Accreditation

Joint Commission elaborates on accreditation reports, suicide risks, and toilet seats

Briefings on Accreditation and Quality, December 1, 2017

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The 2017 Chicago session of The Joint Commission’s annual Executive Briefings saw a far-ranging discussion on the future of accreditation. Attendees from around the country came and listened to the latest news on risk assessments, the SAFER Matrix, documentation, and suicide prevention.

Adjusting suicide risk expectations

Chief Medical Officer and Executive Vice President Ana Pujols McKee, MD, acknowledged to attendees the seriousness, expense, and difficulty of reducing suicide risk in hospitals. McKee spoke on September 29 just outside Chicago, in the second of the three briefings held each year to update hospital executives on upcoming Joint Commission changes.

For instance, The Joint Commission is working with manufacturers to identify products that will satisfy current concerns about ligature points in treatment areas designated for behavioral health patients. But products allowed can vary state to state. For instance, some states have restrictions on the kinds of bathroom doors that may be used.

“This is very, very complicated,” said McKee.

Although The Joint Commission is working with CMS, she warned that those federal surveyors are declaring immediate jeopardy (IJ) over many ligature risks. Much like the Joint Commission finding of immediate threat to life (ITL), an IJ finding threatens a hospital’s ability to bill Medicare.

“We know there have been mixed messages,” she said. “We know it’s difficult … we’ve been living it with you.”
The Joint Commission is trying to clarify CMS concerns to make sure commission surveyors will be looking for the same problems “so that CMS will not come in behind us and then have an IJ. … We’re trying to bring the logic of reason to the discussion. So stay tuned, everybody; there will be more on this,” said McKee, during a session the morning of September 29.

By the afternoon, The Joint Commission was indeed able to offer some good news—particularly about toilet seats.

You heard right: Toilet seats

Carrie Mayer, who oversees strategic and operational excellence activities for The Joint Commission’s accreditation and certification operations, offered an update on future changes to expect from the organization, including some newly approved expectations involving suicide risk.

To get insight into the debate, Mayer explained, The Joint Commission has formed an expert panel to address the heightened suicide risk reduction goals both The Joint Commission and CMS have been pushing since last year.

The panel includes professionals across many healthcare settings and fields of expertise, including representatives from Veterans Affairs and psychiatric hospitals and several major health systems throughout the nation, said Mayer.

That group has been able to offer help on one issue in particular, Mayer said.

“My boss Mark Pelletier, who many of you may know, thanks all of you who sent pictures of toilet seats,” said Mayer, as she acknowledged the consternation that has followed after surveyors began citing certain kinds of toilet seats earlier this year as a danger for patients looking to hang themselves.

Both Pelletier, The Joint Commission’s chief operating officer over accreditation and certification operations, and Mayer have received photographic examples of how hospitals were trying to comply with an issue many questioned even truly existed.

While removing the toilet seats is a problem, she noted, fastening them in place with Gorilla Glue is likely an infection control issue, eliciting a laugh from the audience.

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