Joint Commission Hot Topics 2020: Advance Directives, Contracts, Grievances, Informed Consent, 2020 Changes and More
Description:-
This webinar will cover a number of Joint Commission hot topics in 2020. It will cover the new changes in the July and September 2020 Joint Commission standards. It will discuss the Joint Commission requirements for advance directives, contract management, grievances, informed consent, and more.
Objectives:-
- Recall that the Joint Commission has two sections in the manual that addresses the issue of informed consent
- Discuss that the Joint Commission requires hospitals to have an informed consent policy
- Describe that the Joint Commission has contract management standards and that the hospital should evaluate every contract to ensure the performance indicators are met
- Remember that Joint Commission requires hospitals to provide patients with written information on admission on advance directives
- Recall that TJC states that patients and families have a right to have a complaint reviewed and it must be done timely
- Discuss that TJC has changed to the hospital standards in July and September of 2020.
Detained Outline:-
Contract Management LD.04.03.09
- Contract standard and the EPs
- The same level of care
- Updates
- Hospital leader responsibility for contracted services
- Safety and quality requirements
- Limited applicability to patient care services
- Consults and referrals not subject to requirements
- Staff competence
- Credentialing/privileging
- Performance improvement requirements
- Ideas on how to review contracts
- Credentialing and privileging
- Nature and scope of services
- Leadership approval of contracts
- Monitoring the performance of contracts
- Contracts with other accredited organizations
- Communicating expectations in writing
- Contracts that do not meet expectations
- Continuity of patient care maintained if contract terminated
- Contract lab services
- FAQs
Joint Commission Informed Consent Standards
- RI.01.03.01 and the revised EPs and recuperation
- Remember state law requirements
- Written policy requirements
- Surgery and procedures requiring consent must be specified
- Consent is a process
- Risks benefits, and side effects
- Elements not required by CMS
- Exceptions to policy
- Emergency surgery
- Consent on chart required before surgery
- Consent for photography
- TJC tracer on consent
Joint Commission Advanced Directives RI.01.05.01 and RC.02.02.01
- End of life care
- Written policy and procedure
- Tracer
- Advance directives and outpatients
- Providing patients with information about Ads
- Honoring advance directives
- Organ donation wishes
- Medical records to contain a copy of AFs
- Recommendations for compliance
Joint Commission Complaints RI.01.07.01
- Patient and family right to have reviewed
- Need complaint resolution process
- Board responsible and delegation
- Acknowledging receipt of a complaint
- Written notice of the decision
- Information in patient rights of who will handle complaints
- QIO and process for resolving complaints
New Standards in July & September 2020
- Emergency preparedness
- History and physicals
- Swing bed changes
- Discharges and transfers
- Infection control
- QAPI
- Self-administered medications
- Record retention
- Organ donation
Who Should Attend?
- CEO
- Compliance Officer
- Chief Medical Officer (CMO)
- Chief Nursing Officer (CNO)
- Chief Operating Officer (COO)
- Joint Commission Coordinator
- Nurse Educator
- Nurses
- Nurse Directors
- Nurse Supervisors
- Nurse Managers
- Hospital Legal Counsel
- Risk Manager
- Board Members
- Physicians
- Medical Staff Coordinator
- Patient Safety Officer
- Senior Leadership
- Chief Risk Officer
- QAPI Director
- Discharge Planners
- HIM director
- Director of Anesthesia
- OR Nurse Director
- Patient Advocates
- Ethics Committee
- Director of Registration
- Consumer Advocates
- Patient Advocates
- HIPAA Privacy Officer
- Quality Improvement Staff
- And others responsible for compliance with meeting Joint Commission standards, and persons responsible for rewriting policy and procedure.
Presenter BIO
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a current board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.
Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.
She also writes many articles for Briefing on the Joint Commission. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over seventeen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.
She has been employed in the nursing profession for more than 30 years. Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers.
Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus. She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.
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