15 Jan 2012    2012 Reading Tips - January State & Psychiatric Hospital Compliance Collaborative's Reading Tips Newsetter (RTN) January 2012, Volume 6, Issue 1 ••Happy New Year! New for the Reading Tips Newsletter (RTN) Review Compilations (RC) - Our best reviews on a selected topic for more depth, quickly All reference article reviews include Tips and are presented in a new 'up front' section Highlights for Psychiatric Hospitals - Monthly highlights from the RTN at no charge More (BHC) tagging to identify articles relevant to community mental health programs New & Returning SPHCC Features MiniWEbNRs - 30-minute lunchtime presentations with Q&A return next month. Suggest Topics. Topical Blogs - The Discussion Board is updated and returns as a blog with RSS feed! Request the February update for your Free Custom Resource Page - 3 Topics updated 3x per yr New SPHCC membership options being developed for July 2012 Updated SPHCC website to launch in July 2012 ••REFS: PR: Joint Commission to Pilot Test New Intracycle Monitoring Process [REF: JCSC, Ldr] PR: Accepted: Final Revisions to Telemedicine Standards [REF: JCSC, MDx] TS: Tracer Methodology 101: Infection Prevention and Control System Tracer [REF: IC, RNx, JCSC] TS: Creating/Implementing a Utilization Review Plan: CMS Expectations & LD.04.01.01 [REF: UrUm, JCSC] TS: Standardizing Processes Based on Clinical Practice Guidelines [REF: P&T, MDx, RNx] TS: Accountability Measure Requirements for 2012 [REF: JCSC, PI, IM, LDR] EC: Top Challenging Standards:Tips/Reminders for Compliance in EC, EM, and LS [REF: EOC, E&M, JCSC] ••PEARLS: Hospital Checklist and C&P Agreement for Telemedicine Entitites (MDx) Definition: Clinical Practice Guidelines (MDx) Compliance Question of the Month (CQM): ••DOWNLOADS: LGBT Community Field Guide CMS Transmittal # R78SOMA: Revised Appendix A, Interpretive Guidelines for Hospitals (12/22/11) WHO Patient Safety Curriculum Guide Summary of Clinical Practice Guidelines We Can Trust (MDx) Table of Accountability Measures Clinical practice guideline for eating disorders (BHC) Clinical practice guideline for schizophrenia and incipient psychotic disorder (MDx) 2012 Survey Activity Guide (JCSC, LDR, PPR) See also [Ftxt] and Full Text Articles below Publication Color Key: Perspectives (PR), The Source (TS), and Environment of Care News (EC), Joint Commission Online (OL) The above is a sample of our free newsletter extract highlighting key articles and aids for compliance relevant to psychiatric hospitals. It is part of our reading service to save you time by weeding through official TJC and CMS publications (and websites) to find what is most useful for our specialty hospitals. Due to copyright restrictions, we cannot provide the articles in the REFS section, but we can tell you which ones are important and where to find them. You can also take advantage of the free references, guides and other tools available in the download section of this extract. Please CLICK HERE TO SUBSCRIBE and receive this publication on a monthly basis. [Note: Our full newsletter provides reviews and summaries of these articles and access to the PEARLS.] Fields & Associates, Inc. 150 St. Marks Drive, Suite 202, Stockbridge, GA 30281-1091, 770.389.3800. CustomerService@fieldsinc.com   15 Dec 2011    2011 Reading Tips - December Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Dec 2011 ••WHAT'S NEW: CMS: Survey and Certification Letter 12-05 - Update of the medication 30-minute rule 2011 Wrap-Up: SPHCC Member Christmas Gift: Click Here Take the SPHCC: 2011 Improvement Survey (5-minutes, 6 Questions) Request your Free 2011 Custom Resource Page - 3 Topics (TJC and/or CMS ) updated 3x per year Coming in 2012: MiniWEbNRs and the Discussion Board features will return Enhance Reading Tips Newsletter (RTN) for mbrs & L2 Assoc only. Free Highlights for non-mbrs & L1 Assoc ••REFS: PR: Joint Commission Revises Influenza Vaccination Standard: Applicability Extending to All Accreditation Programs in 2012 JCSC, IC, LDR, RNx, MDx TS: Immediate Threat to Health and Safety: Complying with APR.09.04.01 JCSC, LDR, SFT TS: 5 Sure-Fire Methods: Complying with WT.03.01.01 JCSC, RNx, HR PS: Up to the Minute: Ensuring Timely Reporting of Critical Test Results MDx, RNx, Lab PS: Effective Relationships: Key to Safety in a Complex Environment LD, HR, StEd, MDx, RNx EC: Coffee with the Crew: Bringing Together Senior Leadership and Facility Management Staff to Discuss Facility Needs : EOC, EM, SFT OL: Sentinel Event #48 - Staff Fatigue MDx, RNx, StEd ••PEARLS: The epidemiology IC.02.04.01 Voice-Over-Powerpoint presentation (approx 25 min) CMS definitions of 'Time-Critical' medication ••DOWNLOADS: TJC 'Flu Myths' Tool for Staff Education CMS Updated Guidance on Medication Administration (30-Min Rule) Sentinel Event Alert #48 ACGME 2011 Duty Hour Standards (Monogram) See also [Ftxt] and Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   9 Nov 2011    2011 Reading Tips - November Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Nov 2011 ••WHAT'S NEW: TJC Intracycle Monitoring (IM) Process Pilot: JCSC, PI, LDR CMS–3244–P: Proposed Reform of Hospital Conditions of Participation (10/24/11): JCSC, LDR, MDx, RNx Please take the SPHCC: 2011 Improvement Survey (5-minute, 6 Questions) Request your Free 2011 Custom Resource Page - 4 Topics (TJC and/or CMS ) updated 3x per year ••REFS: The 'must review and should read' articles for this month!  PR: Joint Commission Adds Accountability Measures for 2011: JCSC, PI PR: Communication and Patient Assessment Remain Primary Factors in SEs: JCSC, PI, LDR TS: Complying with Pain Management Standard PC.01.02.07: RNx, RN, MDx TS: Complying with Standard CTS.02.01.11 for Behavioral Health Care: BHC, FdDt MDx, RNx TS: Calculating Your Composite Performance Rate for Accountability Measures: JCSC, PI TS: Second Generation Contracted Services Tracer in a Hospital : JCSC, LDR, MDx PS: Overcoming Medication Reconciliation Challenges: MD, RN, PtEd PS: Preventing Suicide Among Adolescent Patients: PSY, MDx, RNx, PtEd, BHC CMS: CMS–3244–P: Proposed … Hospital Conditions of Participation: JCSC, LDR, MDx, RNx, Phrm, P&T ••PEARLS: NIH Pain Intensity Scales, Teen suicide risk screening tool CMS Draft Surveyor Worksheets for D/C Planning, IC and PI ••DOWNLOADS: TJC’s 2011 Annual Report TeenScreen Screening Questionnaire Overview See also [Ftxt] and Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   18 Oct 2011    2011 Reading Tips - October Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Oct 2011 ••WHAT'S NEW: Free Book Marking of CMS/TJC Crosswalks (Members only) Request your Free 2011 Custom Resource Page (Sample) - 4 TJC and/or CMS Topics updated 3x per year ••REFS:  The 'must review and should read' articles for this month!   PR: No PPR Submission Required in Year of the Triennial Survey  PR: Top Standards Compliance Issues for First Half of 2011 TS: 101 Data Use System Tracer EC: Questions About Proper Storage ••PEARLS: Useful nuggest picked out of this month's most relevant articles Survey Readiness Toolkit & Checklist  • Green Resources for Hospitals  15 all-hazards planning vignettes • NFPA FAQs Dehydration Management P&P/Assessment   •  MDRO Education Resources   INR Interaction Table  •  Quality and Safety Education for Nurses(QSEN) ••DOWNLOADS: Helpful resources and references from the internet at no cost Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities Toronto Best Practices Initiative for a Hydration Management Policy & Procedure Management of Multidrug Resistant Organisms in Healthcare Settings, 2006 See also [Ftxt] and Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   8 Sep 2011    2011 Reading Tips - September Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Sept 2011 ••WHAT'S NEW: Standards BoosterPak™ for assessing Suicide Risk Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per year ••REFS: PR: 2012 Accreditation and Certification Decision Rules TS: Complying with IM.02.02.01 TS: Tracer Methodology 101: Tracing Pain Management TS: Survey Readiness Checklist PS: Sentinel Events: Preventing Violence in the Health Care Setting EC: Supporting Safe Equipment: A Closer Look at Preventive Maintenance Strategies ••PEARLS: Definition of Immediate Threat to Health or Safety ••DOWNLOADS: Improving the Quality of Care Through Pain Assessment and Management. See also Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   18 Aug 2011    2011 Reading Tips - August Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Aug 2011 ••WHAT'S NEW: Special Report! The Joint Commission's 2012 National Patient Safety Goals Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per year ••REFS: PR: New Standards BoosterPak Available for Assessing Suicide Risk PS: Special Report! The Joint Commission's 2012 National Patient Safety Goals EC: Training for an Active Threat in a Health Care Organization ••PEARLS: Stages of Maturity in Health Care Organizations' Path To High Reliability 2012 NPSG Applicability Table ••DOWNLOADS: Standards BoosterPak™, Suicide Risk (NPSG.15.01.01) See also Full Text Articles (6) below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   20 Jul 2011    2011 Reading Tips - July Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Jul 2011 ••WHAT'S NEW: Welcome Back 9 Illinois State Hospitals! - Your first Custom Resource Pages are now available Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per year ••REFS: TS: Implementing Revised Standards Aligned with CMS Requirements TS: Prioritizing Risk: Complying with Standard IC.01.03.01 EC: Options for Evaluating Environmental Cleaning ••PEARLS: Sample IC Risk Prioritization Tables ••DOWNLOADS: WHO Report on the Burden of Endemic Health Care–Associated Infection Worldwide See also Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   14 Jul 2011    2011 Reading Tips - June Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Jun 2011 ••WHAT'S NEW: Standards BoosterPak™ for assessing Suicide Risk Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per year ••REFS: PR: Directory of Free Tools Available to Accredited Organizations PR: Clarification: Safe Use of Scribes in Clinical Settings TS: Five Sure-Fire Methods for Complying with RI.01.01.01 TS: Tracermethodology 101 Individual Tracer in a Mental Health Center TS: Providing Information to Your Board JO: New on Connect! Standards BoosterPak™ for assessing suicide risk ••PEARLS: Directory of Free Tools Available to Accredited Organizations Keeping Your Hospital Property Smoke-Free: Successful Strategies for Effective Policy Enforcement and Maintenance, ••DOWNLOADS: Standards BoosterPak™, Suicide Risk (NPSG.15.01.01) Keeping Your Hospital Property Smoke-Free: Successful Strategies for Effective Policy Enforcement and Maintenance1106., CMS-3228-F HTML , PDF , SUMMARY 11/19/10 Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation To Ensure Visitation Rights for All Patients See also Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   20 May 2011    2011 Reading Tips - May Click above for full newsletter Psychiatric Hospitals Compliance Highlights: May 2011 ••WHAT'S NEW: Second Generation Tracers are being introduced - Review the three related reference articles below. Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per year ••REFS: PR: TJC Top Standards Compliance Issues for 2010 PR: 2nd Generation Tracer Methodology: Detailed Exploration of High-Risk Areas TS: 2nd Generation Tracer Methodology: A Closer Look TS: 2nd Generation Tracer for Cleaning, Disinfection, and Sterilization of Equipment TS: Complying with MS.08.01.03 EC: Preventing Suicide in Non-Behavioral Health Care Units ••PEARLS: The epidemiology and prevention of suicide: A systematic review, Environmental Risk Checklist ••DOWNLOADS: FPPE/OPPE BoosterPak, TJC-LPL: FPPE OPPE Policy, TJC-LPL: Physician Performance Toolkit , See also Full Text Articles below [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   18 Apr 2011    2011 Reading Tips - April Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Apr 2011 ••ALERTS: Drs. Chassin/Loeb article focuses on high reliability and health care Federal Register: Approval of TJC for Deeming Authority for Psychiatric Hospitals Request your Free 2011 Custom Resource Page - 3 TJC/3CMS Topics updated 3x per yr ••REFS: PR: New Core Measure Solution Exchange PR: New Standards BoosterPak Available for Medical Staff Evaluations TS: Tracer Methodology 101 The Patient Flow Tracer in a Hospital ••DOWNLOADS: FPPE/OPPE BoosterPak, Pt Flow Tracer Worksheet, Tdap Vaccination Strategies for Adolescents and Adults, Including Health Care Personnel, Guideline for Isolation Precautions See also Full Text Articles below. [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   15 Mar 2011    2011 Reading Tips - March Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Mar 2011 ••ALERTS: Free 2011 Custom Resource Page for all SPHCC Members: Identify your top CMS and TJC issues and we will pull relevant materials from the SPHCC libraries onto a customized resource page for your facility. Click here to schedule your set up. ••REFS: TS: Minimizing Physical Holding of Children and Youth TS: Individual Medication Management Tracer in a Hospital PS: Medication Reconciliation: Complying with NPSG.03.06.01 EC: Tracing the Environment of Care … Identifying Safety Risks and Compliance Issues ••DOWNLOADS: Standards Revisions Related to the Centers for Medicare & Medicaid Services CoPs Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care- A Roadmap for Hospitals Therapeutic Crises Intervention (TCI) Bulletin Wisconsin Hospitals Guide for Mass Casualty Events & Disaster Documentation Short Forms Guide to the United Nations Globally Harmonized System of Classification and Labeling of Chemicals See also Full Text Articles below. [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   15 Feb 2011    2011 Reading Tips - February Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Feb 2011 ••ALERTS: JCO: Field review: performance expectations for ORYX accountability measures JCO: New R3 Report details rationale/research behind Joint Commission requirements ••REFS: TS: Person-Centered Approach New Standards Chapter for Behavioral Health Care TS: Status Check Are You Prepared to Meet Revised MS.01.01.01? TS: Tracer Methodology 101 Conducting a Quality Improvement Expertise/Activities Tracer TS: Top Identified Causes of Hand Hygiene Failures EC: It All Starts with a Good Plan Master Planning Creates a Road Map for Change JCO: R3Report Issue 1, focuses on Patient-centered communication standards for hospitals. ••DOWNLOADS: Hand Hygiene Project : Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project Pressure Ulcer Prevention Quick Reference Guide Braden and Norton scales for Pressure Ulcers The Johns Hopkins Fall Risk Assessment Tool The Morse Fall Scale The Schmid Fall Risk Assessment Tool The Hendrick Fall Risk Assessment Application of risk management for IT networks incorporating medical devices—Part 1: Roles, responsibilities, and activities Home Health Quality Improvement National Campaign Best Practice Intervention Package - Fall Prevention See also Full Text Articles below. [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   31 Jan 2011    2011 Reading Tips - January Click above for full newsletter Psychiatric Hospitals Compliance Highlights: Jan 2011 ••ALERTS: EC: Field review: proposed performance expectations for ORYX accountability measures ••/REFS: PR: Approved: Modifications to National Patient Safety Goal on Reconciling Medication Information PR: Sentinel Event Alert A Follow-up Report on Preventing Suicide EC: Refined Decision Categories Approved Accreditation and Certification Category Modifications in Effect January 1, 2011 EC: Requesting Life Safety Extensions and Equivalencies A Brief Outline of the Submission Process JCo: New BoosterPak on MS.08.01.01 and MS.08.01.03 ••PEARLS: Joint Commission Releases Innovative Leading Practice Library, ••DOWNLOADS: Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Hand Hygiene TST (HH-TST), The PFI Change Request & Equivalency Request Information [Perspectives (PR) - The Source (TS) - Patient Safety (PS) - Enviorment of Care News (EC)]   26 Dec 2010    2010 Reading Tips - December   22 Nov 2010    2010 Reading Tips - November   19 Nov 2010    2010 Reading Tips - October   16 Sep 2010    2010 Reading Tips - September   23 Aug 2010    2010 Reading Tips - August   15 Jul 2010    2010 Reading Tips - July   3 Jun 2010    2010 Reading Tips - June   17 May 2010    2010 Reading Tips - May   5 Apr 2010    2010 Reading Tips - April   2 Mar 2010    2010 Reading Tips - March   1 Feb 2010    2010 Reading Tips- February   4 Jan 2010    2010 Reading Tips - January   30 Nov 2009    2009 Reading Tips - December   2 Nov 2009    2009 Reading Tips - November   5 Oct 2009    2009 Reading Tips - October   2 Sep 2009    2009 Reading Tips - September   3 Aug 2009    2009 Reading Tips - August   6 Jul 2009    2009 Reading Tips - July   5 Jun 2009    2009 Reading Tips - June   4 May 2009    2009 Reading Tips - May   1 Apr 2009    2009 Reading Tips - April   4 Mar 2009    2009 Reading Tips - March   2 Feb 2009    2009 Reading Tips - February   4 Jan 2009    2009 Reading Tips - January   3 Dec 2008    2008 Reading Tips - December   5 Nov 2008    2008 Reading Tips - November   6 Oct 2008    2008 Reading Tips - October   2 Sep 2008    2008 Reading Tips - September   1 Aug 2008    2008 Reading Tips - August   1 Jul 2008    2008 Reading Tips - July   3 Jun 2008    2008 Reading Tips - June   1 May 2008    2008 Reading Tips - May   1 Apr 2008    2008 Reading Tips - April   2 Mar 2008    2008 Reading Tips - March   1 Feb 2008    2008 Reading Tips - February   2 Jan 2008    2008 Reading Tips - January   2 Dec 2007    2007 Reading Tips - December   3 Nov 2007    2007 Reading Tips - November   1 Oct 2007    2007 Reading Tips - October   3 Sep 2007    2007 Reading Tips - September   30 Jul 2007    2007 Reading Tips - August   1 Jul 2007    2007 Reading Tips - July   1 Jun 2007    2007 Reading Tips - June   8 May 2007    2007 Reading Tips - May   31 Mar 2007    2007 Reading Tips - April   4 Mar 2007    2007 Reading Tips - March   1 Feb 2007    2007 Reading Tips - February   8 Jan 2007    2007 Reading Tips - January

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