Joint Commission Hot Topics 2023: Identifying High Risk Standards and Processes for Compliance

Product Id : HLT69
Instructor : Darlene Evans, MSN, RN, CPHQ
Apr 06, 2023 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 60 Minutes

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This webinar will cover several Joint Commission hot topics for 2023.  It will discuss the Joint Commission requirements for identifying high risk standards and processes for compliance as well as review the TJC 2021 and 2022 high risk and hot topics including infection control, life safety code, sentinel events, and more. Though surveyors review all aspects of a facility during a review, they target specific areas involving patient care.

For 2023, there is a focus on infection prevention and control, emergency and pain management, workplace violent, and life safety. Much of what Joint Commission requires for certification and deemed status follow the Conditions of Participation from CMS.  Hospitals who receive deemed status through Joint Commission are not required to have a certification survey by CMS to participate in Medicare reimbursement. 

Learning Objectives:

  • Detail overview discussion of frequently cited standards in infection control, and if there is a process failure, then staff should know what steps to take.
  • Describe the most challenging standards including medical gas and vacuum systems, pain management, and informed consent.
  • Remember that staff members must be able to locate policies and directives that govern their practice.
  • Recall that TJC states that patients and families have a right to have a complaint reviewed and it must be done timely.
Program Outline:

  • Policies and Procedures
  • TJC 2022-2023 Frequently Cited Standards
  • 2023 Clinical Standards
  • 2022 EOC/LS
  • Infection Control Frequently Cited and High Risk
  • Infection Control Instruments
  • Infection Control Sterile Storage
  • Infection Control MIFU
  • NPSG 15.01.01 EP 1 Suicide Risk Assessment 
  • MM 06.01.01 EP 3
  • MM 06.01.01 EP 1
  • EC 02.06.01 EP 1
  • EC 02.05.01 EP15
  • IC 02.01.01 EP 1
  • IC 02.02.01 EP 4
  • Findings at NPSG 15.01.01 EP5
  • Frequently Cited Standards NPSG 15.01.01 EP4
  • Challenging Standards 
  • Healthcare Disparities Moved to NPSG
  • Sentinel Event Data 2022

Who Should Attend?

  • CEO
  • Compliance Officer
  • Chief Medical Officer (CMO)
  • Chief Nursing Officer (CNO)
  • Chief Operating Officer (COO
  • Joint Commission Coordinator
  • Nurse Educator
  • Nurses
  • Directors/Supervisors/Managers
  • Hospital Legal Counsel
  • Risk Manager
  • Board Members
  • Physicians
Speaker Profile:

Darlene Evans is a healthcare quality leader with more than 25 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and business development. With her expertise in Centers for Medicare and Medicaid Services, Joint Commission, and Healthcare Facilities Accreditation Program standards and her commitment to education and collaboration, Darlene has a proven track record of helping clients identify opportunities for improvement and achieve sustainable, long-term results. She has also helped lead organizations through projects in areas such as operational effectiveness, infrastructure, staffing and productivity, fiscal stewardship, leadership development, and care delivery.

Darlene was Senior Manager of Clinical Operations, Quality, Safety, and Performance Improvement with Quorum Health Resources. In this role, she provided consultative services to 150 client hospitals, including accreditation, quality, and life safety and environment of care assessments, and the implementation of operational process improvement tools and best practices, as well as other specialty patient quality and safety initiatives. Previously, Darlene worked with the Joint Commission International as a hospital and  ambulatory care accreditation surveyor for healthcare organizations in Turkey, India, Ireland, Saudi Arabia, UAE, and China. In addition to her consulting and surveyor experience, Darlene has served in full-time leadership roles including Chief Nursing Officer, Vice President of Patient Care Services, Assistant Vice President of Nursing Services, and Director of Quality Management and Education.

Darlene earned her Master’s Degree and Bachelor's Degree in Nursing from Troy State University in Troy, AL. She has also taken courses in business and management and is Lean Six Sigma certified. Darlene is a Registered Nurse, a Certified Professional in Healthcare Quality, and a member of the American College of Healthcare Executives and the National Association for Healthcare Quality

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