Big Changes Are on the Horizon for Small, Rural Hospitals

New guidance, revised standards, and clarifications from the Joint Commission.

Jeannell Mansur
Jeannell Mansur

The past year has been tough on hospitals, and smaller, rural locations are no exception. The impact has even extended to the Joint Commission’s survey process, which attendees were updated on during Sunday’s session, “Joint Commission Update 2021: Focus on Small and Rural Hospitals.”

Led by Jeannell Mansur, principal consultant for medication management and safety for Joint Commission Resources/Joint Commission International, the session detailed some of the challenges the Joint Commission has had to face and some of the changes accredited institutions can expect to see coming down the road.

“I know that it has been a very challenging year for healthcare in general and I know that the small, rural hospitals have been especially hit,” she said. “You’ve been working with an influx of patients and your hospital capacities are at limits because of COVID-19. It is sometimes the case that your communities have a higher percentage of unvaccinated citizens and that has presented an increased demand in your hospital setting.”

Mansur said that due to the pandemic, the Joint Commission started the year with a backlog of surveys but has been making good progress in closing that backlog and getting things back on track. She addressed a number of things rural hospitals need to be on the lookout for as the survey process returns to normal.

Hospitals and health systems that use the Joint Commission survey to attain Centers for Medicare &  Medicaid Services certification, for example, will not be able to have a virtual survey.

“They will have to be able to come on site,” she said. “(And there are) very specific methods of looking at COVID rates in your community to decide whether or not you can come on site.”

There will also be revised standards clarifications from the Joint Commission on antimicrobial stewardship requirements coming in 2022. Draft standards were available for field review in September 2021 and the final standards  are expected to be unveiled at the end of January.

“We don’t know what’s going to be in the final standard, but I will tell you that the field review detailed some very specific requirements for antimicrobial stewardship,” Mansur said. “(Those include) detailed requirements as to what leadership support looks like, requirements for organizations to develop guidelines for managing different types of infections, and a requirement to collect data on at least one of those infections to see that there is proper antimicrobial selection and proper duration of therapy.”

Mansur spent much of Sunday’s session going over titration orders—specifically, three new allowances made for those orders by the Joint Commission in 2020.

The first allowance is for urgent situations and allows for a lower amount of information to be documented once a block charting episode has been initiated during those situations. The episode cannot exceed four hours. After that, the nurse would need to initiate a new block charting episode.

“These are situations where the patient is so critical that the nurse really needs to be making very frequent adjustments of rates up and down to manage that very unstable patient,” Mansur said. “He or she would not have the time to be able to record every dose change and every physiologic endpoint at the time that he or she made that change.”

The second allowance is for titrations in critical care — specifically, patients who receive more than one titratable drug for the same indication.

“Let me give you an example,” Mansur said. “A patient may be on two drugs for sedation and the management of when you give one versus another is something that is really a skill that nurses have who work in the critical care setting. This allowance lets nurses make the determination of when they give one drug or another, (permitting) them to use their judgement.”

And the third allowance is for situations when patients can be weaned off their titrated medications while safely maintaining their goal physiologic parameters. Mansur said that the Joint Commission does not consider that a formal discontinuation of the medication that would require a physician’s order.

Mansur also had an update on standard MM.05.01.01, the pharmacist review of medication orders. She said surveyors have seen a lot of problems with these orders and they should be carefully considered.

“Pharmacists are supposed to be reviewing all of these orders and they should be identifying problems of incomplete orders, unclear orders or therapeutic duplication and correcting those,” she said. “That’s part of the order process. 

Mansur highlighted a few new areas to watch, one of which involves upcoming new guidance on insulin pumps.

“The Joint Commission was asked if this is a patient-owned medication scenario or a patient self-administered medication scenario?” she said. “The answer is yes and yes.”

The new guidance instructs hospitals to create a policy that outlines the specific requirements for how the device and its medication are going to be assessed. The policy should include information about the patient’s own medication processes, the creation of appropriate provider orders, medical record documentation, and information about the self-administration of insulin.

Lastly, Mansur drew everyone’s attention to a Sentinel Event Alert that was issued in April of this year on improving the safety of infusion smart pumps that are using dose error recognition software (DERS).

“This is a technology that’s in such a high percentage of our hospitals and you might think that it’s providing the safety net it was designed to provide, but The Joint Commission is saying not necessarily so,” she said. “There are ways to circumvent these pumps, there are problems with the drug libraries—and people overriding the drug libraries—and all of these have led to dosing errors with infusions, which these pumps were meant to prevent.”

ASHP members benefit from updates like this one from The Joint Commission, a well-known standards-setting and accrediting body in healthcare.