The Joint Commission Requirements (Hospital) (BHC) For all standards revisions published in Perspectives since last issuance/update of the accreditation manual. Often includes full text articles.
Miscellaneous(e.g., Accreditation-Related Consulting Services, External Evaluations, Early Survey Policy Option (ESP), Federal Requirements, Performance of SurveyPeriodic, Representation of Accreditation Status, Reporting of Safety and Quality Concerns, Submission of Information to The Joint Commission, Survey Observations)
§Clarifications(Relevant definitions, interpretations, how to advice, etc)
Accreditation Manager Plus{Info1/2/10} By Joint Commission Resources “An Interactive Toolkit for Continuous Compliance”
J Repository {Info/Demo1/2/10} By Expediate “… a complete set of software modules designed by experienced healthcare consultants to keep your facility in continuous compliance with JCAHO accreditation standards - assessments, quality standard policy manuals, patient event reporting, business processes and corrective action plans are all integrated into a single software application.”
VSurvey{Info/Demo1/2/10} By VergeSolutions “… is a web based software system for managing continuous compliance with the JCAHO Shared Vision-New Pathways Standards.”
Performance Measurement/ORYX
§Clarifications(Relevant definitions, interpretations, how to advice, etc)
o[DL_EM03] 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" (NYemEval -PDF) [NYemEval HTML]
[••REF••] Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care - Workforce Development Curriculum 20091002, Overview Presentation of Curriculum(PDF)1002. This is an excellent NASMHPD/NTAC tool for providing frontline staff with knowledge and skills to support patient-centered care. Includes PowerPoint slides, instructor notes, objectives, post-tests, exercises, video and references
II. Licensed Independent Practitioners (NA for Hosp)
The Five Functions of Management - Ohio State University Extension - Useful review in this extension course that closely parallels the 5 leadership functions in 2009 TJC standards
Decision Tree forDetermining Culpability of Unsafe Acts{PPt}1008 "Use this decision tree when analyzing an error or adverse event that has occurred in your organization, as it may help you identify how human factors and systems issues contributed to the event. This decision tree is particularly helpful when working toward a non-punitive approach in your organization." Click here for instructions/definition of the 'Pass Substitution Test1008' box of the decision tree. [Reason, J., Manageing the Risks of Organizational Accidents]
The Swiss Cheese Model1008 - based on James Reason work that illustrates how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard [Human error: models and management. BMJ. 2000;320:768-770
§Clarifications (Relevant definitions, interpretations, how to advice, etc)
JCO 1/12/11New BoosterPak on MS.08.01.01 and MS.08.01.03[REF: JCSC, MDx] TJC developed BoosterPaks to provide (facilities and surveyors) greater understanding and tools/suggestions for improved compliance on complicated standards. The second Standards BoosterPak™ focusing on MS.08.01.01 (Focused Professional Practice Evaluation) and MS.08.01.03 (Ongoing Professional Practice Evaluation) has been released, but is only available on The Joint Commission Connect extranet.
[SL_MS08]Ongoing Professional Practice Evaluation (OPPE) – [OPPE Form] Contrib by ELMHS
[MS_1A3j]Morbidity and Mortality Conference, Grand Rounds, and the ACGME’s Core
Competencies [HTM1007] (PDF1007) by Steven J. Kravet, MD, Eric Howell, MD, Scott M. Wright, MD of the Johns Hopkins University School of Medicine
IX. Acting on Reported Concerns About a Practitioner
X. Fair Hearing and Appeal Process
XI. Licensed Independent Practitioner Health
§Clarifications (Relevant definitions, interpretations, how to advice, etc)
·ISMP Error-Prone Abbreviatons List1001. A comprehensive, printable two-page list of abbreviations, symbols, and dose designations that should NEVER be used in medical communications.
·Brochure on Error-Prone Abbreviations1001. Outlines the scope of the problem and provides a short list of some of the most common and dangerous error-prone abbreviations and recommendations for medical professionals, the pharmaceutical industry, and medical communications professionals. Click here to order copies for distribution within your organization.
·Abbreviations Poster1001. This 17x24 poster can be used in healthcare professional staff areas to remind them of the importance of eliminating error-prone abbreviations. Click here to order copies.
·Abbreviations Slide Set1001. This brief presentation can be used as a stand-alone educational presentation for staff meetings or conferences, or incorporated into an existing program on medication safety.
·FDA Patient Safety Video1001. Use of this brief video is not restricted in any way, and the FDA encourages its further use and distribution as part of educational presentations or training. The video can be viewed either over the Internet(using Windows Media or RealPlayer) or downloaded (MPEG file). A written transcript is also provided.
IIIGoal 3 – Improve the safety of using medications
·§Clarifications (Relevant definitions, interpretations, how to advice, etc)
·[**REF**] Reducing anticoagulation-related adverse drug events: Closely monitoring and managing risks for patients on warfarinin Joint Commission Perspectives on Patient Safety 6:3–4, Jul. 2006.
·Clean Hands Save Live Campaign1001 {VK}The Clincial Excellence Commission, New South Wales, Australia has put together an excellent set of hand hygiene resources to include the following PDF fact sheets suitable for use as posters:
VIIIGoal 8 – Accurately and completely reconcile medications across the continuum
of care.
§Clarifications (Relevant definitions, interpretations, how to advice, etc)
[**REF**] Perspectives October '09 Vol 29 #10Pg01- Approved: 2010 National Patient Safety GoalsNPSG 8 is still being evaluated/refined, is not included in these changes and is not being scored during survey (refer to March RTN review below for more details).
·[*REF*] Joint Commission Perspectives on Patient Safety, Volume 7, Number 8, August 2007 Pg08- Improving Early Recognition and Response to Patient Changes Empowering staff to act quickly to prevent cardiac arrest -
·[**REF**]Patient Safety, Vol8, #6, June, 2008 Pg09-Implementing the Stroke Alert Program at Lutheran General
Brief Psychiatric Rating Scale1103(BPRS) "is an instrument originally developed to characterize psychopathology and to measure change in clinical psychopharmacology research. It permits the recording of severity of 18 (originally 16) distinct signs and symptoms of psychopathology based on clinical interview of a patient".- BPRS Overview 1, BPRS Overview 2
BPRS–18: An abbreviated version of the Brief Psychiatric Rating Scale (18 items)
BPRS-24: An abbreviated version of the Brief Psychiatric Rating Scale (24 items)
Motivation Assessment Scale (MAS)1011Description: The MAS is a sixteen item questionnaire, organized into four categories of reinforcement (attention, tangible, escape, and sensory), that assesses the functions or motivations of behavior problems. It is quick and easy for staff and/or Pts to use. Created/Provided By: V. Mark Durand, Ph.D., and Daniel B. Crimmins, Ph.D. Sample MAS Form (PDF)1011 , Sample MAS Scoring Sheet (PDF)1011 , WebMAS1011 ,
Pella Regional Health Center Uses Lean Methodology to Design Innovative Shift-Change Tool: If SBAR is not your cup of hand-off communication tea, RN leaders may want to try INFORM. Approach is reasonably relevant for Psych hospitals. Sample form included in article. Source, June 2007, Vol5#6 pg9
Perpspectives, April 2010, Vol 30, #4, Pg08-Update: Progress at The Center for Transforming HealthcareFYI: JCSC, LD, GB and PI. Since it began in September 2009, we have been following the Center For Transforming Healthcare (CTH) in TJC articles. CTH was announced in November and in December its first product, a 'Booster Pak' for MM.03.01.01 (Safe Medication storage/labeling) was unveiled. This article provides a brief update on three other projects currently in process related to Hand Hygiene, Hand-off Communications and Wrong-Site Surgery. In the third quarter of this year, fruits of the hand hygiene project should be rolling out. The article says this will include a free, new application that can customize a set of solutions based on your organization's specific demographics. The concepts of Robust Process Improvement (RPI) and Lean Six Sigma (L6S) were prominently featured. LD, GB and PI are again strongly encouraged to familiarize themselves with RPI and L6S.ALERT: IC. SPHCC conducted a phone interview with Rick Morrow (director of Business Excellence at The Joint Commission) and Paul Shuyve, MD, (psychiatrist and Sr. Vice President at TJC) about the center and its projects. There are no psychiatric hospitals currently involved in the center's projects. However, Mr. Morrow offered a special invitation to any of our members who might be interested in participating in the last phase of the pilot experience for the Hand Hygiene project. Contact him quickly to see if he can work you in. He and Dr. Shuyve were certainly open and interested in having psychiatric hospital participation. And, at the pilot level, it is not necessary for an organization to be particularly expert in RPI. Dr. Shuyve pointed out that the new application referenced above is designed to help organizations that may not necessarily have the expertise to take advantage of RPI technology . He says the application's database is cause vs. solution based. So, if an organization can identify the cause(s) of their issue of concern, the application can assist them in navigating to appropriate solutions. TJC is definitely moving deeper into RPI, but Dr Shuyve assures us that while RPI will be encouraged, it is not likely to be a requirement for accreditation. As a beginning point for greater familiarization with RPI, we have requested permission to obtain and share the center's RPI Roadmap. We should be able to let you know how to get a copy soon. You can contact Mr. Morrow at 630/792-5239 or rmorrow@jointcommission.org or learn more online about the Center For Transforming Healthcare.
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.
For more on RPI and TJC see: Sustaining the Improvement We Need by Mark R. Chassin, MD (11/6/08) [especially slides 16-21] [HTML] (PDF)
