylaws). Another common citation is MS.03.01.01 (practitioners only practice within their scope of privileges).

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