CMS-3228-F HTML , PDF , SUMMARY11/19/10 Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation To Ensure Visitation Rights for All Patients
Pg03 -Joint Commission to Review Its Telemedicine Requirements FYI: MD, This past May, CMS issued new telemedicine credentialing and privileging requirements, (to be effective July 5, 2011) that facilitated the credentialing process in a manner more aligned with the TJC approach. TJC is now reviewing its related standards in light of the CMS modification. No specific date yet for the TJC update.
Pg03 -Directory of Free Tools Available to Accredited Organizations [REF: JCSC] In recent months, TJC has unveiled a number of free compliance assistance tools to include the Leading Practice Library, BoosterPaks™, the Core Measure Solutions Exchange, and the Targeted Solutions Tool™. Leaders and QI/PI Directors should familiarize themselves with these resources. The article includes a chart on page 9 that provides a useful overview of each of the 4 tools and how to access them.
Pg04 -Correction: Standard MM.05.01.09, EPs 7 through 9 FYI: Phrm, RN. There was an error in the lead-in text for MS.05.01.09, EPs 7-9 that should have read “When preparing individualized medications for multiple patients…”
Pg04 -Clarification: Safe Use of Scribes in Clinical Settings [REF: IM, TxTm, MD] Although our hospitals rarely employ individuals for the primary purpose of being scribes, certain members of the treatment team sometimes approximate this role during the development of treatment plans. Those who have scribe-like responsibilities for the treatment team may find it useful to be aware of the definition of scribe and key principles related to that function provided in this article. Physicians and other LIP may find it useful to appreciate the limits of the scribe function and the necessity for them to properly authenticate (to include timing of entries if you use TJC for deemed status purposes). See also: TJC FAQ entitled: Use of Unlicensed Persons Acting as Scribes1106
Pg06 -Joint Commission Pledges Support for Partnership for Patients FYI: JCSC, The Obama Administration has launched the Partnership for Patients: Better Care, Lower Costs1106, a new public-private partnership that will help improve the quality, safety, and affordability of health care for all Americans. The Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly.
The two goals of this new partnership are to:
Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.
TJC hopes that its support of Partnership for Patients and other efforts by its Center for Transforming Healthcare will further advance healthcare toward becoming a high-reliability industry.
Pg02 -5 Sure-Fire Methods Complying with RI.01.01.01 FYI: JCSC, PtAd, StEd, On 11/19/10, CMS issued a new condition of participation to ensure patient visitation rights (CMS-3228-F1106) that became effective on January 18 of this year. One of the key points of the ruling was to eliminate limitations and/or discrimination in visitation, particularly those based solely on sexual orientation and gender identity. These requirements are addressed by TJC in standard RI.01.01.01, EPs 28 and 29. These EP were first slated for implementation in a pilot phase and depending on feedback from the field were to be fully implemented in “early 2012”. In that context, this article provides suggestions for compliance with those two EPs. Much of the advice is based on TJC’s earlier work on improving communication, cultural competence and patient/family-oriented care. It is captured in the monogram, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (PDF)1106. Your are strongly encouraged to review the Roadmap if you have not already done so. If nothing else, pay particular attention to pages 61-63 in Appendix C that specifically address the revisions to EPs 28 and 29 and provide self-assessment guidelines. Then review your visitation policies, patient satisfaction data related to visitation and consider any needed refinements of patient orientation and staff training that might be useful to refine your level of compliance.
Pg06 -Tracermethodology 101 Individual Tracer in a Mental Health Center Engaging Concepts from the New “Care, Treatment, and Services” Chapter[REF: JCSC, BHC] If you have an organizational component that is surveyed under BHC standards, then you should now be familiar with the new Care, Treatment and Services (CTS) chapter that recently replaced Provision of Care, Treatment, and Services” (PC) chapter in the BHC manual. You may have noticed that the chapter is largely organized in a manner that flows with a patient from entry into and through an organization. For that reason TJC believes it fits well with tracer methodology. This month the illustration focuses on a suburban mental health center providing group and individual counseling, substance abuse counseling, and medication management. The individual traced was a 62-year old female with serious mental illness and substance use. As always, the article encourages you to perform mock surveys similar to the one described and it provides a bit of the tracer flow (scenario) and sample questions.
Pg10 -Providing Information to Your Board [REF: JCSC, LDR, GB, PPR] This is a useful checklist of the standards that directly or indirectly require specific information to be provided to the governing body.
Pg01 -State of the Art: Hospitals Engage Technology to Improve Hand Hygiene, Part 1 of 2 FYI: IC, IT, LDR The state of the art being touted in this article is the use of radio frequency identification (RFID) technology. Four of the eight hospitals from TJC’s Transforming Healthcare Hand Hygiene Project also volunteered to participate in an RFID pilot. The goal was to address a couple of the common root causes for inadequate hand hygiene identified in the Center’s related Targeted Solutions Tool™ (TST). One of these was not collecting or reporting hand hygiene compliance data. As described in the article, “participants in each of the four hospitals received a badge that communicated with infrared sensors installed on hand sanitizer dispensers. When they pressed the dispenser while wearing the badge, a green light lit up to signal that they were washing their hands and thus, compliant. The technology stored data on workers’ compliance rates”. Although the current deficits facing most state hospital systems is not likely to allow for state of the art investments right now, the concept is worth being aware of. Hopefully the recession will eventually end and the future comes sooner than we think… especially when one has limited ideas or plans for it. See also: Patient-Centered Communication: Tips for the New Standards, The Source, Dec 2010
Pg02 -Patient Safety Pulse: Your Patient Safety News Suicide Rates Rise and Fall with Economy FYI: JCSC, In the first-ever study to compare age-specific suicide rates to U.S. business cycles, the rate of suicide in America rises and falls in relation to how well the economy is doing. The study, “Impact of Business Cycles on the U.S. Suicide Rates, 1928-2007,” was conducted by the CDC and released online by the American Journal of Public Health on April 14, 2011. The study found a significant link between suicide and economic downturn in Americans who were in their prime working years, ages 25 to 64. This underscores NPSG 15 and the need for particular attention to that population (by healthcare and the community in general) and additional suicide prevention measures when the economy weakens.
[Index] [Blog] Environment of Care News(June Vol 15 #6)
Pg01 -Ouch! I've Been StuckReducing the Likelihood of Sharps Injuries FYI: SFT, EOC, PI, LDR. This article highlights the efforts of Loyola University Medical Center (LUMC) to reduce/eliminate their most prevalent injuries, those related to sharps. This is part of its five-year “Journey to Zero”, a PI initiative to reduce, and ultimately eliminate, preventable employee injuries. Although sharps are not likely to be our highest volume injury issue, it is significant. The International Sharps Injury Prevention Society reports that “one out of every seven (healthcare) workers is accidentally stuck by a contaminated sharp each and every year”. For that reason, insights into the Loyola approach could be useful. Consider some of their ideas such as developing an electronic survey for any staff member injured by a sharp or their Safety Cross tool (page 3) for better tracking the number of injured staff. Beyond this, leaders may find it valuable to consider the concept of a five-year improvement initiative to significantly reduce (if not eliminate) whatever your preventable injuries are.
Pg06 -Nobody Likes It HotPreventing Heat Stress in At-Risk Workers FYI: StEd, HR, EOC,The first thing is to be aware of and identify patients and/or staff who may be at risk for heat-related injuries. Basically, this is anyone who might spend a significant amount of time outdoors. Then make sure those staff and relevant providers know the early warning signs and symptoms of the various heat-related conditions such as rashes, cramps, exhaustion, collapse and stroke. Know that obesity, hypertension, diabetes, heart disease, viral infections, gastroenteritis, pregnancy, and the use of antihistamines, diuretics, and certain psychotropic medications can make one more vulnerable to heat. A key take home point is that “Thirst can’t be relied on as a guide to the need for water. Instead, workers in a hot environment should drink water every 15 to 20 minutes. “. Additional suggestions for staff training are provided.
R2111CP: Outlier Reconciliation and other Outlier Manual Updates for the Inpatient Prospective Payment System (IPPS) - FYI: F&B
R2089CP: Implementation of edits for the Emergency Department (ED) adjustment policy under the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) - FYI: F&B
New hospital standard establishes 85 percent compliance rate for accountability measures FYI: JCSC, PI On January 1, 2012, performance expectations on accountability measures will be integrated into into accreditation standards. On that date, hospitals will be required to meet the new, direct impact requirement of standard PI.02.01.03, EP1 to achieve an 85% composite performance compliance rate for ORYX Accountability Measures (not the monthly ORYX performance measures). The composite rate is a single, calculated rate for all of your reported accountability measures. The details of that calculation is described in the article. It should be noted that after the effective date, failure to achieve the required composite rate will result in an RFI. How to address the RFI and consequences (including evaluation for Contingent Accreditation) for failing to meet the 85% rate are also described in the article.
New on Connect! Standards BoosterPak™ for assessing suicide risk[REF: JCSC, MDx, PI, SFT, StEd]TJC’s third Standards BoosterPak™, Suicide Risk (NPSG.15.01.01) is available via TJC Connect in the Quality Improvement Tools section. The 3-chapter, 7-section, 27-page document not only contains the usual explication of the requirement and definition of key terms, but also FAQs, insights into the surveyor assessment process, and a number of useful implementation/compliance suggestions and references. It is well worth reading, especially sections A1 (Implementation Suggestions), A2 (Assessing Compliance During the On-Site Survey), B1 (FAQ’s) and B3 (Proactive Risk Assessment)
