The Joint Commission Workplace Violation PowerPoint Presentation

The Joint Commission Workplace ViolationVirginia Mason Healthcare

HLT – 313V

“An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States” (Joint, 2019). The Joint Commission is recognized as a Quality that reflects an organization’s commitment to meeting certain performance standards.

The Joint Commission

05/22/16 Initial DenialLast On-Site Survey was completed in 2013 and Accreditation was given.The Joint Commission denied full Accreditation after discovering safety issuesA Surprise May Audit revealed noncompliance with 29 standardsPossible Hepatitis B ExposureThat Exposure affecting nearly 650 patients

Accreditation Denial

“that posed a threat to patients or other individuals served,” according to the report, and the Joint Commission issued a preliminary denial of accreditation (Beckers, 2016)June 1 – “has successfully abated an immediate threat to life situation through direct observation or other method,” among other possibilities (Beckers, 2016).

Accreditation Denial

Initial Denial – 05/22/16Contingent Accreditation – 06/3/16Contingent Accreditation – 06/07/16Contingent Accreditation – 07/21/16Contingent Accreditation – 07/27/16Full Accreditation – 09/25/16

Accreditation Timeline

06/03/16 The Joint Commission released the actual violation information which as followed:“Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services”.“Care, treatment, and services provided through contractual agreement are provided safely and effectively”.“Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins”.“Medical staff bylaws address self-governance and accountability to the governing body”.

Actual Violations: Denial

“Resuscitation services are available throughout the hospital”.“The governing body is ultimately accountable for the safety and quality of care, treatment, and services”.“The hospital conducts fire drills”.“The hospital effectively manages its programs, services, sites, or departments”.“The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community”.

Actual Violations: Denial

“The hospital has an infection prevention and control plan”.“The hospital implements its infection prevention and control plan”.“The hospital inspects, tests, and maintains medical equipment”.“The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply”.“The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed”.

Actual Violations: Denial

“The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation”.“The hospital provides care, treatment, and services for each patient”.“The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation”.“The hospital provides orientation to staff”.“The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia”.

Actual Violations: Denial

“The hospital reduces the risk of infections associated with medical equipment, devices, and supplies”.“The hospital safely stores medications”.“The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process”.“Existence at time of survey of a condition, which in the Joint Commission’s view, poses a threat to patients or other individuals served”.

Actual Violation: Denial

“The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply”.“The hospital manages fire risks”.“The hospital manages medical equipment risks”.“The hospital manages risks associated with its utility systems”.“The hospital manages risks related to hazardous materials and waste”.“The hospital manages safety and security risks”.“The hospital provides and maintains systems for extinguishing fires”.

Actual Violations: Denial

2016 had a total of 6 Surveys completedVirginia Mason after fixing the 29 Standards violations was given full Accreditation on 9/25/16Since then they have not had any further issuesLast Survey was completed 04/26/19 and was given Accreditation

The Outcome of the Violation

A lot of the 29 standard violations were repeat of simple issues that can be avoided.Have a Risk & Safety Management Team would be top priority. Educating staff and new hires on the policies that were placed not only by the hospital but by The Joint CommissionEssential element of quality improvement is monitoring high-risk, problem prone areas and having the Risk Management team will help with this.General areas of study include access to care, the intake process, continuity of care, emergency care and adverse patient events, including all deaths (NCCHC, 2019).

The Future and How to Avoid This

Beckers Healthcare. (2016, June 22). Joint Commission denies Virginia Mason full accreditation after discovering safety issues. Retrieved July 28, 2019, from (2019). Quality Improvement on Risk. Retrieved July 28, 2019, from Joint Commission. (n.d.). Accreditation History. Retrieved July 28, 2019, from Joint Commission. (2019). The Joint Commission: Mission Statement. Retrieved July 28, 2019, from