Joint Commission Update
National Credentialing Forum
Paul Ziaya MD
Field Director
Accreditation and Certification Operations
The Joint Commission
© Copyright, The Joint Commission
San Diego, California
February 5, 2015
Objectives
2
© Copyright, The Joint Commission
1. Briefly discuss the most commonly cited
medical staff standards
2. Discuss OPPE as a performance
improvement process
3. Introduce the Patient Safety Systems
Chapter
4. Share Initiatives in Physician Engagement
Most Often Cited Standards
MS.01.01.01- Medical staff bylaws address
self-governance and accountability to the
governing body.
– Relates to structure, function and activities of
the organized medical staff
– The medical staff complies with the medical
staff bylaws, rules and regulations, and
policies.
3
© Copyright, The Joint Commission
Most commonly EP 5
Most Often Cited Standards
MS.08.01.03 - Ongoing
Professional Practice Evaluation
4
© Copyright, The Joint Commission
– All elements of performance among
the top 10 medical staff EP cited
– Single most common related to lack of
effective use of the data in decision
making
Most Often Cited Standards
MS.03.01.01 - Organized medical
– Medical staff oversight of radiology
and nuclear medicine
– Monitoring the quality of histories and
physicals
– Practicing in scope of privileges
5
© Copyright, The Joint Commission
staff oversees the quality of patient
care, treatment, and services
Most Often Cited Standards
MS.08.01.01 – Focused
Professional Practice Evaluation
6
© Copyright, The Joint Commission
– Primarily lack of a process for all
initially requested privileges
OPPE: A Performance Improvement
Process
Selection
of Metrics
Physicians
Review
Performance
Reports
Accuracy in
Measurement
Departmental
Review and
Analysis
7
© Copyright, The Joint Commission
Education,
Simulation,
Training,
Coaching
© Copyright, The Joint Commission
8
Opportunities
 From performance monitoring to performance
improvement
 Resolving problem areas for each specialty or
department
 Selected by the department/chair and approved
by the MEC
 Can be changed
9
© Copyright, The Joint Commission
– OR first start times
– Improving specific documentation
– Adherence to order sets and practice guidelines, as
appropriate
Attribution
Selecting appropriate measures for the
specialty
Triggers
Zero data is data
Physicians seeing the data
Frequency of assessment - < 12 months
Use of the data
10
© Copyright, The Joint Commission
Challenges
© Copyright, The Joint Commission
11
New for 2015
12
© Copyright, The Joint Commission
Patient Safety Systems
Chapter
Overview
13
© Copyright, The Joint Commission
There are no new requirements
The chapter serves as a road map for
hospital leaders to use existing requirements
to improve patient safety.
The chapter is only included in the 2015
Comprehensive Accreditation Manual for
Hospitals.
Describes the framework of an integrated
patient safety system
Discusses how hospitals can develop into
learning organizations
Describes how to evaluate status and
progress
Focuses on prevention through proactive
risk reduction activities
Identifies all standards and requirements that
support a patient safety system
14
© Copyright, The Joint Commission
The Chapter…
People continuously learn, and thereby
enhance their capabilities to create and
innovate
Transparent, non-punitive approach to
error reporting so that the organization
can report to learn
Fair and just safety culture enriched by
sharing lessons learned
Data driven improvement
15
© Copyright, The Joint Commission
Learning Organizations
Promote learning
Motivate staff to uphold a fair and just safety
culture
Provide a transparent environment in which
patient safety events are honestly reported
Model professional behavior
Remove intimidating behavior that might
inhibit a culture of safety
Provide the resources and training
necessary to take on improvement initiatives
16
© Copyright, The Joint Commission
Role of Hospital Leaders
Valuing transparency, accountability
and mutual respect
Safety as everyone’s first priority
Undermining behaviors not acceptable
Collective mindfulness –close calls
mean improvements are needed
Reporting errors is valued
Learning from those reported errors
17
© Copyright, The Joint Commission
Safety Culture
Data Use and Analytics
18
© Copyright, The Joint Commission
Data use and reporting systems
Proactive risk reduction strategies
Statistical tools
Resources and references
19
© Copyright, The Joint Commission
It is about Patient Safety
Systems and Safety as a
Core Competency
The Joint Commission’s
Physician Engagement Goal
20
© Copyright, The Joint Commission
Help physician leaders in our accredited
organizations meet or preferably exceed
their patient safety and performance
improvement goals
Aspiring Higher:
Organizations will need to achieve optimal physician
engagement
Some Physicians
Participate Some of the
Time
Searching for
Stability
Building for Success
Optimal Physician
Engagement
Achieving
Superior
Performance
Quality and Safety Continuum
21
© Copyright, The Joint Commission
Overall Physician
Indifference
CMO Academy
Physician Leader Forum
Physician Leader E Letter
Social Media
Fellowship Rotations at TJC
IHI CMO Mini Course
22
© Copyright, The Joint Commission
TJC Physician Engagement
Strategies
23
© Copyright, The Joint Commission
Questions?
For Standards/NPSG question:
– 630-792-5900, Option 6 or
– http://www.jointcommission.org/Standards/
OnlineQuestionForm/
Paul Ziaya
24
© Copyright, The Joint Commission
– 630-792-5749
– pziaya@jointcommission.org
The Joint Commission Disclaimer Statement
 These slides are only meant to be cue points, which
were expounded upon verbally by the original
presenter and are not meant to be comprehensive
statements of standards interpretation or represent
all the content of the presentation. Thus, care should
be exercised in interpreting Joint Commission
requirements based solely on the content of these
slides.
 These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
25
© Copyright, The Joint Commission
 These slides are current as of February 3, 2015.
The Joint Commission reserves the right to change
the content of the information, as appropriate.