1 May 2008
ALL: Everybody, CHP: Chaplain, C&P: Credentialing & Privileging, E&M: Engineering & Maint, EOC: Environment of Care, FB: Finance/Business, FdDt: Food services/Dietary, GB: Gov Body, HR: Human Resources/Personnel, HST: Human Service Tech/Aid, IC: Infection Control, IM: Info Mgt/Med Records, IT: Info Technology, JCSC: Jt Com Survey Coordinator, LDR: Leadership/Mgt, MEC: Med Exec Committee, MD: Medical Staff, ofco: Officer and/or Committee, PI: Performance/Quality Improvement com/dept, PPR: PPR team mbrs/ldrs, P&T: Phrm & Therapeutics Com, Phrm: Pharmacy, PSY: Psychology, PtAd: Patient Advocate, PtEd: Patient Education, RHB: Rehab/Activity Therapy, RN: Nursing, SFT: Safety, StEd: staff ed & training dept, SW: Social Work, TxTm: Treatment Team, x: Exec, Dir or Chief (e.g., MDx = Medical Director)
.Refs: Assessing Risk
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations ( May 2008)
[Note: All of the 2008 issues of this publication have been significantly delayed. April is now the most current issue. When a more current issue becomes available it will be reviewed and posted.
- Accreditation
- Performance Measurement
- Public Information
- Updated sentinel event statistics Top 10 of reported SE's includes Suicide (#2), Med Errors (#4), Treatment Delay (#5), Falls (#6), Assault/Rape/Homicide (#7), Death/Injury in Restraints (#8)
- Communications
- Upcoming
- Free audio conferences Finally, they are back. Here are the first 3:
- Thursday, July 24 SII overview for home care organizations
- Monday, July 28 SII overview for hospitals and critical access hospitals
- Thursday, July 31 SII overview for ambulatory organizations and office-based surgery practices
- Save the date for the National Conference; conferences survey Joint Commission Resources’ 22nd Annual Conference on Quality and Safety, 11/19- 21/08 in Chicago {Info}
*Audio conferences usually begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Accredited facilities are sent call announcements about one week before a call. If you missed the call,there are several make up options: 1 - A replay may be available for 60 days afterward. 2 - A written 'Discussion Brief' or a call transcript is usually posted within two weeks. 3 - Download and listen to an MP3 when available. Access these options on the TJC Website, your Connect extranet or goto SHCC Calendar for date of missed call.
[Index] Perspectives (May, Vol 28 #5)
Pg01- The Joint Commission's Latest White Paper Urges Development of a National Performance Measurement Data Strategy: The new white paper, Health Care at the Crossroads: Development of a National Performance Measurement Data Strategy (PDF), was released by the Joint Commission March 6, 2008 and can be found in the TJC website in its Public Policy section. FYI: LDR and IT. The paper details 22 principles developed by an expert roundtable for developing a national PI data infrastructure and the following three broad strategies:
• Create the framework for a national performance measurement system
• Build a data highway to support the exchange of health information
• Engage stakeholders and engender trust by addressing concern over the privacy of personal health information. - by VK
Pg04- Approved: Approach for Establishing Target Measure Ranges for Performance Measure Reporting: [**REF**] Starting January 2009 TJC will use “target” measure ranges instead of national averages to show organization performance on hospital core measures. Since it will ultimately be reflected in your Quality Reports, IT, JCSC and LDR will want to understand the change and the implications as described in this article.
Pg05- Approved: Inclusion of a Clarification Validation Survey (CVS) as Part of the Appeal Process: Effective immediately, a facility attempting to remove itself from PDA using the clarification process will now undergo a CVS before any final decision is made. FYI: JCSC and LDR
Pg07- Update: MS.1.20 Implementation Task Force: Implementation of MS.1.20MEC has sparked significant controversy in the field. The TJC task force for analyzing and improving the implementation of MS.1.20 is to make recommendations to the board on 5/31/08. However, at the last board meeting both its charge and membership were refined. MDx, and LDR need to keep up with this issue and may find it useful to review the background provided in this article.
Pg08- Clarification: Process for Responding to a Complaint about a Joint Commission-Accredited Organization : Article provides a brief clarification of the process for responding (by you and TJC) to a complaint about your organization. FYI: LDR and JCSC
Pg09- Approved: Time Limits for Organizations to Eliminate an Immediate Threat to Life Situation: The time limit is 72 hours. Article provides additional details on the process and its relationship to PDA. FYI: LDR, MDx, JCSC.
Pg10- Update: Updated Speak Up™ Materials on Infection Control: IC and PtAd can go to TJC Speak Up to obtain brochures and posters for “Five Things You Can Do To Prevent Infection,” as well as other topics.
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[Index] The Source (May Vol 6 #5)
Pg01- Restraint and Seclusion Documentation: Complying with Standard PC.12.190: Although this article does not directly address restraint and seclusion it provides a good review of documentation principles for behavioral health care patients. Specific suggestions to improve documentation are provided for Physical Assessments, Psychosocial Assessments, Analysis Summary (aka integrated summary) and Problems/Needs list. [Click here for more details] TIP: You can expect that these suggestions are also examples of what surveyors will be looking for. In that context, this article (and the sample 2-page Interdisciplinary Care Plan provided in the online version) are well worth reading by anyone who provides chart documentation (e.g., TxTM, MD, RN, SW, Psy). - by VK
Pg03- Sustaining a Patient's Positive Self-Image: Keys to Standard RI.2.140: Most psychiatric hospital staff are well trained to address self-image and respect continuously as a basic component of recovery, so much of this article describes everyday practices. Areas covered include encouraging long-term inpatients or residents to create a home-like environment; ensuring that staff knock on doors and announce themselves before entering; avoiding the use of nicknames that can sound patronizing; and addressing elderly patients as “Mr” or “Ms” unless they specify otherwise. TIP: The final point probably is the most important reminder for psychiatric hospitals: staff must also treat coworkers with respect to create a a more pleasant, communicative workplace that can promote the positive self image of patients. FYI: StEd, Chp - by VK
Pg05- Continuity of Care: Access for the Next Caregiver and Standard IM.6.60: This IM article uses references for RN principles of documentation but is more generally applicable. It discusses requirements for tracking the location of all components of the medical record in electronic or paper formats. This involves developing a documentation system that can be used to assemble required information or make available a summary of information relative to the care provided, including outpatient clinics. Other items addressed include: the 2003 ANA Principles for Documentation (Info); development of Electronic Medical Record Systems; use of PDAs; sidebar list of The Nurse’s Role in Preserving the Medical Record; medication reconciliation; and reporting medication errors after discharge. - by VK See also ANA publications: Documentation, Part 1: Principles for Self-Protection and Documentation, Part 2: The Best Evidence of Care.
Pg08- Saint Joseph HealthCare Anticoagulant Safety: Meeting the Challenges of Standard MM.6.20: This is an overview of several initiatives to improve safety of anticoagulant therapy within the organization and to reduce the incidence of, and potential for, anticoagulation medication-related adverse events. TIP: The article includes approaches that may offer some ideas for psychiatric hospitals as they address NPSG 3E such as the use of a measurable indicator (rate of coumadin-related ADE's) to determine the effectiveness of NPSG 3E implementation. FYI: P&T, Phrm and those implementing 3E at your facility. - by VK See also NPSG Highlights page for Reference Articles on 3E
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[index] Patient Safety (May Vol 8 #5)
Pg01- Catching a Superbug: Screening Inpatients for Methicillin-Resistant Staphylococcus Aureus (MRSA): This is a good update for RN and IC on MRSA and effective approaches implemented at Loyola University Medical Center. Loyola attributes their success to three key elements: testing technologies, collaborative communication, and evidence-based resources. TIP: It is estimated that more than 7% of the US population has MRSA whether they know it or not. Each hospital needs to have clear guidelines to follow for positive cultures, including those who are colonized for MRSA but do not have an infection. - by VK [Note: In 2007 Illinois passed legislation requiring MRSA screening of 'high risk' patients. Their statewide IC comittee is developing a responsive policy. Check back later this month for a further update and possible sample policies]
Pg02- Patient Safety Pulse: The American Heart Association reports that two standard interventions for heart attacks are dangerous for patients who have recently used cocaine. - by VK
Pg05- Patient Safety Pulse: NPSG 3E aims to protect patients from anti-coagulant-related errors. This article focuses on Implementation Expectation 5 that requires organizations to make available a baseline INR for patients being started on warfarin therapy and to keep available a current INR for all patients receiving warfarin. TIP: RNx, StEd, P&T and Phrm should consider incorporating this info into their educational support of NPSG 3E implementation as required by expectations 9 and 10. Remember the next phase-in “milestones” for 2008 is July 1st. - by VK See also NPSG Highlights page for Reference Articles on 3E
Pg10- Influenza Vaccinations for Geriatric Patients: Risks, Benefits, and National Patient Safety Goal 10: This provides an up to date discussion about influenza and vaccination. Recent studies have reported that vaccinating elderly patients may not be as effective as previously thought in preventing death among the elderly; however, the vaccine provides substantial protection against complications that can result in hospitalization and death. Along with the CDC and CMS, the Joint Commission recommends flu vaccine for adult residents and staff in long term care and assisted living facilities as well as anyone 50 years of age or older. TIP: IC and JCSC should review the 5 "Key Steps for implementing NPSG 10 provided in this article. There is also a useful sidebar summarizing which patients are most at risk. - by VK See also Centers for Disease Control and Prevention. Seasonal flu shot questions & answers
[Index] Environment of Care News (may Vol 11 #5)
Pg01- EC Standards Interpretation Update: Senior Engineer in Standards Interpretation Group Shares News, Clarifications, and Insights: George Mills is the senior engineer in TJC's Standards Interpretation Group. EC and SFT will want to pay particular attention to the clarifications and interpretations he offers in this article on a variety of subjects to include:
• Damper Inspection Extension (changed from 4 to 6 years) (EC5.40)
• Combining Emergency Power Tests (EC.7.40)
• Use of Expanding Foam Insulation Replacing
• Old Firestop Materials
• Sprinkler Piping: Not a Support (for electrical wires)
• Sprinkler Heads in Elevator Mechanical Rooms
• Foam and Alcohol-Based Hand Rub (both acceptable) see also 4/06 EC news, pg 11)
• Corridor Clutter
• 96 Hour Emergency Operations Plans (EC.4.12)
• Missing EC Documentation Concerns (addressed under LD.2.20)
• Effective Environmental Tours (EC.1.20)
Pg06- Assessing Risk: Proactively Identifying and Responding to Hazards Within the Environment of Care: [**REF**] For EC and SFT this is a good review of the risk assessments expected under the EC standards. Article includes a suggested approach to pro-active risk assessment. Tip: Establish a specific process for risk assessment that will assure its consistency, comprehensiveness and appropriate responses to identified risks.
Pg08- When Medication-Related Technology Doesn't Work Correctly: This is the same article published earlier this year in Patient Safety but it lacks the sidebar included in March. Here is our earlier review again:
Notes from the Field: When Medication-related Technology Doesn't Work Correctly Useful discussion of key considerations for organizations evaluating or implementing various medication-related technologies (e.g., CPOE) IT, Phrm, P&T should note the encouragement for developing more awareness about health care informatics and the related references/resources provided. Also check out the Sidebar: Mitigating Risks During the Medication Management Process. (Patient Safety, March 2008, Vol8#3 pg3)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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INTERNET HIGHLIGHTS
National Association of State Mental Health Program Directors (NASMHPD)
SHCC Additions
- SL1: SL1- 1040.20 NPSG 16: Establish Criteria for Activating the Rapid Response Team {HTML}
- SL1: 1310.04 MS - Core/Bundled Privileges: TJC FAQ ( NEW! April 2008)
- SL1: SL1- 1120.02- PC - 3/14/08 new waived tests (PDF)
- SL1: SL1- 1040.20 NPSG 13: Patient Involvement (and communication) {Info}
- SL3: Joint Commission Resources: (Good Practices Database) - JCR accepted policies, procedures and forms (e.g., falls, critical tests, etc.)
- DIS: Get more out of our Discussion Board! Read the updated tips at the bottom of the DB homepage and bookmark this shortcut: www.shccDiscuss.com
- EL: Following courses at 50% discount (code MAY08) during May: Adolescent Suicide, Anxiety Disorders: Diagnosis and Treatment and Overview of Mental Health Issues in Older Adults {Instructions}
- DYN: Did You Know? Vol1 #3: Clinical Decision Support & Medication Error Reduction
- FdBK: New feature! 15-second Feedback re: The Did You Know Column
Recent Member Surveys (SL5)
- 2008/01-tjc- LIncoln Regional Center (LRC) [PSQ - pending]
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F&A
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