The Joint Commission is pleased to announce it is recognized by Modern Healthcare as one of the Best in Business of 2024. Modern Healthcare has acknowledged The Joint Commission in the Accreditation and Certification category, for its impact over the past year to enable and affirm the highest standards of healthcare quality and patient safety for all.
The Best in Business program celebrates organizations that drive innovation, efficiency and excellence across the healthcare industry. By acknowledging leading innovators within the industry, Modern Healthcare aims to highlight the pivotal role these organizations play in enhancing the overall healthcare ecosystem.
Tanashiya Randall, from Texas State University, has been awarded the Commission on Accreditation of Healthcare Management Education (CAHME)/The Joint Commission Fellowship for Advancing Sustainable Health Care for 2025.
This unique fellowship provides an in-depth understanding of The Joint Commission's processes, hospital quality, and sustainability initiatives, while also helping CAHME enhance its approach to healthcare leadership. This accomplishment also reflects the commitment of Texas State University's faculty to providing an outstanding education in healthcare leadership.
The December issue of the Joint Commission Journal on Quality and Patient Safety features a study on the effects of the COVID-19 pandemic on professionalism in the perioperative environment. Included in the study were reports of professionalism-related events (PRE), such as disruptive behavior, disrespectful communication, and institutional policy violations.
The article – “Strategies to Mitigate the Pandemic Aftermath on Perioperative Professionalism,” is authored by Crystal C. Wright, MD, FASA; Maureen D. Triller, DrPH, PMP, PHR, CMQ; Anne S. Tsao, MD, MBA; et al, and was conducted at MD Anderson Cancer Center. The retrospective comparative cohort study covers three periods: pre-pandemic, pandemic, and an interventional endemic phase (from Sept. 1, 2011, to March 31, 2023).
The study showed a statistically significant increase in the incidence of PREs during the pandemic compared to the pre-pandemic and endemic periods. During the study period, the authors identify 264 PRE (1.5%): 114 PRE (mean 1.1/month) in the pre-pandemic period, 121 PRE (mean 4.5/month) in the pandemic period, and 29 PRE (mean 2.9/month) in the endemic phase.
The study underscores the importance of implementing professionalism interventions in healthcare work environments to mitigate negative consequences from professionalism lapses. The proposed interventions include a structured, nonjudgmental reporting platform; wellness resources; mental health services; transparent communication; and workplace efficiency policies. The study intervention included the application of the Vanderbilt Professionalism Escalation Model, a framework developed by the Vanderbilt University School of Medicine to promote professional behaviors in healthcare providers.
The December issue of the Journal also includes an editorial, “Supporting Professionalism in a Crisis Requires Leadership and a Well-Developed Plan,” by Gerald B. Hickson, MD. In the editorial, Hickson states that organizations that commit to high reliability and safety have a responsibility to build and sustain intentionally designed systems and support accountable professionals who share a commitment with others to deliver safe, high-quality care while modeling respect for patients, coworkers, and established safety practices. In addition, he states: “As the authors point out, professionalism promotes psychological safety, trust, and teamwork. That said, medical practice is stressful, and all professionals are subject to lapses. Within a crisis, however, stress levels may rise and perhaps patience and levels of tolerance fall.”
The Joint Commission updated the advanced Total Hip and Total Knee Replacement (THKR) certification program’s performance measure THKR-5: Postoperative Functional/Health Status Assessment to align with a similar measure adopted by the U.S. Centers for Medicare & Medicaid Services (CMS). The updated measure that was effective Jan. 1, 2024, requires providers to submit postoperative functional/health status assessments (FSAs) for the patient-reported out-come measures (PROMs) and/or FSAs at one year (within 300-425 days).
The Joint Commission is providing the following guidance to ensure that organizations understand what data need to be submitted to the Certification Measure Information Process (CMIP) tool and when that data are due.
Organizations are required to submit data for THKR-5 to CMIP in the month that corresponds to the procedure discharge date. Organizations can leave the THKR-5 CMIP fields blank until the 300-425 days postprocedure date range. CMIP will issue alerts when the data should be available and entered. Organizations have until the end of the next quarter to submit THKR-5 into CMIP. The data fields within CMIP remain open for the previous eight quarters.
The following are examples of data submission time frames:
- For a procedure date of Jan. 1, 2024, the assessment completion date range (300-425 days postprocedure) is Oct. 27, 2024-Mar. 1, 2025, with a deadline for CMIP data submission of June 30, 2025, and the month the date is entered into the CMIP field is January 2024.
- For a procedure date of Feb. 1, 2024, the assessment completion date range (300-425 days postprocedure) is Nov. 27, 2024-Apr. 1, 2025, with a deadline for CMIP data submission of Sept. 30, 2025, and the month the date is entered into the CMIP field is February 2024.
- For a procedure date of Mar. 1, 2024, the assessment completion date range (300-425 days postprocedure) is Dec. 26, 2024-Apr. 30, 2025, with a deadline for CMIP data submission of Sept. 30, 2025, and the month the date is entered into the CMIP field is March 2024.
Organizations are not required to submit four months of THKR-5 data into CMIP prior to initial certification. However, submitting four months of data is still required for all other THKR measures. The collection of THKR-5 data should begin for procedures conducted four months prior to the initial certification decision.
Questions regarding performance measurement may be directed to the Question Forum on The Joint Commission’s website.
Join The Joint Commission, Centers for Medicare & Medicaid Services, and Mathematica for the Expert to Expert webinar series, which addresses the eCQM Annual Updates and introduces new eCQMs for 2025 implementation.
Common questions from JIRA and other sources will be addressed. Continuing Education credits (CEs) are offered for the webinars in this 2025 Reporting Year series that address eCQMs for STK, VTE, PC-02 and -07, Opioid Related Adverse Events, Global Malnutrition Composite Score, Pressure Injury, Hyper- and Hypo-Glycemia, Safe Use of Opioids, Acute Kidney Injury, and Excessive Radiation.
Registration is now open for the following webinars and additional registrations will open soon.
Bookmark this link to access registrations as they open: https://www.jointcommission.org/measurement/quality-measurement-webinars-and-videos/expert-to-expert-webinars/#sort=%40resourcedate%20descending
VTE eCQMs: Venous Thromboembolism Prophylaxis (VTE-1) and Intensive Care Unit Venous Thromboembolism Prophylaxis (VTE-2)
Date: Dec. 19, 2024
Register: https://attendee.gotowebinar.com/register/2011017105723720028
PC eCQMs: Cesarean Birth (PC-02) and Severe Obstetric Complications (PC-07)
Date: Jan. 9, 2025
Register: ttps://attendee.gotowebinar.com/register/2020943497010100060
ORAE eCQM: Hospital Harm - Opioid-Related Adverse Events (HH-ORAE)
Date: Jan. 16, 2025
Register: https://attendee.gotowebinar.com/register/6288118437595289181
GMCS eCQM: Global Malnutrition Composite Score
Date: Jan. 23, 2025
Register: https://attendee.gotowebinar.com/register/1278037575619576158
NEW for 2025 – HH-PI eCQM: Hospital Harm: Pressure Injury
Date: Jan. 30, 2025
https://attendee.gotowebinar.com/register/881574573364658013
See the registration pages for details on CEs and learning objectives.
An on-demand webinar is now available on the fully revised Infection Prevention and Control (IC) chapters for Assisting Living Communities (ALC) and Nursing Care Centers (NCC) that are effective Jan. 1, 2025. This Pioneers in Quality webinar will introduce the new and revised requirements for each setting, offer examples of practical applications of the requirements, and highlight available resources, including a reference guide and a new infection prevention and control program assessment tool, to assist organizations in meeting the requirements.
Participant learning objectives are:
- Discuss the rationale for the IC standards rewrite
- Explain the structure and content of the new IC standards and Elements of Performance
- Demonstrate application of the Infection Prevention and Control Program Assessment Tool
This webinar is approved for 1 Continuing Education (CE) credit or Qualifying Education Hour until Jan. 24, 2025.
For reference in advance of the webinar, view the Prepublication Standards.
Go to the webinar on revised Infection Prevention and Control chapter for ALC and NCC.
A new Infection Prevention and Control & Antibiotic Stewardship Center is now available from The Joint Commission. The center offers curated collections of resources with actionable strategies and tools for infection prevention and control professionals, from novice to expert, to support their efforts in complying with Joint Commission accreditation requirements for infection control and antibiotic stewardship.
Effective infection prevention and control practices, along with antibiotic stewardship, are essential for preventing disease spread, safeguarding vulnerable populations, and maintaining a safe environment. This resource center supports organizations in developing comprehensive programs to protect the health and safety of patients and staff.
The resource center includes:
- Search capabilities by setting, topic, Joint Commission standard, pathogen, and healthcare-associated infection (HAI) type
- Answers to Frequently Asked Questions
Users can sign up for e-Alerts to be notified when resources are added.
Jonathan B. Perlin, MD, PhD, president and chief executive officer, The Joint Commission and Joint Commission International, is featured on the newest episode of the Commission on Accreditation of Healthcare Management Education’s (CAHME's) Master Your Healthcare Career podcast.
This episode examines Dr. Perlin's journey from physician, to Under Secretary for Health and CEO of the Veterans Health Administration, to President of Clinical Operations and Chief Medical Officer with HCA Healthcare, to his current role with The Joint Commission.
Dr. Perlin provides valuable insights to early careerists entering the world of a profession that needs to balance health equity, environmental sustainability, and performance improvement.
While it is the giving season, The Joint Commission would like to remind accredited, certified, and verified organizations of our gift policy that prohibits the acceptance of any gifts. The policy helps ensure the integrity of The Joint Commission’s accreditation, certification, and verification decision process, as well as to ensure independence in business judgment.
Gifts can include anything of value given to or by Joint Commission employees, including cash, cash equivalents, or entertainment; gratuities; meals (except for modest onsite meals); gift certificates; tickets to sporting events, cultural or community events, or invitations to performances or other events; favors (specially arranged for the recipient and not commonly offered to everyone); discounts; free services; space; equipment; loans; education; lodging; or transportation.
Gifts do not include emergency healthcare, security, or safety provisions to protect staff while onsite for consultation or survey/review.
Few exceptions are allowable for accepting gifts. To avoid any potential conflicts of interest, it is in the best interest of organizations not to offer – and for surveyors and reviewers not to accept – gifts. However, if an organization feels it necessary to provide something, surveyors and reviewers can accept promotional mementos and souvenirs of nominal (i.e., little) value if given after the survey or review and when there is no apparent attempt to influence a business decision. Good judgment and caution are necessary in these situations. Examples of gifts of nominal value include promotional items such as a pen, coffee mug, cap, or T-shirt that carries an organization name or logo.
Questions related to the gift policy may be directed to Matt Selander, JD, MHA, Corporate Compliance and Privacy Officer and Senior Assistant General Counsel.