RTP Vol 2 # 9
2 Sep 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)
GAO Publishes 13 HAI Guidelines for Hospitals
Go to 'SHCC Additions' below or RTP Peals-Sep'08
Ref: Nursing Concept
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations (September 2008)
*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 (September, Vol 28 #9)
Pg01- New Hospital Deeming Law and The Joint Commission : Previously reviewed in August RTP
Pg08- Correction: Accreditation Decision Rule CON02 for All Programs : The correction makes a distinction between CON02 and PDA02. If an individual is practicing without a license or outside the scope of that license a determination of CON vs. PDA is based on the presence (PDA) or absence (CON) of risk to patients. FYI: JCSC, HR, MD
Pg08- The Joint Commission Issues Sentinel Event Alert on Stopping Bad Behaviors Among Health Care Professionals : Previously reviewed in August RTP
Pg09- Top Standards Compliance Issues for Full-Year 2007: [**REF**] FYI: JCSC, PPR. For 2007, the top 10 non-compliant hospital program requirements (including 2 newcomers) were:
- MM.2.20 (43%) Med storage
- Goal 2, Requirement 2C (36%) Critical test results and values.
- EC.5.20 (29%) Life Safety Code
- IM.6.10 (26%) Complete medical record
- IM.6.50 (25%) Verbal or telephone orders
- Goal 2, Requirement 2B (25%) Abbreviations, acronyms
- Universal Protocol 1, Requirement 1C (21%) Conduct a 'time out'
- MM.3.20 (20%) Medication orders
- Goal 8, Requirement 8A (19%) Medications reconciliation
- Goal 3, Requirement 3D (18%) Label all medications
- EC.5.40 (18%) Fire-safety equipment
- PC.13.20 (18%) Operative or other procedures are planned
[Index] The Source (September Vol 6 #9)
Pg01- Revisions to Scoring and Accreditation Decision, Effective January 1, 2009 : FYI: JCSC. This is important information about the 2009 standards, but it has been previously presented (Special Edition of August Perspectives) and previously reviewed (August RTP). For more details see: SL1 1010.50 - Standards Improvement Initiative {Info Page}
Pg04- Methods for Resolving Patient Complaints Complying with Standard RI.01.07.01 : When revised standard RI.07.01 becomes effective 1/1/09, it will more specifically require a patient complaint resolution process. The article includes some standard compliance tips such as capturing, categorizing and tracking complaints, good listening, quick and effective responses. It also suggest establishing a complaint resolution team. LDR and PtAd should remember that effectiveness in this area can help mitigate against patient perceptions of negligence when adverse events occur.
Pg06- From Home to Health Care Organization Managing Medications and Standard MM.03.01.05 : The revisions to MM.03.01.05 (medications brought from home) are primarily refinements of wording and not of content or intent. The article seeks to heighten our vigilance to polypharmacy which is increasing in our aging populations. To reduce the risks associated with polypharmacy (especially for the elderly) it outlines medication reconciliation steps and provides 5 tips (including the use of a form) for effective medication reconciliation. FYI: Phrm, P&T. See also: Pt. Safety Jul '08 Vol 8 #7 Pg06- Medication Reconciliation: Taking a Systematic Approach to National Patient Safety Goal 8 [**REF**]
Pg08- High-Quality Care Using Contracted Staff Complying with Standard LD.04.03.09 : This article does speak to some specific compliance concerns such as the need to properly orient and evaluate (e.g., after 1 week and q 6-months thereafter) contract staff. However, its larger focus is on achieving greater value from such staff by fostering a more supportive environment and relationships with them. It suggest that much of this is done up front through preparatory explanation and clarification of duties with permanent staff. This is a worthwhile read for HR, RNX and MDx.
Pg10- Creating Time-Out for Progress Notes or Reports Record of Care, Treatment, and Services : This article briefly discusses discusses the new standards chapter, “Record of Care, Treatment, and Services” that is destined to "encompass all standards related to medical records in a single reference." There is an equally brief discussion of some pros and cons for the role of electronic medical records (EMR) in complying with RC.01.01.01 (formerly IM.6.10 - complete medical record). Much of the article highlights the importance of educating and communicating with MDs as part of planning for and implementing an EMR. FYI: IM, IT
[index] Patient Safety (September Vol 8 #9)
Pg02- Patient Safety Pulse: Your Patient Safety News: Joint Commission Issues New Sentinel Event Alert on Disruptive Behavior : FYI: LDR, JCSC, MDx, StEd. The July issuance of Sentinel Event Alert #40 is again announced with some examples of intimidating and disruptive behavior given. More TJC dtails at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.
Pg05- Advantages and Disadvantages of Bar Code and Radio Frequency Technologies : FYI: LDR, IT. Two patient identification systems are compared along 5 parameters. Radio Frequency Identification (RFID) uses a wristband-embedded chip that costs a bit more (under $1.00 each vs under 10¢ each for bar codes) but provides more info. It is also less subject to physical issues (e.g., soiling, wrinkling)…except, of course, for patient removal
Pg06- A Nurse Leads Change: Transforming Care at the Bedside : [**REF**] The nursing concept of transforming care at the bedside (TCAB) is explored through a series of questions to Hassmiller, Ph.D., R.N., F.A.A.N., of the Human Capital Team at the Robert Wood Johnson Foundation. Getting nurses back to the bedside is discussed as a means of empowering them and improving patient care quality and safety. RNx may find some of the examples and innovations useful food for thought.
Pg10- Educating Patients About Infection Control: Complying with NPSG.13.01.01 : To help comply with the requirements of NPSG.13.01.01, this article briefly discusses hand hygiene, respiratory hygiene, contact precautions and patient education on infection control. The information and suggestions are basic but worth reviewing and reinforcing with staff by IC, RN and PtEd. It also ties in to the speakup campaign
[Index] Environment of Care News (September Vol 11 #9)
Pg01- The 2009 Emergency Management Chapter: Shifting Focus to an All-Hazards Approach : There are no new standards in the new Emergency Management chapter. Its purpose is to reinforce the idea that EM is "not just the responsibility of one department…" The article also provides a basic overview of the new chapters 3-part structure and gives a brief summary of the six critical EM areas (i.e., Communication, Resources & Assets, Safety & Security, Staff Responsibilities, Utilities Management and Patient Clinical & Support Activities). FYI: EOC, SFT and LDR.
Pg04- Emergency Management in Washington, DC: Increased Urgency and Greater Focus on Human-Initiated Events at Georgetown University Hospital : When considering the possibility of future terrorist attacks, Washington, DC is probably at increased risk. In that context and from its 911 experience, Georgetown University Hospital has provided some insights and a 9-point checklist for better emergency preparation. For example, they believe that when EM drills work perfectly little is learned/gained. They encourage testing the limits of your management system by drilling to the point of failure. FYI: EOC, SFT, LDR.
Pg06- How to Perform a Hazard Vulnerability Analysis : TJC requires re-evaluation of your HVA on an annual basis as per EC.4.11, EP #11. This brief overview does not give much detail on the 'how to' of HVAs, but does encourage the use of a multidisciplinary approach and emphasizes community involvement. FYI: PI, EOC, SFT and LDR
Pg07- Life Safety Code® Specialist Role Expanded : Since June of this year, the LSC specialist have been accepting the e-SOC on survey day 1 (in lieu of the team leader) and surveying hospitals against standards in the entire EC chapter (not just the LSC). Apparently what is new for January 2009 is that the foregoing will also apply to critical access hospitals. FYI: JCSC, EOC
Pg05- Eliminating Hallway Obstructions: How M.D. Anderson Cancer Center Keeps Corridors Clear : Ideas such as an obstruction reporting phone number and committee along with staff education and involvement are presented in this case study. Although this issue is rarely a priority in our hospitals, it deserves evaluation. Hint: Consider asking your EOC/SFT touring team to perform a baseline evaluation of hallway obstruction during their next inspection. Then decide if more attention is warranted.
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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 (Note: This section may be updated throughout the month)
- SL1: 1010.50 - New library section on TJC standards, SII added
- 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: 1220.30 LD - Sample Code of Ethics/Conduct, courtesy of API
- 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: 2113: S&C -8-18 [Info] (PDF) (04/11/2008) [**REF**] Restraint/Seclusion Interpretive Guidelines & Updated SOM Appendix A [More details @ 2101 Highlights]
- SL3: United States Government Accountability Office (GAO) Report: GAO -08-283 Report (March 2008): HAI: (Report) (Highlight) [**REF**] Good overview and ref for CDC's13 published guidelines on HAIs
Recent Member Surveys (SL5)
- 2008/08-tjc-Elgin Mental Health Center (EMHC)__2Ad7Fr [PSQ - pending]
- 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- Taylor Hardin Secure Medical Facility (THSMF)_3Fr*HBIPS [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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