RTP Vol 2 # 7
1 Jul 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)
Happy Birthday SHCC!
Site Search Now Available!
SHCC is now 1 year old and thanks to your feedback, we are celebrating by launching our new website search engine. As we continue to grow you will be able to find more information even faster. Click here on FIND or in any page with a shortcut bar in the header or footer.
.
THE JOINT COMMISSION (TJC and JCR)
.
.
Publications
Joint Commission This Month For State Hospital Associations (July 2008)
• Use of bullets minimized
• No more supplemental findings.
• Category B EPs eliminated.
• Category A EPs: Defined and scored as before but, now, may also be related to a Medicare Condition of Participation.
• All findings of non-compliance will require an (ESC).
• ESC timeline will depend on its criticality/immediacy of risk.
• ESC within 45 days for ‘Direct Impact EPs’
• ESC within 60 days for ‘no Direct Impact EPs’
*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 (July, Vol 28 #7)
Pg01- The Joint Commission Announces the 2009 National Patient Safety Goals and Requirements FYI: JCSC, P&T, IC and RN. Upcoming goals have been reformatted to be consistent with the overall standards renumbering process. What is new includes:
• 3 additional goals related to hospital acquired infections. (NPSG#7)
• 1 goal to decrease transfusion errors from misidentification (NPSG#1)
• Refinement of the Universal Protocol.
The hard copy of this special issue of Perspectives does not include the implementation expectations or elements of performance as they are now to be called. You can obtain PDF's of the full version and a crosswalk from TJC's 2009 NPSG section online.
Pg03- Update: Joint Commission Suspends Standard MS.1.20 Implementation Date: Implementation Task Force to Continue Work on Medical Staff Standard Revision The controversial changes to Standard MS.120 are no longer to be implemented on 7/1/09. A special task force will make additional recommendations to the TJC board in August which will likely trigger field reviews through Sept 2008. Based on the filed review outcomes the board is expected to establish a new implementation date at its November meeting. MDX and LDR should keep continue to follow this issues. More background is available in previous issues of Perspectives (September 2007, pg 3-6and October 2007, pg 8)
Pg04- Update: Life Safety Code Specialist Role Expanded for Critical Access Hospitals and Hospitals Last month (6/1/08) The Life Safety Code Specialist (LSCS) became the person to accept the e-SOC on the first day of survey instead of the survey team leader. The article further describes how this is to be handled when the LSCS does not arrive at the same time as the survey team. JCSC, EOC and SFT should read those details. There is also an official listing of the primary standards to be surveyed by any LSCS (i.e., EC5.20, 5.40, 5.50, 7.40 and 7.50)
Pg05- Approved: Revisions to Accreditation Participation Requirement 17, for All Programs APR 17 encourages staff to report safety concerns. Previously it was made clear that staff specifically included physicians. Now that clarification is being expanded to include "any other individual who provides care, treatment or services…" FYI: TxTm
Pg10- New Hospital-Based Inpatient Psychiatric Services Measure Set Available to Meet ORYX® Requirements Beginning October 1st free-standing psychiatric hospitals (and other hospitals with acute inpatient psychiatric services) can begin using the new 7-parameter HBIPS core measure set. However, since the measures are not yet NQF endorsed, related data will not be publicly reported. Details for how to enroll are not yet available and JCSC or IM should not contact Mr. Frank Zibrat (630/792-5992 or fzibrat@jointcommission.org.) before early August when vendor arrangements and enrollment mechanisms are expected to be in place. The 7 HBIPS measures are:
• Admission screening for violence risk, substance use, psychological trauma history, and patient strengths completed
• Hours of physical restraint use
• Hours of seclusion use
• Patients discharged on multiple antipsychotic medications
• Patients discharged on multiple antipsychotic medications with appropriate justification
• Post-discharge continuing care plan created
• Post-discharge continuing care plan transmitted to next level of care provider upon discharge
Note: state hospitals will also have the option of remaining with the 9 non-core measures… at least until NQF endorsement and HQA approval are obtained. Then the measures would become mandatory . For more details see: National Hospital Inpatient Quality Measures- Hospital Based Inpatient Psychiatric Services (HBIPS) Core Measure Set Last Updated 5/30/08
.
[Index] The Source (July Vol 6 #7)
Pg01- Measuring Pain and Joint Commission Standard PC.13.40 [**REF**] In the Consumer Assessment of Health Providers and Systems Hospital Survey (CAHPS) over 30% of patients reported "their pain was not always controled during a recent hospital stay." In that context, this is an excellent review for RN and nursing staff about effectively communicating with patients to better manage pain assessment and reassessment. 8 spedifc, useful tips are provided. StEd should consider including this article as a handout during orientation or annual updates. See also: Patient Safety and Quality: An Evidence-based Handbook for Nurses - Chapter17 Improving the Quality of Care Through Pain Assessment and Management (PDF file, 193 KB) Nancy Wells, Ph.D.; Chris Paseo, R.N., F.A.A.N.; and Margo McCaffery, R.N., F.A.A.N.
Pg04- Accreditation Essentials: Complying with Discharge Standard PC.15.20 - According to CMS and AHRQ, more than 20% of patients feel they do not recieve adequate discharge information. SW, RN, PtEd and others involved in the patient discharge process may find particular value in this article. Among the 6 strategies it recommends for improving discharge quality, particular emphasis is given to providing simple, easy-to-read, written materials to patients at discharge. A list of suggested documents is included that also helps meet the requirements of PC.15.20.
Pg06- Hand Hygiene Guidelines by the World Health Organization (WHO) [**REF**] 7 Steps are provided for complying with WHO hand hygiene guidelines. However since most state hospitals chose to comply with the CDC guidelines, the most valuable content is a 2-page compliance checklist based on both CDC and WHO for standard IC.01.0301 (aka IC.4.10). This is a must read for IC and any IC-related PPR team. Get (and use) a copy.
Pg09- Spotlight on Success: Lincoln Medical Center's Survey "Dress Rehearsal" Praised by Staff A small, rural medical center improves its mock surveys by 'swapping' its mock survey team with that of another hospital. GB, LDR and JCSC. will find the principle and description of lessons learned worth considering by state hospitals with their sister facilities.
.
[index] Patient Safety (July Vol 8 #7)
Pg01- Conducting a Root-Cause Analysis of Infection-Related Sentinel Events Complying with NPSG.07.02.01 FYI: IC, JCSC. Although we do not expect to have infection related deaths in psychiatric hospitals, this article provides a good reminder that some patients experience an infection and then die of a MI or some other unanticipated event. The article provides useful suggestions and questions to guide HAI-related RCAs and a related tool/position paper from APIC*. - by VK *APIC Position Paper (2004): Integrating Sentinel Event Analysis Into Your Infection Control Practice (PDF)
Pg02- Joint Commission Revises Numbering for National Patient Safety Goals National Patient Safety Goals have been re-numbered for 2009 to reflect the numbering of accreditation standards. The revised system is displayed on Pg 11. (Note that Behavioral health and Long term care will keep their current numbering system until 2010.) - by VK
Pg05- Ask the Expert: What are the five most prevalent infection control challenges currently facing health care organizations? FYI: IC. The five items identified are:
• Antibiotic Resistance and Multidrug Resistant Organisms (MDROs)
• Public Reporting of Infection Rates and Selected Infections and Organisms
• Accomplishing the Expanded Functions of Infection Prevention, including the ICP’s role
• The Movement to Target Zero Infections
• Increasing Visibility and Requirements for Infection Prevention Programs
- by VK
Pg06- Medication Reconciliation: Taking a Systematic Approach to National Patient Safety Goal 8 [**REF**] This is a good review of NPSG 08 expectations. The article discusses individuals who are at high risk for inadequate medication reconciliation, including older patients, those who receive care from multiple specialists, people with chronic conditions who take many medications, and those whose health literacy is low. The article discusses the importance of providing a format for medication reconciliation and developing an interview process that staff can follow when using the tool. The expectation is that responsibility for medication reconciliation will be clear and that involved staff, providers, and patients will be educated. Also, the success of the program needs to be measured. (Sample tools* to address medication reconciliation are provided on page 13 and 14.) FYI: P&T, MD, RN, PtEd, PI - by VK *See also: S.Carolina Hospital Association's Universal Medication Form for patients
Pg09- Labeling Medications in the Operating Room: Compliance Strategies for NPSG.03.04.01 Note that although most psychiatric hospitals have no operating rooms, many do have dental clinics and podiatry services, and some provide suturing. NPSG 03 applies anytime there is a sterile field. Phrm,P&T and MD should review this article. - by VK
[Index] Environment of Care News (July Vol 11 #7)
Pg01- Introducing the Joint Commission's New 2009 "Life Safety" Chapter: New and Improved Linkings with NFPA and CMS Requirements Among Highlights This article describes the new Life Safety chapter for standards manuals, beginning in 2009. The article includes an overview of the new Life Safety chapter, including an outline of standards that address administrative activities and standards that address the Life Safety Code requirements. The new chapter is intended to make the standards more clear, consistent, and easier to evaluate. The format of the LS chapter is consistent with the format of the Life Safety Code, NFPA and the scoring system will be the same format as the scoring for all the other standards chapters. Even though there are no new requirements, EOC, E&M and LDR are encouraged to particular attention to advice in the new chapter overview on what an organization can/should do when provisions of the LSC cannot be met. Note should also be taken of TJC's definition of and encouragement (its not required) to have a Building Maintenance Program. - by VK & RF
Pg04- Emergency Management Watch: Achieving Resiliency: Complying with the 96-Hour Principle of Emergency Management This article points out that any healthcare organization during time of disaster may serve as a beacon for the community and draw more people to its doors because of its stability. The “96-Hour Principle” is explained as a management principle rather than a rule. The intent is for each organization to determine in advance whether it can sustain itself, considering the six critical areas of emergency management (Communication; Resources and assets; Safety and security; Staff responsibilities; Utilities management; Patient clinical and support activities). If the organization cannot sustain itself for 96 hours, leaders need to plan in advance what decision steps will be used to determine when to evacuate. The article includes factors to consider related to conserving resources; considering curtailing services; and planning for evacuation. FYI: EOC, E&M, SFT and LDR. - by VK
Pg06- Emergency Management Alert: Change in Compliance Expectations for the 2008 Emergency Management Standards Note: This is a reprint of the lead article in last month's Perspectives. In response to concerns from the field, the Joint Commission has re-evaluated deadlines for meeting the new Emergency Management Standards. Nine EPs are required by January 1, 2008 due to immediate consequences impacting the safety of patients, and these are listed in the article. Fifteen additional EPs are identified as having the extended deadline of no later than December 31, 2008. The article provides a clear chart that lists the involved EPs and the deadline date for each one on pages 7-10.. FYI: JCSC, LDR, PPR, SFT. - by VK
.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
.
- What's New Page - April 2008 (pdf, 10 kb) FB
- 5/30/08: Transmittal 1522: Charges to Hold A Bed During SNF Absence (PDF)
- 5/23/08: Transmittal 343 New Contractor Numbers for the States of CT and New York (PDF)
- 5/16/08: Transmittal 89 Medical and Other Health Services Furnished to SNF Patients
- 5/7/08: CMS-1401-N: Updates the prospective payment rates for Medicare inpatient psychiatric facilities (IPF) beginning 7/1/08 FB
INTERNET HIGHLIGHTS
National Association of State Mental Health Program Directors (NASMHPD)
SHCC Additions
- SL1: 1030.20 - SE Alert: Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety [SE Alert] [JCR Resources]
- SL1: 1040.20 NPSG07 - APIC Position Paper (2004): Integrating Sentinel Event Analysis Into Your Infection Control Practice (PDF)
- SL1: 1040.10 - 2009 NPSG: {Info}, Full Version (PDF), Crosswalk (PDF) , see also 1040.00
- 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)
- 2008/04-cms-Southeast Louisiana Hospital (SELH)_3AD1Ca*S&R*AdolNeuro¥ [PSQ - pending]
- 2008/01-tjc- LIncoln Regional Center (LRC) [PSQ - pending]
.
.
F&A
|
