Advocacy Group Calls for Hospitals to Make Joint Commission Compliance Available to Public

This post by Cheryl Clarke of Health Leaders Media sheds some interesting light on the future level of transparency Hospitals may be required to make public.  Chief among concerns seems to be from patients who are ultimately affected by a hospitals failure to follow compliance guidelines as well as way to prove guidelines were followed, here is a brief excerpt …

“Patient advocacy groups and patients harmed have “shared stories (that) reflect a common theme: delayed complaint responses and investigations, the need for transparency and improved communication, and no clear way to offer rebuttal to what may very well be incomplete information provided by the offending hospital or facility during the complaint investigation.”

It seems that lack of compliance data, or questions about its accuracy is frustrating both, the clinical managers responsible for documenting and passing Joint Commission inspections as well as concerned patients.  With the potential for providers to be required to make public these records the need to automate documentation heavy workflows such as tissue tracking in the operating rooms has never been greater.

In light of Managing Today’s Operating Room Suite 2011 in Chicago rapidly approaching (and Mobile Aspects live demo of a complete tissue tracking system @ the show) i thought it would be a good time to review the latest standards in place today.

The Joint Commission Requirements

The Joint Commission followed by publishing standards under the Provision of Care section (PC 17.10, PC 17.20, PC 17.30) requiring that all (tissue) implants be tracked and documented from acquisition to implantation or disposal. These standards were revised under a new chapter entitled Transplant Safety (TS). The revised standards use simple, direct language and fewer hard-to-measure words. The accreditation process includes a new scoring process, an electronic manual, a dynamic history tracking feature for standards and an unannounced survey process: 18 to 39 month survey window. These standards became effective January 2009.

TS.03.01.01 – The hospital uses standardized procedures for managing tissues.

• Assign responsibility for appropriate management of tissue.

• Coordinate ordering, transportation, receipt, documentation, handling, and storage (temperature & alarm), per manufacturer’s instructions.

• Validate that tissue suppliers are compliant with regulations and are state licensed or registered with the FDA.

• Comply with state and/or federal regulations when acting as a source facility that supplies tissue.

TS.03.02.01 – The hospital traces all tissue bi-directionally.

• Identify the materials and instructions used to prepare tissue.

• Document dates, times, and staff involved when a tissue is accepted, prepared, and issued.

• Document the tissue type and its unique identifier in the medical record.

• Maintain records for a minimum of 10 years.

• Complete and return the tissue usage information card.

TS.03.03.01 – The hospital investigates adverse events related to tissue use or donor infections.

• Written procedures to investigate adverse events.

• Report adverse event to tissue supplier.

• Sequester tissue whose integrity may have been compromised or is suspect.

• Identify and notify affected recipients.

It will certainly be interesting to see how providers will react to the increasing need to have accurate, real time and accessible information related to these detailed requirements …