Each year, the Massachusetts Health and Hospital Association (MHA) invites hospitals from across the state, as well as leaders from the Joint Commission, to gather together to discuss the latest news related to the Joint Commission survey process. This year, representatives from Brigham and Women’s Faulkner Hospital were invited to share insights from the hospital’s latest survey with the group.
During the first half of the day, the Joint Commission presented on the challenging standards from 2017 and the new standards to look for in 2018. Despite having completed a successful survey this year, for Executive Director of Patient Safety, Quality, Risk, Infection Control, CDI and Clinical Compliance, Christi Clark Barney, MSN, RN, and Project Coordinator for Quality Improvement, Patient Safety, Accreditation and Infection Control Chris Haffenreffer who represented BWFH at the conference, these sessions provided valuable information for BWFH going forward.
“The Joint Commission talked a lot about ligature risk in behavioral health rooms,” says Haffenreffer. “Going forward, any rooms outside of an inpatient psychiatry unit that are meant specifically for behavioral health patients must follow the inpatient psychiatry room guidelines surrounding ligature risk. For example, the rooms that treat behavioral health patients in the ED must be ligature free.”
Haffenreffer also took away some tips that are specifically useful to the compliance team. “There is a new feature on the Joint Commission website that will allow us to easily filter our survey results, enabling us to efficiently review certain areas of citation,” he explains. “Additionally, there will be a function to export the report to Excel for further filtering/sorting/analysis of our citations.”
Finally, Haffenreffer says he learned about citations that will carry over to future surveys. “We now know that citations that fall into certain higher level boxes of the SAFER matrix will be read by future surveyors before they start their next survey. In the past, minimal material from prior surveys carried forward to future surveys. This means that it is very important for us to maintain our corrective actions and sustain our new process changes to show that we are adhering to our corrective action plans and to prevent future repeat citations,” he says.
During the second half of the day, Barney and Haffenreffer shared what BWFH learned during its 2017 survey. “We were asked to present in part because we were cited for ligature risks, one of the areas of most citation across the entire United States in 2017. We worked very hard to correct those issues and we hoped to share some of what we learned with other hospitals so that they could more pro-actively address this risk,” says Barney. “We were very transparent about the things that did not go well, but also celebrated the things that did go well.”
For Barney and Haffenreffer, sharing what BWFH learned is part of a spirit of collaboration among hospitals in Massachusetts. “The day proved to be a good reminder that we are all in the same boat in some ways,” says Barney. “Every year the Joint Commission throws a curve ball at us. And in some ways it’s affirming to see how far ahead of other hospitals we are in certain areas. For example, we learned that the Joint Commission will be focusing on the care of the transgender patient. That’s an area where BWFH has already laid a solid foundation for the work ahead. We have also worked hard to develop high reliability solutions using our just culture/safety culture algorithm. The Joint Commission’s increasing focus on high reliability and zero harm to patients aligns with our own vision and process for the safest care for our patients.”
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