Perspectives, Feb 2009 Vol 29 #2Pg10- Update: Accreditation and Certification Deposit and Fee InformationFYI: LDR, JCSC andFB. The TJC fee policy sections addressing Forfeiture of Survey Deposit and Survey Fees has been revised. The first issue is primarily a concern for initial customers/first-time surveys. The full revision to include details for making credit card payments is provided in the article.
The Source, Feb 2009 Vol 7 #2 Pg01-Interviewing with Ease Staff interviews during Joint Commission surveys can be less stressful if staff members know what to expect. Surveyors usually focus their questions on how each individual provides treatment and his/her role in the treatment team. When a staff member does not know an answer, the appropriate reaction is to tell the surveyor that he/she knows where to find the answer and then proceed to do so. Management and supervisory staff who hover over staff and surveyors during interviews are distracting and anxiety provoking for staff. JCSC may want to consider this article as a reassuring handout for unit staff.
The Source, Feb 2009 Vol 7 #2 Pg06-Tracer Methodology 101: The Medication Management Tracer This article describes how to conduct a Medication Management Tracer with a Pediatric Focus. However, JCSC, Phrm and P&T can find information useful for any Medication Management Tracer including a list of sample tracer questions and a sidebar “Tips Checklist” of tracer strategies.
Mar 2009
The Source, Mar 2009 Vol 7 #3Pg06-Tracer Methodology 101: The MRSA-Related TracerGiven the increasing significance of MRSA and articles like this, IC and JCSC should be prepared for an MDRO-focused tracer. A basic scenario for such a tracer is provided as are sample questions. The latter should be considered a heads up for those expecting survey and a useful basis for conducting one's own practice tracers.
Apr 2009
May 2009
Source May '09 Vol 7 #5 Pg06Tracer Methodology 101: The Continuity of Care Tracer[••REF••] Essentially this is a program tracer that evaluates the process of ordering and following through on diagnostic testing. Although this tracer is primarily 'applicable' to ambulatory health care (AHC) organizations, but TJC leaves itself options to apply it "organizations that provide complex services across the continuum of care". Interpret that to mean if your organization is found to have problems with any aspect or phase of diagnostic testing, you could be subjected to this tracer. JCSC would be wise to consider incorporating this tracer into their practice tracer methodology. The article provides 16 sample questions for the process.
Perspectives May 09 Vol 29 #5 Pg01-UPDATE: Summary of March Changes from CMS Hospital Deeming Application: [ALERT: JCSC,MD]. This is the Perspective update promised by TJC in the March 26 conference call. As most of you know by now, TJC has been bringing its standards more closely in line with relevant CMS Conditions of Participation (COP). This is a long needed process that has been 'inspired' by TJC's need to re-apply and be re-approved for deeming privileges with CMS. The latest refinement of standards reduced the modified number of new and revised requirements from 165 to 87. And, of that remaining number, TJC assures us that " In most cases, Joint Commission standards already covered these topics, just not in the specificity now required by CMS". However, there are about 37 new EP in 4 areas that would be exceptions to that statement. 2 of these areas apply to our hospitals. The first has to do with seclusion and restraint (27 EP). If you use TJC accreditation for deemed status (as most state hospitals do) then revised StandardsPC.03.05.01 through PC.03.05.19 will replace PC.03.02.01 through PC.03.03.31. The second area of exception relates to the history and physical exam (3 EP). The article includes a chart of CMS-Related Changes Scheduled for Implementation April 6, 2009. Audio replay (until the end of this month) and a transcript of the March 26th Deeming Status Teleconference are available. Support materials (e.g., AMP, automated PPR, E-dition) for accredited hospitals will be updated by July 1, 2009
Jun 2009
Perspectives, June '09 Vol 29 #6 Pg08-Update: Additional Scoring Changes for All 2009 Accreditation Manuals[ALERT: JCSC, EOC, SFT, P&T, PPR] Last month and now again this month, TJC has found the 'need for additional' scoring changes. Effective 7/1/09 most of the latest changes (14 EP in EC, 17 In LS, 6 MM, 2 PC, 3 PI, 1 RI and 1 in LD) will be applicable to hospitals.
Perspectives, June '09 Vol 29 #6 Pg10-Q&A: Understanding Hospital Deemed Status Accreditation Reports[••REF••] JCSC should review the Q&A on deemed status surveys. Among the explanations is that different levels of CMS deficiencies found during TJC surveys will require differing types of follow-up. Specifically, a standard-level deficiency will require an ESC (in 45 or 60 days) while a condition-level deficiency will require an ESC and unannounced follow-up survey. Note: TJC has standards with subordinate EP whose scoring has a precise, pre-defined relationship to the determination of compliance with its related standard. CMS has Conditions of Participation (CoP) with subordinate standards whose scoring does not have a pre-defined, precise or consistent relationship to determinations of compliance at the related condition level. Determinations are made case-by-case based on the deficiencies impact on “the provider’s . . . ability to furnish adequate care or . . . adversely affect the health and safety of patients” (42 CFR 488.24(b)).
Source, Nov. '09, Vol 7 #11 Pg01-Redesigning the Process The Joint Commission Uses Lean Six Sigma for Robust Improvements[••REF••] In this article, TJC confirms its commitment to the concept of Robust Process Improvement (RPI). TJC has defined 4 levels of champions and sponsors for the process and actually implemented its own training program for what it calls green belts, black belts and change agents. Reported examples of RPI application to internal TJC processes include improving the e-App and reducing the post-survey report turnaround time to 10 days. There is currently no requirement for an organization to use RPI in its PI processes, but GB, LDR, PI and JCSC are encouraged to familiarize themselves with RPI. See also Making Health Care a High-Reliability Industry: The Joint Commission Launches Center for Transforming Healthcare in Patient Safety below.
Perspectives, Dec. '09 Vol. 29 #12Pg03-Protecting Organizations' Confidential Accreditation Information[••REF••] GB, LDR and MD should find this a useful review of TJC's position on protecting confidential information (including that related to sentinel events/RCAs) from our hospitals. Those uncomfortable with sharing such information with TJC should note the following statements from the article. "The Joint Commission has never been compelled to produce confidential accreditation information in response to any state court–issued subpoena, whether issued by a court in or outside of Illinois". "The Joint Commission is aware of no case where the confidentiality of sentinel event–related information was lost because it was shared with The Joint Commission."
Reference Articles
Perspectives, Dec. '09 Vol. 29 #12Pg03-Protecting Organizations' Confidential Accreditation Information[••REF••] GB, LDR and MD should find this a useful review of TJC's position on protecting confidential information (including that related to sentinel events/RCAs) from our hospitals. Those uncomfortable with sharing such information with TJC should note the following statements from the article. "The Joint Commission has never been compelled to produce confidential accreditation information in response to any state court–issued subpoena, whether issued by a court in or outside of Illinois". "The Joint Commission is aware of no case where the confidentiality of sentinel event–related information was lost because it was shared with The Joint Commission."
Source, Dec. '09 Vol 7 #12 Pg06-Tracer Methodology 101 The Suicide Prevention Tracer[••REF••] This program tracer is specifically applicable to psychiatric hospitals, hospitals with inpatient units and crisis stabilization units that are part of a behavioral health care program. It is designed to evaluate the effectiveness of organization's suicide prevention strategies/efforts and issues/processes that might contribute to suicide attempts. JCSC, RNx, MDx, Psy and TxTM should note the emphasis on staff education/competency, take advantage of the suggested sample questions and incorporate this tracer into survey prep and ongoing risk assessment efforts.
Source, Nov. '09, Vol 7 #11 Pg01-Redesigning the Process The Joint Commission Uses Lean Six Sigma for Robust Improvements[••REF••] In this article, TJC confirms its commitment to the concept of Robust Process Improvement (RPI). TJC has defined 4 levels of champions and sponsors for the process and actually implemented its own training program for what it calls green belts, black belts and change agents. Reported examples of RPI application to internal TJC processes include improving the e-App and reducing the post-survey report turnaround time to 10 days. There is currently no requirement for an organization to use RPI in its PI processes, but GB, LDR, PI and JCSC are encouraged to familiarize themselves with RPI. See also Making Health Care a High-Reliability Industry: The Joint Commission Launches Center for Transforming Healthcare in Patient Safety below.
Perspectives, June '09 Vol 29 #6 Pg10-Q&A: Understanding Hospital Deemed Status Accreditation Reports[••REF••] JCSC should review the Q&A on deemed status surveys. Among the explanations is that different levels of CMS deficiencies found during TJC surveys will require differing types of follow-up. Specifically, a standard-level deficiency will require an ESC (in 45 or 60 days) while a condition-level deficiency will require an ESC and unannounced follow-up survey. Note: TJC has standards with subordinate EP whose scoring has a precise, pre-defined relationship to the determination of compliance with its related standard. CMS has Conditions of Participation (CoP) with subordinate standards whose scoring does not have a pre-defined, precise or consistent relationship to determinations of compliance at the related condition level. Determinations are made case-by-case based on the deficiencies impact on “the provider’s . . . ability to furnish adequate care or . . . adversely affect the health and safety of patients” (42 CFR 488.24(b)).
Source, Apr 2009 Vol 7 #4 Pg06-Tracer Methodology 101: Staff Training for Tracers[••REF••] The 'how to' series on tracer methodology continues with this installment actually including a bit of a behavioral health care organization scenario. We believe all hospital LDR and JCSC should conduct practice tracers for improvement purposes as well as survey readiness. This article suggests useful tips, steps and strategies for training staff to conduct tracers. Key concepts include focusing on process improvement vs. staff competency and conducting tracers on a regular basis as part of a culture of safety. The latter practice not only prepares staff but also improves the skills of those who conduct tracers.
Perspectives, July '09 Vol 29 # 7Pg01-The 2009 Accreditation Decision Process: A Closer Look at Central Office Reviews [ALERT: JCSC] Last December, TJC announced that the number of direct-impact RFIs would no longer serve as an automatic trigger for CA or PDA. Instead the numbers depending on the size and complexity of your hospital (aka 'band;) would trigger a central office screening (i.e., a more in-depth evaluation of your survey results) for possible CA or PDA. This update only describes 2 possible outcomes of that screening (vs. 3 outcomes in December article and it fails to include the earlier chart indicating the triggering number of direct-impact RFIs. However, it does provide useful examples of Central Office Survey Report Review Objectives that LDR and JCSC should review. See our 2008 Dec RT review by Glenn D. Krasker, MHSA for more details.
TMFSH June, Survey of staffing effectiveness standards suspended; interim EPs being field reviewed: [ALERT: JCSC, HR, PT] Effective immediately, survey of the Staffing Effectiveness standards (PI.04.01.01 for hospitals and HR.1.30 for long term care organizations) has been suspended. Two interim elements of performance, EPs 12 and 13 at PI.02.01.01 (PI.2.10 for Long Term Care) are being field reviewed until 7/22/09. See Field Review: Staffing Effectiveness in our June RT.
Source, Apr 2009 Vol 7 #4 Pg06-Tracer Methodology 101: Staff Training for Tracers[••REF••] The 'how to' series on tracer methodology continues with this installment actually including a bit of a behavioral health care organization scenario. We believe all hospital LDR and JCSC should conduct practice tracers for improvement purposes as well as survey readiness. This article suggests useful tips, steps and strategies for training staff to conduct tracers. Key concepts include focusing on process improvement vs. staff competency and conducting tracers on a regular basis as part of a culture of safety. The latter practice not only prepares staff but also improves the skills of those who conduct tracers.
Perspectives Aug 09 Vol 29 #8 Pg01-Staffing Effectiveness Standard Suspended for Hospitals and Long Term Care[ALERT: JCSC, HR, PT] We first alerted you to this in our July RT review of This Month For State Hospitals. It is now confirmed and made official by publication in Perspectives. Effective immediately, survey of the Staffing Effectiveness standards (PI.04.01.01 for hospitals and HR.1.30 for long term care organizations) has been suspended. Two interim elements of performance, EPs 12 and 13 at PI.02.01.01 (PI.2.10 for Long Term Care) were field reviewed until 7/22/09.See Field Review: Staffing Effectiveness in our June RT.
Perspectives Aug 09 Vol 29 #8Pg07- Approved: 2010 Updates to Accreditation and Certification Decision Rules[ALERT: JCSC] The effective date is Jan 1, 2010 and most of the changes are editorial. However, FOLL_U (which is actually a survey type and not a new decision category - See JCO below), is the requirement for follow up surveys to Medicare deemed status condition-level deficiencies and it became effective 7/1/09.
Source Aug 09 Vol 7 #8 Pg06-Tracer Methodology 101: The Data Use System Tracer[••REF••] A scenario and sample questions are provided to help organizations, JCSC and IM conduct their own data use tracers. When doing so it is suggested you consider using a 'pinpoint data tracer' to focus on a particular aspect of data use such as infection control.
Source, Dec. '09 Vol 7 #12 Pg06-Tracer Methodology 101 The Suicide Prevention Tracer[••REF••] This program tracer is specifically applicable to psychiatric hospitals, hospitals with inpatient units and crisis stabilization units that are part of a behavioral health care program. It is designed to evaluate the effectiveness of organization's suicide prevention strategies/efforts and issues/processes that might contribute to suicide attempts. JCSC, RNx, MDx, Psy and TxTM should note the emphasis on staff education/competency, take advantage of the suggested sample questions and incorporate this tracer into survey prep and ongoing risk assessment efforts.
