RTP Vol 2 #10
6 Oct 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 a Patient's Risk for Pressure Ulcers: Compliance Tips for National Patient Safety Goal 14, Fire Safety Eqivalencies, Latex Danger
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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)
[Note: All of the 2008 issues of this publication have been significantly delayed. September 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 (October, Vol 28 #10)
Pg01- How SII May Affect Your PPR See review and article above: Countdown to 2009: Upcoming changes for PPR
Pg03- Modifications to the Electronic Statement of Conditions™ for States Requiring Suspension of Testing Activities [**ALERT**] If your state is one of several imposing restrictions on emissions that might prevent performance of generator testing (EC.7.40), then you should note accommodating changes in the e-BBI. If you meet the criteria and properly document a government required testing suspension, you can be temporarily excused from TJC testing requirements. You should then resume within 30 days of the suspension's end. E&M an SFT should read this article for details.
Pg09- National Quality Forum Endorses Eight Joint Commission Stroke Measures This article identifies 8 of the NQF's 17 voluntary consensus standards which TJC has adopted as performance measurement for its accredited primary stroke centers . However, given the implications for stroke in NPSG # 16 that are relevant to our hospitals, this information is worth reviewing by MDx, P&T, SFT and StEd. See also: TJC's Stroke Performance Measurement Implementation Guide 2nd Edition and NQF's National Voluntary Consensus Standards for Prevention and Management of Stroke Across the Continuum Of Care.
Pg10- Joint Commission Resources Launches The Flu Vaccination Challenge: JCR Encourages Hospitals to Help Protect Patients by Promoting Flu Vaccinations for All Health Care Workers See review and article above: JCR challenges hospitals to increase flu vaccination rates among health care workers
Pg10- Accreditation Manuals and Updates Have Been Mailed: 2009 Comprehensive Accreditation Manuals Redesigned as Part of SII FYI: LDR and JCSC. Accredited hospitals should be receiving a complementary copy of the 2009 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH) in the "portable" 9”x9” 3-ring binder format (with a CD-ROM of the History Tracking Reports showing 2008 to 2009 standards revisions) by October 15th. If not, contact your account representative.
[Index] The Source (October Vol 6 #10)
Pg01- Tracer Activities and Patient Flow Standard LD.04.03.11: Measuring and Improving the Patient Care Process: This is TJC's 3rd article (Jan and Aug) this year on Patient Flow/Standard LD.04.0.11. This one more specifically addresses what surveyors will be looking for and provides a series of tips. The issue of discharge backups is emphasized. Patient flow tracers are applicable to state hospitals. As such, we again encourage you to to identify and evaluate any significant delay trends or patterns of difficulty accessing/providing services. LDR, MDx and RNx might make the issue more relevant by framing it as a question of timeliness for patient processes such as admission, transfer, discharge, lab result returns, consultation request/response, etc. See also:
• RTP Vol2 #3 or Perspectives (2008 March, Vol 28, #3) Pg10- New Patient Flow System Tracer for Critical Access Hospitals and Hospitals
• RTP Vol2,#08 or The Source (2008 Aug, Vol 6, #8) Pg01- Patient Flow: Keep Patients Safe and Moving Toward Recovery with Leadership Standard LD.04.03.11
Pg04- North Memorial Captures Delirium Superimposed on Dementia in Hospitalized Patients: Best-Practice Notes from the Hartford Institute of Geriatric Nursing: If your patient population includes those who are elderly and/or suffer from dementia your RN and MDs might find some of the resources identified in this article useful. PEARL: The Hartford Foundation Institute for Geriatric Nursing (HFIGN) has a program called Nurses Improving Care for Health System Elders (NICHE) that provides best practice and evidence-based approaches/tools for this population (e.g., resources and tools on Geriatric Fall Risk Assessment and Avoiding Restraints In Patients with Dementia)
Pg07- Focus on Standard MS.1.20 Task Force Issues: MS.1.20 contains several potentially challenging and/or controversial provisions (e.g., what must be in bylaws vis P&P and relationship of MS to the GB. It was revised in June 2007 with an implementation set for July 2009 that was subsequently suspended. The current version of the standard is still in effect, but "there is an indefinite moratorium on the implementation of Element of Performance (EP) 19 of the current MS.1.20 standard". As such, this article points out that "… Joint Commission survey activities assess whether each of the topics identified in EPs 1 through 18 are addressed in the bylaws and whether necessary detail is addressed in either the bylaws, rules and regulations, or policies. The survey does not assess how much of the detail is placed in rules and regulations or policies, rather than in bylaws; that decision is left to each medical staff and governing body." The task force that has been trying to achieve consensus on key provisions reports progress and will update the TJC board again in November. Given TJC's policy of a 12-month advance notice on revisions, implementation still appears a ways off, but LDR, GB and MEC should continue to track this issue and make sure to weigh in on its next field review.
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[index] Patient Safety (October Vol 8 #10)
[Index] Environment of Care News (October Vol 11 #10)
Pg01- Gaining Fire Safety Equivalencies [**REF**] When your building(s) do not meet all requirements for applicable Life Safety Code, the Joint Commission has procedures for granting two types of equivalencies:
#1Traditional Equivalency is based on sound fire safety principles confirmed by at least one acceptable life safety professional and sent to the Joint Commission (by mail or electronically).
#2 Fire Safety Evaluation System (FSES) is an approach that assesses the entire building and uses a measurement method to determine acceptable alternatives to the LSC and must be sent to the Joint Commission by paper mail. In addition to equivalencies, Plan for Improvement (PFI) expectations are covered briefly, emphasizing that six months is the maximum timeline. Some details for requesting extensions are also provided. A sidebar on pg 11 pictures the online submission form for traditional equivalency. A sidebar on pg 5 outlines information to include when submitting an extension (for PFI) or Equivalency request to TJC. Note also that, even though TJC and CMS both use the 2000 edition of the LSC, they do not recognize each other’s equivalency. FYI: EOC, E&M, and SFT - by VK
Pg01- Perspectives on MRSA The article reminds us that:
• Most common sources of transmission are pts who already have MRSA or who carry the bacteria on their bodies but do not have symptoms. Often they have a compromised immune system or are elderly.
• Main method of transmission is through human hands
• Workers can take MRSA infections home with them on their clothing and equipment or when they themselves become colonized
• MRSA is everywhere, especially in health care facilities and health clubs
• MRSA can live for days and weeks on almost any surface
OSHA expects employees, employers, and clinicians to take a shared responsibility to protect health care workers and also requires knowledge of their regulations. Precautions focus on Standard Precautions for providing care to everyone and Contact Precautions for providing care to those with MRSA. The Joint Commission recommends following advice from the Healthcare IC Practices Advisory Committee for pts who have MRSA and the guidelines are listed on pg 6. The article further recommends emphasis on personal protective equipment and good hand hygiene. A sidebar lists the CDCs steps for hand washing on pg7. These can be accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm. FYI: EOC and IC. - by VK
Pg01- The Dangers of Latex [**REF**] : RN, RNx. Among health care workers, the incidence of latex sensitization is estimated at between 3% and 22%. There are three levels of allergic reaction to latex: #1 Irritant is evidenced by contact dermatitis: #2 Allergic contact dermatitis is evidenced by more severe symptoms of dermatitis and may spread to other body parts. #3 Latex hypersensitivity is evidenced by hay fever like symptoms, exacerbated by hives and cramps, and potential anaphylactic shock. A side bar on pg 9 lists a Latex Allergy Checklist for individuals who are allergic to latex. An important recent finding is that many skin reactions that were attributed to latex in the past are now considered to be due to repeated hand washing and/or the powders on gloves that include corn starch or calcium carbonate. The authors recommend these essential steps for staff related to latex:
• Staff members should assume full responsibility for their own health, including any allergic reactions
• Determine your own level of sensitivity
• Practice careful hand washing
• Make sure you are using the right glove for the right reason
• Familiarize yourself with alternatives to the use of gloves and other products made of latex, including Nitrile and Guayule, approved by the FDA in April, 2008
• Bring any possibility of latex allergy to the attention of hospital management
- by VK
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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)
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SL1: 1030.20 - SE Alert: Issue 41 - Sep 24, 2008: Preventing Errors Relating to Commonly Used Anticoagulants [SE Alert] [JCR Resources] [7.5-Min Podcast] [**REF**] JCSC, P&T, Phrm, RNx and MDx be sure to pick up on the risk reduction strategies and other suggested actions.
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SL2: 2113: S&C -8-18 [Info] (PDF) (04/11/2008) [**REF**] Restraint/Seclusion Interpretive Guidelines & Updated SOM Appendix A [More details @ 2101 Highlights]
Recent Member Surveys (SL5)
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2008/08-tjc-Elgin Mental Health Center (EMHC)__2Ad7Fr [PSQ - pending]
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2008/07-tjc-Kirby Forensic Psychiatric Center (KFPC)_3Fr [PSQ - pending]
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2008/06-tjc-Queens Children Psychiatric Center (QCPC)_!2Ca [PSQ - pending]
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2008/06-tjc-South Beach Psychiatric Center (SBPC)_!7Ad1Ca*Consumer Ntwrk [PSQ - pending]
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2008/04-cms-Southeast Louisiana Hospital (SELH)_3AD1Ca*S&R*AdolNeuro¥ [PSQ - pending]
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2008/04-tjc-Creedmoor Psychiatric Center (CPC)_!9Ad*DBT*Lang [PSQ - pending]
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2008/04-tjc-Mid-Hudson Psychiatric Center (MHPC)_6Fr [PSQ - pending]
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2008/01-tjc- Lincoln Regional Center (LRC) [PSQ - pending]
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F&A
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