3 Jun 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)
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***Password/Bookmark Updating*** An upgrade of the SHCC log in process will go into effect July 1, 2008. This will allow customized, easier-to-remember bookmarks for each state along with a new password. Please contact your hospital representatives for the new password after June 23, 2008
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations ( June 2008)
[Note: All of the 2008 issues of this publication have been significantly delayed. June is now the most current issue. When a more current issue becomes available it will be reviewed and posted.
*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. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
[Index] Perspectives (June , Vol 28 #6)
Pg01- Alert: Change in Compliance Expectations for Emergency Management Standards This article addresses new EPs announced in June 2007 for hospital, long term care, critical access hospital, and Medicare/Medicaid certification-based LTC. It differentiates nine EPs that required compliance by January 1, 2008 and 15 EPs required as soon as possible but no later than December 31, 2008. FYI: JCSC, LDR, PPR, SFT - by VK Pg07- Update: New Speak Up™ Materials on Understanding Your Doctor—Joint Commission Campaign Urges Patients to Take an Active Role in Their Health Care FYI: PtAd, PtEd, The latest release is entitled 'Understanding Your Doctors and Other Caregivers' (Info/Brochures/Etc). - by VK
Pg08- Approved: Requirement for Accredited Nursing Homes to Notify the Joint Commission When They Become a Special Focus Facility Effective immediately, the requirement (new EP 3 of APR 1) is for nursing homes (JCSC, LDR) to notify Joint Commission before the designation is publicly announced by CMS. The Special Focus Facility” initiative (SFF) identifies nursing homes with "a history of serious quality issues" and supports them with a program to "stimulate improvements…" - by VK
Pg10- The Joint Commission's Latest Report Provides Tool to Assess and Overcome Language, Cultural Barriers This past April, the Joint Commission released a report based on findings from a multi-year study* of sixty hospitals. The report entitiled “One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations.” focuses on four specific areas to help develop strategies to better address diversity. LDR, JCSC, PtAd and others can obtain the report (PDF) or a podcast (MP3) - by VK
* Also see the study: Hospitals, Language, and Culture: A Snapshot of the Nation (PDF), (TJC Info) (Summary) - by VK
Pg11- Update: Standards Improvement Initiative—Organizations to Receive Free Electronic Manual The 2009 accreditation program manuals will be available electronically as “E-ditions”, beginning in November 2008. In addition to the customary free copy of the print manual, organizations will receive one free e-dition which can be upgraded to a site license for a fee. For more information go to: http://www.jointcommission.org/Standards/SII - by VK
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[Index] The Source (June Vol 6 #6)
Pg01- Standards Improvement Initiative Update: Eliminating the Mystery FYI: JCSC, LDR, PPR. This article gives a thorough overview of the changes and includes timelines for various manuals. Beginning in July ’08, the revised standards and elements of performance (EPs) will be posted on the TJC website. There are three major changes:
1. Standards are re-organized into various chapters, numbering is changed, Category “B” EPs are eliminated, and language is simplified.
2. Scoring is replaced by a new decision process that focuses on critical standards and EPs. The survey report will not have a supplemental section. (Note: A sidebar on pg 3 clarifies the new Decision Process.)
3. Comprehensive accreditation manuals will be available in an electronic format that is searchable and will available for hospitals in November,’08. - by VK
Pg04- The Response to an Adverse Drug Event: Complying with Standard MM.6.20 An Adverse Drug Event (ADE) is defined as "an injury resulting from a medication either because of a pharmacological reaction to a normal dose or because of a preventable adverse reaction to a drug resulting from an error", such as incorrect dose, inappropriate prescribing, etc. The discussion explains ADE requirements of MM.6.20 and includes both long-term and short-term strategies that can assist organizations to comply. Although “blame-free” error reporting is encouraged, the author points out that that incident reporting alone may not provide adequate assessment of adverse events and should be supplemented with other more systematic forms of data collection. FYI: P&T, MDx, RNx, IM - by VK
Pg06- Verification of Identity and Standard MS.4.10 [**REF**] This is a discussion of the standard MS.4.10 that requires practitioners unknown to the organization who apply for initial privileges to be verified as the same person who arrives at the hospital to provide care. A sidebar on pg 7 provides a clear summary of the process. A sidebar on pg 11 summarizes three interesting cases of individuals who practiced in hospitals without proper credentials or licensure. FYI: MD, MDx. - by VK
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[index] Patient Safety (June Vol 8 #6)
Pg01- Pediatric Medication Errors: Using the National Patient Safety Goals to Protect Patients Potentially harmful med errors occur three times as often in pediatric patients. This article discusses various precautions, including pediatric medication competencies for P&T, PHRM and RN. Various NPSGs are related to medication errors, including: #2A “Write and read-back”; 2E Standardization of handoff communications; #3C Look-Alike/Sound-Alike; #3D Labeling; #8 Medication Reconciliation. - by VK
Pg02- Top 5 in the News The top 5 include: 1. A new “trigger tool” effectively detects adverse drug events in hospitals; 2. GAO concludes the CDC not providing complete picture of extent of HAI problem ; 3. Estimate that 188,000 lives in the US involved “Failure to Rescue” (from life threatening changes) between 2004-2006; 4. More than 25% of children in the US do not receive vaccinations on schedule; 5. Incidence of C.Diff infections rose by nearly 200% between 2000 and 2005. - by VK
Pg06- Creating a Backup System: Ensuring Timely Reporting of Critical Test Results and Values This is a discussion of various approaches to NPSG 2C, including clear identification of the responsible provider and contact information at any given time, maintaining an effective electronic or paper tracking system for monitoring all test results, including the patient in the backup system, and ensuring that the provider writes down and reads back the reported results. FYI: P&T, MD, RN, IM. - by VK
Pg09- Implementing the Stroke Alert Program at Lutheran General [**REF**] This article describes a stroke-specific program that is a specialized part of a rapid response team to address NPSG 16A. The number of strokes that occur in psychiatric hospitals is not known, but an estimated 25% of all stroke victims are hospital inpatients. Stroke Program Alert may be appropriate to adapt to psychiatric settings. A sidebar on pg11 outlines the model and websites used to educate staff members on common stroke signs. FYI: PtEd, MD, RN. - by VK Article references include:
- National Stroke Association's Stroke Factsheet (PDF)
- National Institute of Neurological Disorders and Stroke (NINDS) Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke {HTML}. Includes useful recommendations
[Index] Environment of Care News (June Vol 11 #6)
Pg01- Looking Ahead to the New 2009 EC Chapter: Standards Improvement Initiative Reorganizes Chapter for Ease of Use, Adds Important Clarifications FYI: EOC, E&M, LDR, SFT, IC. This is an overview of major EC changes, including the following:
- Requirements for all seven management plans have been consolidated as elements of performance under one new standard, EC.01.01.01.
- Safety and security are combined under one new standard and they can be addressed as one activity or as separate activities.
- When a written document is required, the words “in writing”, “written” or “documented” appear in the text.
- Proactive risk assessment expectations are clarified as ongoing processes.
- A new “Emergency Management” chapter emphasizes that EM is not just an EC issue
- Management of Infectious Waste standards are relocated to the IC chapter.
- Life Safety compliance has become a new “Life Safety” (LS) chapter.
- Standards regarding patient smoking appear in the PC chapter only. - by VK
Pg04- Preventing Workplace Violence: Tips for Safety in Emergency Department and Psychiatric Hospitals [**REF**] To address EC.2.10, management of security risks, this article is based on OSHA statistics and guidelines. It covers factors related to workplace violence in health care; the five main components of a program to prevent workplace violence; getting staff buy-in for the program; and safety tips for staff. A sidebar provides a summary of tips for recognizing and defusing anger and violence, which involves application of “de-escalation” skills. FYI: SFT, LDR, RNx. - by VK
Pg06- Safety in Treating Inmates and Arrestees: How One Organization Developed a Statewide Forensic Protocol This article focuses on the general hospital that treats prisoners, but any psychiatric hospital that serves inmates and arrestees may find useful information here. On page 7 there is a sidebar that lists eleven duties of inpatient hospitals within a recently constructed Forensic Protocol. FYI: SFT (and security staff), HR, StEd. - by VK
Pg08- To Catch a Falling Star: How Edward Hospital Uses Branding in Its Fall Prevention Program [**REF**] To address NPSG 9B, this is a program that uses “branding” in the form of yellow STARS on patient’s charts and wrist bands to alert staff of fall risk as well as teaching at risk patients the logo: “Call, Don’t Fall”. The discussion includes some ideas that could be useful to augment existing falls prevention programs in psychiatric hospitals. FYI: RN, PtEd, IM. - by VK Article references that should be useful for any falls program included:
- JCI Center for Patient Safety: Patient Safety Practices Related to Patient Safety Goal 9B: {Info}
- Falls Toolkit offered by the National Center for Patient Safety (NCPS) of the U.S. Department of Veteran’s Affairs {Info}
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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: 1010.30 SHCC Advisory - After Survey RFI Mitigation
- SL1: 1010.40 SHCC Advisory - Daily Briefing/RFI Mitigation
- SL1: 1040.20 NPSG 09: - National Center For Patient Safety: Falls Tool Kit {Info}
- SL1: 1040.20 NPSG 16: Establish Criteria for Activating the Rapid Response Team {HTML}
- SL2: 2401 EC Highlights IHA/DMH: Recommendations to Improve the Assessment, Treatment, and Transfer of Psychiatric Patients to State-Operated Hospitals” [HTML] {PDF} - includes position paper and hospital monitoring forms [special thanks to St of Illinois]
- SL3: Joint Commission International: Pt Safety Practices (PSP) - includes TJC suggested practices for NPSG compliance
- 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
Recent Member Surveys (SL5)
- 2008/02-tjc- New Orleans Adolescent Hospital (NOAH)__!1Ad1Ca [PSQ - pending]
- 2008/01-tjc- LIncoln Regional Center (LRC) [PSQ - pending]
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F&A
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