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Joint Commission Hot Topics 2020: Advance Directives, Contracts, Grievances, Informed Consent, 2020 Changes

Presented by Sue Dill Calloway
Duration - 120 Minutes

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Description

Joint Commission Hot Topics 2020: Advance Directives, Contracts, Grievances, Informed Consent, 2020 Changes and More

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.

Learning 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.

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 are 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.

Speaker

Sue Dill Calloway

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management, and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. Sue Dill Calloway was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

Sue Dill Calloway is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.