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JOINT COMMISSION AND RESUSCITATION

The mission of the Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations. Each year, the Hospital Accreditation Standards (HAS) are updated to facilitate a hospital’s continuous operational improvement, as well as the self-assessment of its performance against Joint Commission hospital standards. The HAS includes all the information a hospital needs for continuous operational improvement: standards, rationales, elements of performance, scoring, decision rules and accreditation policies and procedures. The HAS also provides a better understanding of the connection between safety and quality-focused standards and day-to-day activities and the accreditation process. Included in the HAS are the yearly Joint Commission’s National Patient Safety Goals for hospitals.

In 2004, the focus for the accreditation process shifted from survey preparation to continuous operational improvement by encouraging hospitals to incorporate the standards as a guide for routine operations. The hospital is to complete the Periodic Performance Review annually and submit it to the Joint Commission along with an action plan that contains measures of success for those standards identified as “not compliant.” Unannounced hospital surveys are performed by the Joint Commission to evaluate compliance with the standards, and accreditation is granted as appropriate. Services of the Joint Commission are available for an annual fee subscription, and a fee is charged for the on-site survey.

What Are Joint Commission Hospital Standards Related to Resuscitation Services?

Standards are defined by the Joint Commission in the HAS chapter “Provision of Care, Treatment, and Services” that relates to resuscitation services in hospitals:

Standard PC.9.30  Resuscitation services are available throughout the hospital.

  • Policies, procedures, processes, or protocols govern the provision of resuscitation services.
  • Equipment is appropriate to the patient population (for example, adult, pediatric).
  • Appropriate equipment is placed strategically throughout the hospital.
  • An evidence-based training program(s) is used to train appropriate staff to recognize the need for and use of designated equipment and techniques in resuscitation efforts.

Several standards in the chapter on “Medication Management” apply to the use of medications in emergencies:

Standard MM.2.20  Medications are properly and safely stored.

Standard MM.2.30  Emergency medications and/or supplies are consistently available, controlled, and secured. 

What Are Joint Commission Standards Related to Code Documentation and Quality Review of Codes?

The chapter on “Improving Organization Performance” contains standards that are helpful related to code documentation and quality efforts for resuscitations. Data help determine performance improvement priorities. The data collected for high-priority and required areas are used to monitor the stability of existing processes, identify opportunities for improvement, identify changes that lead to improvement or sustain improvement.

Standard PI.1.10  The hospital collects data to monitor the performance of potentially high-risk processes, e.g., resuscitation and its outcomes.

Standard PI.2.10  Data are systematically aggregated and analyzed.

  • Data are analyzed and compared internally over time and externally with other sources of information when available.
  • Comparative data are used to determine if there is excessive variability or unacceptable levels of performance when available.

Standard PI.2.20  Undesirable patterns or trends in performance are analyzed.

Standard PI.3.10  Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

The chapter on “Information Management Planning” contains further standards that apply to how resuscitation information should be managed. A hospital’s ability to make decisions depends on having ready access to reliable and accurate information to support the decision-making process, the hospital captures, processes, stores and retrieves the needed information. It then supplies the information to management and others involved in the decision-making process.

Standard IM.3.10  The hospital has processes in place to effectively manage information, including the capturing, reporting, processing, storing, retrieving, disseminating and displaying of clinical/service and non-clinical data and information.

  • Information technology industry standards or hospital policies are used and address uniform data definitions, capture, display and transmission.
  • Quality control systems are used to monitor data content and collection activities.
  • Data are organized and transformed into information in formats useful to decision makers. 

Making the Joint Commission Resuscitation Standards Alive within a Hospital

The completeness, accuracy and timeliness of code data for individual patients are important to patients, families and clinicians in planning patient care. Additionally, the data recorded at a code and reported concerns are vital to the CPR committee and others who are reviewing the event for quality. These Joint Commission standards mentioned above support the use of a code documentation tool in which all the data elements are clearly defined according to the American Heart Association ‘Utstein’ template so that aggregate data can be tabulated, analyzed and compared with that of like institutions. The resuscitation data must be presented in a meaningful way in order to help staff plan for the hospital’s work of continuing improvement. Both use of ZOLL CodeNet for resuscitation information management and subscription to the National Registry of CPR are invaluable to help achieve these Joint Commission standards in an efficient, cost effective-manner.

Reference: 

Joint Commission on Accreditation of Healthcare Organizations. 2007 Hospital Accreditation Standards