Perspectives Feb '09 Vol 29 #2 Pg03-Update: The Joint Commission's Hospital Deeming Authority Application [**ALERT**] In order to successfully apply for renewal of its deeming authority (TJC accreditation affording deemed status for certain CMS requirements), the Joint Commission has had to bring its standards into fuller alignment with CMS. In most cases this has meant a refinement of language, but in some instances, it has meant new standards or elements of performance. Although the modifications and/or additions are still in draft status for the next 6 months, JCSC should definitely obtain, review and distribute them now. Those revisions that are not further refined will need to be implemented (and will be surveyed/scored) starting in July of this year. If you have not already done so, download New & Revised 2009 Accreditation Requirements in Response to CMS Deeming Application
Mar 2009
Apr 2009
May 2009
Jun 2009
July 2009
Patient Safety July 09 Vol 29 #7Pg01-Protecting the Patient: The Joint Commission Collaborates on Developing Infection Prevention and Control Compendium: [••REF••] Four major healthcare organizations (SHEA, IDSA, AHA, APIC) have joined with TJC to produce the A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals that organizes all the evidence- based strategies that have been found to prevent those HAIs causing the greatest mortality (including MRSA and CDI) into practical guideline that can serve as a one-stop prevention resource. Strategies are organized into 4 categories. Basic practices and Special approaches for certain high-risk populations have good or moderate evidence to support their use (i.e., A or B-level recommendation). Level C recommendations are categorized as 'Unresolved issues'. There is a final category of approaches that should not be implemented. The guideline also includes performance measures and patient guides (http://www.preventinghais.com/) for each HAI. IC and related PPR should not only review relevant sections of the compendium, but strongly consider performing a gap analysis between your current approaches and their A or B-level recommendations to better ensure compliance with NPSG.07.03.01, NPSG.07.04.01 and NPSG.07.05.01 that TJC says were directly influenced by the compendium.
Aug 2009
Perspectives Aug 09 Vol 29 #8 Pg07-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.
Sep 2009
Oct 2009
Nov 2009
Pt. Safety, Nov. '09, Vol 9 #11 Pg01-Special Report! 2010 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them[••REF••] Although there are no new NPSG for 2010 there have been a significant number of refinements. JCSC and PPR may want to pay particular attention to the numerous changes in EP criticality and scoring. Remember, no matter when your survey occurs, scoring is based on continuous compliance from the first of the year. The article also provides a brief review of NPSG scoring and confirms the 'on hold' status of NPSG 8 while it's re-evaluation continues. Surveyor findings related to NPSG 8 will not affect accreditation decisions or generate RFI.
Dec 2009
Source Dec. '09 Vol 7 #12Pg01-Joint Commission Now Giving “Booster Shots” for Standards Compliance First BoosterPak Focuses on Safe Medication Storage[••REF••] Last month in an article on Redesigning (Its) Process(es) with Lean Six Sigma, there was a brief mention of the development of BoosterPaks for problematic standards. The first BosterPak (BP) became available on 11/19/09 and is a well-designed compliance reference and resource for the Standard MM.03.01.01. This particular standard has been cited more in more than 30% of TJC hospitals every year since 2005. In the first half of this year 21% of our members also reported this citation. Although the article does not provide links, TJC says it sent announcements of the BP to all hospitals. JCSC, Phrm, P&T, RNx and MDx should at least review the first 22 pages of this 33-page compendium by going to BoosterPaks in the What's New section of your TJC Connect site or downloading BP_MM_03_01.pdf. The contents include implementation expectations (Pgs 2-11), the survey assessment process (Pg 12), FAQs (Pgs 13-15), key definitions (Pg 16), special issue discussion (e.g., Crash Cart Storage) (Pgs 17-22) and additional references and links.
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.
Reference Articles
Pt. Safety, Nov. '09, Vol 9 #11 Pg01-Special Report! 2010 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them[••REF••] Although there are no new NPSG for 2010 there have been a significant number of refinements. JCSC and PPR may want to pay particular attention to the numerous changes in EP criticality and scoring. Remember, no matter when your survey occurs, scoring is based on continuous compliance from the first of the year. The article also provides a brief review of NPSG scoring and confirms the 'on hold' status of NPSG 8 while it's re-evaluation continues. Surveyor findings related to NPSG 8 will not affect accreditation decisions or generate RFI.
Patient Safety July 09 Vol 29 #7Pg01-Protecting the Patient: The Joint Commission Collaborates on Developing Infection Prevention and Control Compendium: [••REF••] Four major healthcare organizations (SHEA, IDSA, AHA, APIC) have joined with TJC to produce the A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals that organizes all the evidence- based strategies that have been found to prevent those HAIs causing the greatest mortality (including MRSA and CDI) into practical guideline that can serve as a one-stop prevention resource. Strategies are organized into 4 categories. Basic practices and Special approaches for certain high-risk populations have good or moderate evidence to support their use (i.e., A or B-level recommendation). Level C recommendations are categorized as 'Unresolved issues'. There is a final category of approaches that should not be implemented. The guideline also includes performance measures and patient guides (http://www.preventinghais.com/) for each HAI. IC and related PPR should not only review relevant sections of the compendium, but strongly consider performing a gap analysis between your current approaches and their A or B-level recommendations to better ensure compliance with NPSG.07.03.01, NPSG.07.04.01 and NPSG.07.05.01 that TJC says were directly influenced by the compendium.
Source Jul '08 Vol 6 # 7Pg06-Hand Hygiene Guidelines by the World Health Organization (WHO) [**REF**] 7 Steps are provided for complying with WHO hand hygiene guidelines. However since most state hospitals chose to comply with the CDC guidelines, the most valuable content is a 2-page compliance checklist based on both CDC and WHO for standard IC.01.0301 (aka IC.4.10). This is a must read for IC and any IC-related PPR team. Get (and use) a copy.
Free TJC Publication Download: The Joint Commission Perspectives, Special Issue, August 2008: Improving the Accreditation Process: Countdown to 2009 Note: This entire issue should be considered a [**REF**]and necessary reading forJCSC, PIand selectedLDR.
Pg01- Improving the Accreditation Process: Countdown to 2009: This is the introduction to this Special Issue of The Joint Commission Perspectives® that promises to provide details on each of the main components of SII. Also includes a Program Applicability table.
For more details: SII, at http://www.jointcommission.org/Standards/SII/
For questions: standardsimprovement@jointcommission.org
Pg05- Improvements to the Decision Process: This article provides another summary of the key changes in standards. (see Countdown to 2009: Simplified scoring process above) However, it may be significant to note that most of the article was devoted to various aspects of the new concept of 'criticality'. For additional details on criticality check out TJC's "Standards Improvement Initiative - [PPT] - Updated July 2008 (especially sides 26-37).
Pg08- Understanding the New Standards Numbering System: Bottom line is that all standards (and NPSG) have been renumbered using a 6-digit approach that will allow the savvy to understand that requirement's location within a chapter and to effectively sort them when working in electronic formats. History Tracking Reports (think crosswalk) will also be available.
Pg09- SII Brings Changes to the Accreditation Manuals: The free manual will be smaller ( 6" 9" 3-ring binder format) and the chapters in the standards manual will be arranged alphabetically. Several new icons are also explained. Look for the Complimentary single-user access to E-dition (electronic manuals) in November. TJC is touting "Three-click access to most standards".
Pg11- SII Introduces Standards Language Revisions and Chapter Reorganization: The language of the standards has also been refined to eliminate/minimize Hard-to-Measure Words and create a more 'logical flow' As a result, a number of chapters have also been re-organized. The IC chapter is used as an example.
Pg12- 10-Day Clarification Time Frame for All Programs: Starting in January of 2009, the 10-day clarification option will now be available for any RFI. However, choosing this option will not afford any additional time for ESC submission.
Pg13- APPROVED: 2009 Accreditation Decision Rules for All Programs: Changes in the 2009 accreditation decision rules are summarized and then provided in full detail in tables over the next 6 pages of the publication.
EOC News, Aug '08, Vol 11 #8 Pg06-Emergency Management Tips: The Emergency Management Tracer: How to Help Your Organization Follow the Roadmap[**REF**] State hospitals should note that since the beginning of this year emergency management tracers have been applicable to all hospitals regardless of size. This is the best TJC review and summary of the emergency tracer process we have seen to date. The basic strategy suggested for preparation is to comply with the requirements for 1- preparing an HVA (EC.4.11) and 2- developing/documenting an Emergency Operations Plan (EOP) and testing it at least twice a year. (EC.4.12). Some detail is also provided about the 2-part emergency management (EM) tracer and the manner in which one of its 17 scenarios (including at least one with nuclear elements) will be utilized to evaluate compliance across relevant EC and HR standards. JCSC, LDR, E&M, SFT and EOC should find this a useful review and augmentation of the meager information provided in the 1-page description of this process in the Survey Activity Guide available on TJC Connect. Hint: Pay particular attention to the top three emergency risks identified in your EOP and consider conducting mock EM tracers. - by FJM
See also: The JCAHO Approach to Evaluation of Emergency Management (2006) by the New York City Department of Health and Mental Hygiene. Includes a listing of "possible mass casualty simulations" [HTML] {PDF}
