RTP Vol 2 # 8
1 Aug 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)
Nursing Suicide Assessment & Sentinel Event Alert #40
Go to 'SHCC Additions' below or RTP Peals-Aug'08
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Refs: Conflict Mgt, Code of Conduct, EM Tracer, RN Suicide Assessment,
Joint Commission This Month For State Hospital Associations (August 2008)
- Accreditation
- Task Force moves toward consensus on Medical Staff Standard revision Here are the bottom lines for now: 1- The July 2009 implementation of the June 2007 revisions is suspended. 2- MS1.20 from the 2008 manual remains in effect until further notice. 3- There is an indefinite moratorium on implementation of EP# 19 of the current MS.1.20. 4- Surveyors will asses adequacy of documentation for MS.1.20 EPs 1-18 but where the documentation occurs is up to the medical staff for now. FYI: MD, JCSC
- Countdown to 2009: New icons in manuals New standards manual icons for required documentation, situational decision rules, Direct impact requirements, Cat A/C EOs and MOS are depicted. There is a listing of a number of State Hospital Associations that will be hosting programs on the 2009 changes. The Indiana Hospital and Health Association program is scheduled for 9/25 and IHA membership is not required (Details). Hint: Check with your state's hospital association to see if a low-cost 2009 training is available.
*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 (August, Vol 28 #8)
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[Index] The Source (August Vol 6 #8)
Pg01- Patient Flow: Keep Patients Safe and Moving Toward Recovery with Leadership Standard LD.04.03.11 This article and the issue of patient flow focuses primarily on patient congestion in emergency departments. However, standard LD.04.03.11 (and the new patient flow tracer) can be applied to any delay of patient care. As such, state hospital LDRs (especially those with admission units) would be well advised to identify and evaluate any significant delay trends or patterns of difficulty accessing/providing services. Psych hospitals might frame this as a question of timeliness for patient processes such as admission, transfer, discharge, lab result returns, consultation request/response, etc. The end section of this article on gathering and analyzing data has useful suggestions. See also: RTP 08 RTp or Perspectives (2008 March, Vol 28, #3) Pg10- New Patient Flow System Tracer for Critical Access Hospitals and Hospitals
Pg04- Accreditation Essentials: Effective Conflict Management for Leaders, Physicians, and Staff [**REF**] LDR preparing for the 2009 Leadership standards and implementation of conflict management standard LD.01.03.01 (effective in January 2009) should read this article. It provides a useful list of examples of 'disruptive behavior' (e.g., rudeness, criticizing, undermining, withholding information, humiliating, intimidating, and bullying). Hint: Consider incorporating these into relevant policy. There is also a brief discussion of 5 common responses to such behavior (e.g., competing/forcing accommodating, avoiding, compromising, collaborating). Training in conflict management strategies such as mediation is recommended. See also: Leadership Highlights page in the SL1 library
Pg06- Accreditation Essentials: Your Organization's Code of Conduct Policy [**REF**] In the 2009 Leadership standards, EP4 of the conflict management standard LD.01.03.01 calls for a code of conduct. This article provides some insights on 5 types of nurse/physician relationships and gives ideas for code of conduct content. There is also a suggestion for a 'zero-tolerance policy' on disruptive behavior. Most importantly, LDR should be sure that the following recommended 6 basic considerations for writing a code of conduct are addressed in their hospital's code:
• an environment that fosters honesty
• expectations that empower staff to do the right thing
• No threatening or intimidation of staff
• No jeopardy of Pt safety or care quality
• No retaliation against victims or witness in code complaints
• Compliance with applicable laws, rules, and regulations.
See also: Sample Code of Ethics/Conduct, courtesy of API
Pg08- Joint Commission Resources Practice Leader Discusses Strategic Safe Medication Management and Standard MM.01.01.01 TJC's medication safety practice leader (Jeannell Mansur, R.Ph., Pharm.D., F.A.S.H.P.) discusses the importance of patient-specific information as required by standard MM.01.01.01 and applies this to medication reconciliation. Phrm and P&T may find it useful to review her suggestions and strategies for policies and approaches to appropriate accessibility and availability of this information.
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[index] Patient Safety (August Vol 8 #8)
Pg01- Special Report! 2009 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them This entire issue (and the 3 related articles) is a special report on the 2009 NPSG. The first page article reviews fundamentals of facility compliance, surveyor approach and the scoring process. Nothing new there. However, we are again forewarned that while the goals contain no extra documentation requirements, any internal policies or procedures guiding goal compliance not adhered can result in an RFI. The second portion lays out the 2009 goals in detail and identifies changes. A third section presents the goals in summary form without their elements of performance. Here are the bottom lines for JCSC, PI, PPR, LDR and StEd:
Minor Changes:
• NPSG numbering approach has been changed
• “Implementation Expectations” are now “Elements of Performance”
• “phase-in” period over for NPSG.03.05.01 and NPSG.16.01.01
• Editorial changes: Goals 1, 2, 3, 8, 13, 15, 16 and the Universal Protocol
• Renumbered EP: NPSG.01.01.01, NPSG.03.05.01, and NPSG.16.01.01
Major Changes:
• New requirements: Goals 1, 7, and 8
• New EP added: NPSG.01.01.01, NPSG.13.01.01, NPSG.16.01.01, and UP.01.02.01 and UP.01.03.01.
• Retired NPSG: Goal 12
• Applicability changes: Goals 1, 2, 3, 7, 8, 9 and 10
Pg03- Summary of Changes to the 2009 National Patient Safety Goals (See Above)
Pg08- 2009 National Patient Safety Goals, Requirements and Rationales (See Above)
[Index] Environment of Care News (August Vol 11 #8)
Pg01- An Emergency Response Generates Safety Enhancements: How One Organization's Power Outage Improved its Preparedness This case example illustrates a concern you probably see more commonly regarding penetrations that are left by outside vendors working in your ceilings. However, the experience of this hospital with an unexpected failure of their emergency generator traces back to a similar need to monitor the completed work of such vendors more carefully in other areas as well. In addition, EOC, E&M and SFT might also benefit from this facility's suggests to re-test emergency generators after work is completed by outside vendors.
Pg06- Emergency Management Tips: The Emergency Management Tracer: How to Help Your Organization Follow the Roadmap [**REF**] State hospitals should note that since the beginning of this year emergency management tracers have been applicable to all hospitals regardless of size. This is the best TJC review and summary of the emergency tracer process we have seen to date. The basic strategy suggested for preparation is to comply with the requirements for 1- preparing an HVA (EC.4.11) and 2- developing/documenting an Emergency Operations Plan (EOP) and testing it at least twice a year. (EC.4.12). Some detail is also provided about the 2-part emergency management (EM) tracer and the manner in which one of its 17 scenarios (including at least one with nuclear elements) will be utilized to evaluate compliance across relevant EC and HR standards. JCSC, LDR, E&M, SFT and EOC should find this a useful review and augmentation of the meager information provided in the 1-page description of this process in the Survey Activity Guide available on TJC Connect. Hint: Pay particular attention to the top three emergency risks identified in your EOP and consider conducting mock EM tracers. - by FJM
See also: The JCAHO Approach to Evaluation of Emergency Management (2006) by the New York City Department of Health and Mental Hygiene. Includes a listing of "possible mass casualty simulations" [HTML] {PDF}
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- 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 (Note: This section may be updated throughout the month)
- SL1: 1010.50 - New library section on TJC standards, SII added
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- SL1: 1030.20 - SE Alert: Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety [SE Alert] [JCR Resources] [8-Min Podcast] [**REF**] JCSC, LDR, HR, StEd, RNx and MDx be sure to pick up on the Alert's 11 recommendations.
- SL1: 1040.10 - 2009 NPSG: {Info}, Full Version (PDF), Crosswalk (PDF) see also 1040.00
- SL1: 1040.20 NPSG15 - Suicide Risk Assessment/Prevention/Treatment - {Info} : Assessing Suicide - Nursing Made Incredibly Easy: May/June 2008 Page 46-53 {Full Text PDF} Nursing CE available with this article until June 30, 2010
- SL1: 1230.01 EC - Emergency Management: The JCAHO Approach to Evaluation of Emergency Management (2006) by the New York City Department of Health and Mental Hygiene. Includes a listing of "possible mass casualty simulations" [HTML] {PDF}
- SL2: 12401 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: National League for Nursing (NLN) - Nursing education, nurse educator certification
Recent Member Surveys (SL5)
- 2008/07-tjc-Kirby Forensic Psychiatric Center (KFPC)_3Fr [PSQ - pending]
- 2008/06-tjc-Queens Children Psychiatric Center (QCPC)_!2Ca [PSQ - pending]
- 2008/06-tjc-South Beach Psychiatric Center (SBPC)_!7Ad1Ca*Consumer Ntwrk [PSQ - pending]
- 2008/04-cms-Southeast Louisiana Hospital (SELH)_3AD1Ca*S&R*AdolNeuro¥ [PSQ - pending]
- 2008/04-tjc-Creedmoor Psychiatric Center (CPC)_!9Ad*DBT*Lang [PSQ - pending]
- 2008/04-tjc-Mid-Hudson Psychiatric Center (MHPC)_6Fr [PSQ - pending]
- 2008/01-tjc- Lincoln Regional Center (LRC) [PSQ - pending]
- 2007/07-tjc-Greater Binghamton Health Center (GBHC)_3Ad1Ca1Ge*Smoke [PSQ - pending]
- 2007/07-tjc-Pilgrim Psychiatric Center (PPC)_!11Ad3Ge [PSQ - pending]
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F&A
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