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Joint Commission Anticipates More Discussion on Physician Early in 2009, The Joint Commission revised its definition of physicianin order to align with the definition used by the Centers for Medicare & Medicaid Services (CMS) in the Medicare Conditions of Participation for hospitals. This alignment of definitions was a necessary change to support the Joint Commission’s application for deeming authority. The Joint Commission plans to discuss this issue further with CMS in the hope of coming to a better understanding of the use of the term physician in the context of quality standards.

Historically, The Joint Commission defined physicianas a “doctor of medicine or doctor of osteopathy who, by virtue of education, training, and demonstrated compe- tence, is granted clinical privileges by the organization to perform a specific diagnostic or therapeutic procedure(s) and who is fully licensed to practice medicine.” This defini- tion was consistent with the American Medical Association’s definition of the term.

However, during The Joint Commission’s recent application for renewal of its hospital deeming authority, CMS required The Joint Commission to more closely align its definition of physicianwith the federal statutory definition of the term in Sec. 1861.[42 U.S.C. 1395x] of the Social Security Act. On July 1, 2009, the Medicare definition (based in federal law) replaced the definition of physicianin the Glossary of the Comprehensive Accreditation Manual for Hospitals (CAMH). The current definition is shown in the box on page 3 (see also June 2009 Perspectives, page 6).

At the same time, The Joint Commission also revised all hospital ele- ments of performance (EPs) in which the term physicianwas used. If the EP corresponds to a Medicare Condition of Participation that references physicians, the EP retains the term physicianand a 1 Joint Commission Anticipates More Discussion on Physician 2 In Sight 4A PPROVED :Revisions to Requirements for Critical Access Hospitals with Distinct Part Units 6 Health Care Organizations Can Report Privacy Concerns to Joint Commission 8C LARIFICATION :Site Marking Under the Universal Protocol 8C LARIFICATION :Eligibility for Two Advanced Certification Programs 9HHS R EPORT :Infection Prevention Professionals, Hospital Representatives Recommend Steps to Simplify and Streamline Federal HAI Tracking System 11 How to Access Perspectives Online http://www.jointcommission.org Contents Continued on page 3 2 http://www.jointcommission.org The Joint Commission PerspectivesFebruary 2010 Executive Editor Helen M. Fry, M.A.

Senior Project Manager Christine Wyllie, M.A.

Manager, Accreditation Products Diane Bell Executive Director, Publications Catherine Chopp Hinckley, Ph.D.

S UBSCRIPTION INFORMATION :The Joint Commission Perspectives (ISSN 1044- 4017) is published monthly (12 issues per year) by Joint Commission Resources, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL 60523. Send address corrections to Joint Commission Perspectives, Superior Fulfillment, 131 W 1st Street, Duluth, MN 55802-2065. Annual subscription rates for 2010: United States, Canada, and Mexico—$319 for print and online, $299 for online only. Rest of the world—$410 for print and online, $299 for online only.

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Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes the materials under license from The Joint Commission. The mission of The Joint Commission is to continuously improve health care for the public, in col- laboration with other stakeholders, by eval- uating health care organizations and inspir- ing them to excel in providing safe and effective care of the highest quality and value.

Visit us on the Web at http://www.jcrinc.com. This column informs you of developments and potential revisions that can affect your accredita- tion and certification and tracks proposed changes before they are implemented. Items may drop off this list before the approval stage if they were rejected at some point in the process.

APPROVED ● Proposed standards on communication and culturally competent patient-centered care for the hospitalprogram, effective January 1, 2011 (see January 2010 Perspectives, pages 5–6) ● Proposed revisions to the staffing effectiveness requirements for the hospitaland long term careprograms, effective July 1, 2010 (see January 2010 Perspectives, page 7) ACCEPTED ● Revisions to Critical Access Hospitals with Rehabilitation and Psychiatric Distinct Part Units to align with CMS requirements for the critical access hospitalprogram, effective January 1, 2010 (see article, pages 4–5) CURRENTLY IN FIELD REVIEW ● Proposed revisions to National Patient Safety Goal 8 on medication reconciliation for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, long term care, Medicare/Medicaid certification–based long term care,and office-based surgeryprograms CURRENTLY IN DEVELOPMENT ● Proposed revisions to the “Provision of Care, Treatment, and Services” chapter for the behavioral health careprogram. ● Proposed revisions to National Patient Safety Goal 8 on medication reconciliation for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, long term care, Medicare/Medicaid certification–based long term care,and office-based surgeryprograms ● Proposed revisions to Standard MS.01.01.01 in the “Medical Staff ” chapter for the critical access hospitaland hospitalprograms. JOINT COMMISSION INTERNATIONAL Field review notifications are sent out electronically as well as posted on the Joint Commission International (JCI) Web site at http://www.jointcommissioninternational.org. For JCI standards questions, please contact the associate director of Standards Development and Interpretation at [email protected].

APPROVED ● Revisions to international clinical care programcertification standards IN FIELD REVIEW AT JCI ● Proposed changes to the international standards for hospitals IN S IGHT new footnote refers the reader to the revised Glossary defini- tion (that is, the Medicare definition). If the EP is not related to a Medicare Condition of Participation, the term doctor of medicine or osteopathyreplaces physician. These EPs are identi- fied in the box below.

Some physician groups have expressed their concern about The Joint Commission’s use of the Medicare definition of physi- cian. The Joint Commission understands these concerns; how- ever, any future changes to the standards, EPs, or the Glossarydefinition will be made within the context of The Joint Commission’s recently extended hospital Medicare deeming authority. Organizations and practitioners should understand the current Glossary definition of physicianreflects the language of a section of the Social Security Act that is for the purpose of reimbursement. The use of this definition by The Joint Commission does not either expand or contract any health care practitioner’s license or scope of practice, nor is it meant to have any other purpose than that related to the specific EP in which it appears. P http://www.jointcommission.org 3 The Joint Commission Perspectives February 2010 Joint Commission Anticipates More Discussion on Physician (continued) Continued from page 1 The term physician, when used in connection with the perform- ance of any function or action, means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7), (2) a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions, (3) a doctor of podiatric medicine for the purposes of sub- sections (k), (m), (p)(1), and (s) of this section and sec- tions 1814(a), 1832(a)(2)(F)(ii), and 1835 but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them, (4) a doctor of optometry, but only for purposes of subsec- tion (p)(1) with respect to the provision of items or serv- ices described in subsection (s) which he is legallyauthorized to perform as a doctor of optometry by the State in which he performs them, or (5) a chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiro- practor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of sections 1861(s)(1) and 1861(s)(2)(A) and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided.

For the purposes of section 1862(a)(4) and subject to the limi- tations and conditions provided in the previous sentence, such term includes a doctor of one of the arts, specified in such pre- vious sentence, legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1862(a)(4)) are furnished. Source:Social Security Act, Sec. 1861.[42 U.S.C. 1395x] Medicare Definition of Physician EPs That Use the Medicare Definition of Physician “Medication Management” Chapter MM.07.01.03, EP 6 “Medical Staff” Chapter MS.01.01.01, EP 20 MS.03.01.03, EP 1 MS.05.01.01, EP 17 “Provision of Care, Treatment, and Services” Chapter PC.03.05.05, EPs 1, 3, and 5 PC.03.05.07, EP 1 PC.03.05.09, EPs 1 and 2 PC.03.05.11, EPs 1 and 2PC.03.05.15, EP 1 PC.04.01.03, EP 3 “Rights and Responsibilities of the Individual” Chapter RI.01.02.01, EP 1 RI.01.04.01, EPs 1 and 2 EPs That Identify a Doctor of Medicine or Osteopathy “Medication Management” Chapter MM.04.01.01, EP 14 “Medical Staff” Chapter MS.03.01.01, EP 9 MS.03.01.03, EP 4 Hospital EPs That Refer to Physician or Doctor The Joint Commission has revised some requirements to align them with the Centers for Medicare & Medicaid Services (CMS) Medicare Hospital Conditions of Participation (CoPs). The revised requirements pertain to rehabilitation and psychiatric distinct part units (DPUs) in critical access hospitals.

These revisions add nine new elements of performance (EPs), as shown in the box below and on page 6; revise sever- al dozen EPs; and eliminate several dozen more EPs for criti- cal access hospitals with DPUs. The concepts in the eliminat- ed EPs have been addressed in revisions to other EPs, existing language in other EPs, information added to Appendix B inthe Comprehensive Accreditation Manual for Critical Access Hospitals, and within the survey process. All of these changes have been communicated to critical access hospitals with DPUs in phone calls from The Joint Commission.

The new EPs for rehabilitation and psychiatric DPUs in critical access hospitals, which went into effect January 1, 2010, are shown in underlined text in the box below. These new EPs, as well as the revised EPs and a list of the deleted EPs, are on The Joint Commission’s Web site at http://www.jointcommission.org/AccreditationPrograms/ CriticalAccessHospitals. P A PPROVED : Revisions to Requirements for Critical Access Hospitals with Distinct Part Units 4 http://www.jointcommission.org The Joint Commission PerspectivesFebruary 2010 APPLICABLE TO CRITICAL ACCESS HOSPITALS Effective Januar y 1, 2010 Standard LD.01.05.01 The critical access hospital has a medical staff that is accountable to the governing body.

New Element of Performance for LD.01.05.01 A 8. For rehabilitation and psychiatric distinct part units in critical access hospitals: There is a single medical staff. Standard LD.04.01.03 For rehabilitation and psychiatric distinct part units in critical access hospitals: The critical access hospital develops an annual operating budget and, when needed, a long-term capital expenditure plan.

New Element of Performance for LD.04.01.03 A 5. For rehabilitation and psychiatric distinct part units in critical access hospitals: Leaders monitor the imple - mentation of the budget and long-term capital expendi - ture plan. Standard LD.04.01.05 The critical access hospital effectively manages its programs, services, sites, or departments.

New Elements of Performance for LD.04.01.05 A 4. For rehabilitation and psychiatric distinct part units in critical access hospitals: Staff are held accountable for their responsibilities. A 8. For rehabilitation and psychiatric distinct part units in critical access hospitals: The critical access hospital assigns an individual who is responsible for outpatient services. A 9. For rehabilitation and psychiatric distinct part units in critical access hospitals: The anesthesia service is responsible for all anesthesia administered in the criti - cal access hospital. Standard MS.01.01.01 Medical staff bylaws address self-governance and accounta- bility to the governing body. Ofﬁcial Publication of Joint Commission Requirements New Elements of Performance for Rehabilitation and Psychiatric DPUs in Critical Access Hospitals Continued on page 5 http://www.jointcommission.org 5 The Joint Commission Perspectives February 2010 New Element of Performance for MS.01.01.01 A 8. For rehabilitation and psychiatric distinct part units in critical access hospitals: The medical staff bylaws include the following: When departments of the medical staff exist, the definition of the qualifications and roles and responsibilities of the department chair, including the following:

Qualifications ● Certification by an appropriate specialty board or affirmatively established comparable com - petence through the credentialing process Roles and responsibilities ● Clinically related activities of the department ● Administratively related activities of the depart - ment, unless otherwise provided by the critical access hospital ● Continuing surveillance of the professional performance of all individuals in the depart - ment who have delineated clinical privileges ● Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department ● Recommending clinical privileges for each member of the department ● Assessing and recommending to the relevant critical access hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the critical access hospital ● The integration of the department or service into the primary functions of the critical access hospital ● The coordination and integration of interde - partmental and intradepartmental services ● The development and implementation of poli - cies and procedures that guide and support the provision of care, treatment, and services ● The recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services ● The determination of the qualifications and competence of department or service person - nel who are not licensed independent practitioners and who provide patient care, treatment, and services ● The continuous assessment and improvement of the quality of care, treatment, and services ● The maintenance of quality control programs, as appropriate ● The orientation and continuing education of all persons in the department or service ● Recommending space and other resources needed by the department or service Note: When departments of the medical staff do not exist, the medical staff is responsible for the development of policies and procedures that mini - mize medication errors. The medical staff may delegate this responsibility to the organized phar - maceutical service. Standard MS.03.01.01 The medical staff oversees the quality of patient care, treat- ment, and services provided by practitioners privileged through the medical staff process.

New Elements of Performance for MS.03.01.01 A 16. For rehabilitation and psychiatric distinct part units in critical access hospitals: The medical staff deter - mines the qualifications of the radiology staff who use equipment and administer procedures. A 17. For rehabilitation and psychiatric distinct part units in critical access hospitals: The medical staff approves the nuclear services director’s specifications for the qualifications, training, functions, and responsibilities of the nuclear medicine staff. Standard RC.01.05.01 The critical access hospital retains its medical records.

New Element of Performance for RC.01.05.01 A 1. For rehabilitation and psychiatric distinct part units in critical access hospitals: The retention time of the origi - nal or legally reproduced medical record is determined by its use and critical access hospital policy, in accor - dance with law and regulation. New EPs for Rehabilitation and Psychiatric DPUs Approved: Revisions to Requirements for Critical Access Hospitals with DPUs (continued) Continued from page 4 The Joint Commission has always been committed to handling patient information in a way that will protect the confidentiality of the organization, the caregiver, and the patient. Since 2003, if the The Joint Commission identified a security incident or use or disclosure of protected health information by a Joint Commission employee that is not allowed under the business associate agreement in place, it proactively reported the breach to the accredited organiza- tion.

In 2008, The Joint Commission established a method for staff at health care organizations to report any concerns about a Joint Commission surveyor or other staff mishan- dling or breaching the privacy of patient protected informa- tion requested by or provided to The Joint Commission. The Privacy Incident Report Form, on page 7 and on the Joint Commission’s Web site (http://www.jointcommission.org/ AccreditationPrograms/privacy.htm), can be e-mailed or faxed to The Joint Commission’s Compliance and Privacy Officer, who handles the concern and keeps it separate and distinct from the accreditation process. (Seethe contact information in the box at right.) New Federal Regulations The new HITECH (Health Information Technology for Economic and Clinical Health) provisions of the American Recovery and Reinvestment Act of 2009 expand HIPAA (Health Insurance Portability and Accountability Act) regula- tions to include mandatory data breach notifications, height- ened enforcement, increased penalties, and expanded patient rights. The enhanced requirements, effective February 2010, apply to The Joint Commission’s role as a business associate of accredited health care organizations.

The Joint Commission is awaiting further guidance from the Department of Health and Human Services before updating its business associate agreement and will notify organizations on the appropriate steps to take following any revisions. In the meantime, organizations should use the Privacy Incident Report Form to report any concerns aboutThe Joint Commission mishandling an organization’s information. Check Sur veyor Identity Online Although extremely rare, there have been incidents of individuals impersonating a Joint Commission surveyor. To be confident that you are dealing with the appropriate Joint Commission staff, ask for identification. By 7:30 A.M. in the organization’s local time zone on the day of the unannounced survey, The Joint Commission posts on the organization’s secure Joint Commission Connect™ extranet site the letter of introduction, survey agenda, and biographies and pictures of the surveyors assigned to conduct the survey. (For organiza- tions outside the United States and its territories, notifica- tions are posted by 7:00 A.M. Eastern time.) Do not share information with any individual who cannot provide appro- priate documentation. P Health Care Organizations Can Report Privacy Concerns to Joint Commission 6 http://www.jointcommission.org The Joint Commission PerspectivesFebruary 2010 Complaints may be made anonymously. If you would like a response, please include your name and contact infor- mation. The Joint Commission will not disclose the name of people who submit complaints to any other party.

E-mail:[email protected] Fax:630/792-4627 Phone:630/792-5627 Mail:Fran Carroll Compliance and Privacy Officer The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Report a Complaint About Medical Information Mishandled by The Joint Commission Staff Continued on page 7 http://www.jointcommission.org 7 The Joint Commission Perspectives February 2010 Health Care Organizations Can Report Privacy Concerns to Joint Commission (continued) Continued from page 6 Privacy Incident Report Form The August 2009 issue of Perspectives(p. 3) communi- cated a change in eligibility requirements for programs seek- ing disease-specific carecertification that now requires the program’s parent organization to be Joint Commission accredited, if the organization is eligible for accreditation.

Although technically not “disease” programs in the same sense as stroke or asthma, lung volume reduction surgery(LVRS) and ventricle assist device (VAD) programs can be certified under the Joint Commission’s disease-specific care program. This change in policy will not apply to LVRS or VAD programs; a program does not have to be part of an organization that is Joint Commission accredited to be eligi- ble for LVRS or VAD advanced certification. P C LARIFICATION : Eligibility for Two Advanced Certification Programs In the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ (UP), the second bullet for the note to UP.01.02.01, EP 5, states that an alternative site marking process may be needed for proce- dures where the insertion site is not predetermined. That statement conflicts with an existing interpretation indicating that site marking is not required when insertion sites are not predetermined (as published in the Standards FAQs online athttp://www.jointcommission.org/Standards/FAQs, search for “site marking”). The note to UP.01.02.01, EP 5, is being updated to make it clear that site marking is not required for such procedures, as shown in strikethrough text in the box below. This change affects ambulatory care organizations, critical access hospitals, hospitals,and office-based sur- gery practices. P C LARIFICATION : Site Marking Under the Universal Protocol 8 http://www.jointcommission.org The Joint Commission PerspectivesFebruary 2010 APPLICABLE TO AMBULATORY CARE ORGANIZATIONS , C RITICAL ACCESS HOSPITALS , H OSPITALS , AND OFFICE -BASED SURGERY PRACTICES Effective Immediately UP.01.02.01 5. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).Note:Examples of other situations that involve alterna- tive processes include: ● Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice ● Interventional procedure cases for which the catheter/instrument insertion site is not predeter - mined (for example, cardiac catheterization, pace - maker insertion) ● Teeth ● Premature infants, for whom the mark may cause a permanent tattoo Official Publication of a Revision to Joint Commission Requirements Correction to the Universal Protocol Hospital infection prevention professionals and state hospi- tal association representatives participated in regional meetings sponsored in Denver, Chicago, and Seattle last summer by the U.S. Department of Health and Human Services (HHS) and suggested ways that a leading federal system for tracking health care–associated infections (HAI) could be made easier for hos- pitals to use.

Participants included hospital quality leaders represent- ing the Colorado, Illinois, Indiana, Minnesota, Tennessee, Washington, and California hospital associations, hospital infec- tion preventionists, information technology specialists, and state and local public health professionals At the meetings, partici- pants asked about the system—the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN)—and recommended steps to reduce data-collection burdens and to increase usefulness for hospital infection preven- tion and quality improvement programs. NHSN is a secure, Web-based tracking and prevention tool for hospitals and state health departments to submit specific HAI infections and pro- cedural information.

I convened the regional meetings to get stakeholders’ input into the “HHS Action Plan to Prevent Healthcare- Associated Infections,” an initiative my office is leading, as well as to hear about their experiences so far with NHSN.

The HHS Action Plan sets specific targets for monitoring and preventing HAIs nationally and is a blueprint for HAI prevention. (You can find it at http://www.hhs.gov/ophs/ini- tiatives/hai/infection.html.) Leaders and staff from the Agency for Healthcare Research and Quality (AHRQ), CDC, Centers for Medicare and Medicaid Services (CMS), and the HHS Office of Public Health and Science joined me in pre- senting the Action Plan and responding to questions and concerns at these regional meetings.

I have seen great progress over the last year within HHS in developing and implementing this strategy and have seen this initiative gain momentum across the country. In late October, AHRQ awarded $17 million to fund 14 projects to fight HAIs.

Of the $17 million, $8 million will fund a national expansionof the Keystone Project, which within 18 months successfully reduced the rate of central line–associated bloodstream infec- tions in more than 100 Michigan intensive care units and saved 1,500 lives and $200 million. HHS R EPORT : Infection Prevention Professionals, Hospital Representatives Recommend Steps to Simplify and Streamline Federal HAI Tracking System By Don Wright, M.D., Deputy Assistant Secretar y for Healthcare Quality, U.S. Department of Health and Human Ser vices http://www.jointcommission.org 9 The Joint Commission Perspectives February 2010 Continued on page 10 Health care–associated infections (HAIs) continue to be a major barrier to patient safety, and the prevention of HAI in accredited organizations is a strategic goal of The Joint Commission. In October 2008, The Joint Commission partnered with the Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for Professionals in Infection Control and Epidemiology, and American Hospital Association to pub- lish the Compendium of Strategies to Prevent Hospital Acquired Infections. Additionally, as of January 1, 2010, three HAI-focused National Patient Safety Goals (NPSG) based on the Compendium became effective for accredit- ed organizations including: ● NPSG.07.03.01 and the prevention of multi-drug resistant organisms ● NPSG.07.04.01 and the prevention of catheter- associated blood stream infections ● NPSG.07.05.01 and the prevention of surgical site infections The Joint Commission, however, is one of several nation- al organizations that are addressing HAIs. The U.S.

Department of Health and Human Services (HHS) is cur- rently in the process of implementing the “HHS Action Plan to Prevent Healthcare-Associated Infections”. The Joint Commission supports HHS in its efforts to prevent HAIs. The Joint Commission is, therefore, publishing this special article, written by Don Wright MD, HHS Deputy Assistant Secretary for Healthcare Quality, reporting on steps HHS is taking to streamline and simplify the federal system for tracking HAI.

Robert A. Wise, M.D., Vice President, Division of Standards and Survey Methods, The Joint Commission A Partnership in Fighting Infection The Keystone Project was originally started by the Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association to implement a comprehensive, unit-based safety program. The program involves ● Using a checklist of evidence-based safety practices ● Staff training and other tools for preventing infections that can be implemented in hospital units ● Standard and consistent measurement of infection rates and ● Tools to improve teamwork among doctors, nurses, and hospital leaders The new funding will expand the effort to more hospitals, extend it to other settings in addition to ICUs, and broaden the focus to address other types of infections. (A complete list of the institutions funded by the $17 million in AHRQ resources is available at http://www.ahrq.gov/qual/haify09.htm.) Reporting with NHSN In an effort to complement the use of these and other HHS funds, the Department intends to use data from NHSN to help monitor progress toward the Action Plan goals. The Action Plan is guided by the information gathered through NHSN.

Many states have passed laws requiring reporting of facility-specific HAI data to state health departments with public disclosure of infection rates. Twenty-seven states require hospitals to report HAI publicly and most use NHSN. Hospital enrollment in NHSN has increased dra- matically in the past few years, from 300 to more than 2,400 hospitals at the end of 2009.

Participants at our regional meetings asked technical questions about NHSN and encouraged the CDC to find ways to simplify and streamline the system. Many raised questions about the NHSN enrollment process, specifically the requirement that users obtain and install a digital certifi- cate–an electronic security credential that is a prerequisite for NHSN participation. Among other technical problems, they cited difficulties logging onto the NHSN application during peak use times, such as in the middle of the work day, and slow system response times when entering or analyzing data.

Others spoke about the difficulties they experienced in apply- ing NHSN case criteria to pediatric patients for some HAIs; the complexities of how health care–associated pneumonia is defined in the NHSN data collection protocol; and the need to minimize data collection requirements as much as possible for specific types of infections.Many participants said hospital infection professionals face mounting NHSN data-reporting burdens, as the turnover rate in the field is increasing. This, in turn, limits the hospitals’ abili- ty to use NHSN infection data for HAI prevention and quality improvement activities.

Stakeholders also called for NHSN to make greater use of health care data in electronic form and apply information tech- nology that can automate case detection and reporting. Some NHSN users also reported technical difficulties using an NHSN feature that enables electronic imports of surgical proce- dure data.

Daniel Pollock, MD, the Surveillance Branch Chief for CDC’s Division of Healthcare Quality Promotion, and I reported on CDC’s efforts to update NHSN and improve its ease of use. We acknowledged that participants had valid con- cerns about some HAI case criteria and data requirements. We emphasized that simplifying and streamlining the system and assuring sufficient technical capacity and user support are top priorities.

For example, CDC is revising case definitions and data col- lection protocols for HAI urinary tract infections and pneumo- nia. Last year it established an NHSN steering work group of subject matter experts, NHSN users and stakeholders, and information technology specialists to help guide simplification of the system and to make other changes that will make it easier to use. More NHSN staff members were recently hired to per- form comprehensive assessments and upgrades of the system’s technical infrastructure and usability and to provide additional user support for enrollment and training.

Dr. Pollock emphasized that CDC is committed to acceler- ating the transition from manual to electronic case detection and reporting for NHSN and leveraging advances in health information technology as a primary strategy for enhancing NHSN’s functionality and usability. As part of that effort, NHSN now is accepting electronic infection records submitted by hospitals that use commercial infection control surveillance systems. The system will accept bloodstream infection and sur- gical site infection records generated in a standard file format known as Clinical Document Architecture.

We emphasized that CDC works closely with AHRQ, CMS, and the Office of the National Coordinator for Health Information Technology to coordinate efforts to integrate feder- al information systems that provide HAI data. That is part of our commitment here in Washington to support hospitals’ efforts to reduce and eliminate HAIs and to make health care safer for patients and families. For more information on NHSN, visit http://www.cdc.gov/nhsn. P 10 http://www.jointcommission.org The Joint Commission PerspectivesFebruary 2010 HHS Report: Steps to Simplify and Streamline Federal HAI Tracking System (continued) Continued from page 9 http://www.jointcommission.org 11 The Joint Commission Perspectives February 2010 How to Access Perspectives Online Current and archived issues of Perspectivesare available at http://www.ingentaconnect.com/content/jcaho/jcp.

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NOTE: Your Subscription Number is the last name and zip code of the subscriber(example: Smith12345).6.Check the small box to the left of the Joint Commission Perspectivestitle. 5.Under the “Publisher Name” section, click “J” to find and click “Joint Commission Resources.” 4.On the next screen, click “Activating Personal Subscriptions” and then choose the “Add” tab.3.On the “Personal Registration” page, complete all of the required fields. Create your own User Name and Password. (Write them down to refer to the next time you log on.) Click “Register.” 1. Go to http://www.ingentaconnect.com. 2. Look for “Need to register?” on the right side of the screen and click “Sign up here.” Non-Profit Organization U.S. Postage PAID Permit No. 174 Palatine, IL Volume 30, Number 2, February 2010 Send address corrections to:

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Duluth, MN 55802-2065 800/746-6578 http://www.jointcommission.orgThe official newsletter of The Joint Commission Each year, millions of seriously ill patients are admitted to intensive care units (ICUs) around the world. It is imperative that staff keep patient safety as a top priority when caring for these especially vulnerable patients. Patient Safety in the Intensive Care Unit explores how The Joint Commission’s and Joint Commission International’s (JCI’s) requirements guide the organizational efforts in one of the most crucial departments of a hospital—the ICU. Strategies and tools are provided to help ICU staff do the following:

Examine ICU current policies and procedures and compare them to The Joint Commission and JCI hospital requirements Manage issues in the ICU based on Joint Commission requirements:

– Devise practical strategies for improving patient safety – Learn from evidence-based best-practice efforts of ICUs – Implement a plan for quick and sustainable improvement – Use forms, tools, and other illustrative material to improve the function and safety of the ICU Patient Safety in the Intensive Care Unit For more information, or to order this publication, please visit our Web site, at http://www.jcrinc.com, or call our toll-free Customer Service Center, at 877/223-6866.

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