RTP Vol 2 #11
5 Nov 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: Verbal Orders, Storing Meds, Staff Substance Abuse,
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations (October 2008)
[Note: All of the 2008 issues of this publication have been significantly delayed. October 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 (November, Vol 28 #11)
Pg09- Reminder: The Joint Commission's Gift Policy
FYI: JCSC. The bottom line is that your surveyors cannot/should not accept "any gift of value" from you. However, a "modest on-site meal is acceptable". A foot note to the article provides a more detailed definition of gifts and "nominal value'.
Pg09- Update: Standard MS.1.20 FYI: MD, MDx. The indefinite moratorium on the implementation of EP#19 is still in effect.
Pg12- Correction: Accreditation Decision Rule Requirement Links for All Programs FYI: JCSC. Accreditation Decision Rule Requirement Links for All Programs: This includes corrected links for 4 Hospital decision rules.
Pg13- Sentinel Event Alert: Preventing Errors Relating to Commonly Used Anticoagulants Although SEA #41 has been previously presented, this article includes a summary of some risk reduction and TJC-suggested strategies. Obviously, you can't go wrong (at survey time) with the latter, so they are worth considering by Phrm and P&T.
Pg15- JCR Web Page Contains New SII Videos FYI: JCSC. The page referenced in the title of this article contains 5 videos on the following SII topics:
1 - An overview by Dr. Chassin
2 - Language and numbering system changes
3 - The scoring and accreditation decision model
4 - Changes in the manuals
5 - Introduction to the new E-ditions to be available this month
Note: The URL provided in the article is incorrect. To accees the page they reference, you will need to go to: www.jcrinc.com/Standards-Improvement-Initiative/
[Index] The Source (November Vol 6 #11)
Pg01- Ensuring Accurate Verbal Orders [**REF**] This is a presentation of 9 basic suggestions for full compliance with RC.02.03.07 as follows:
• Define the information needed in a verbal order
• Designate the location where verbal orders should be recorded
• Ensure that qualified staff members receive and record verbal orders
• Set time frames for review and signing of a verbal order
• Require verbal order recipients to “read back” the order
• Spell out a drug name and confirm the dose using single digits
• Ask yourself if the received verbal order makes sense
• Use preprinted order sheets where possible.
Sometimes familiarity breeds laxity. Review the above list and note some of the fine points that may not be attended to closely anymore. For example, has your organization clearly defined what information is REQUIRED in a verbal order? Do you limit the number of staff who can receive such orders? Do you require sound alike medications to be spelled out? RN, MD and StEd should review this article
Pg03- Going Offline, Staying on Course: What You Can Do When the PPR Is Down [**ALERT: JCSC**] After 1/1/09, you will need to repopulate the Open PPR. TJC will provide a link to data tables that can be printed out for this purpose. Here are other key dates to keep in mind:
10/1-12/31/08: PPR offline. Not required to submit any PPR due during this period
11/30/08: Due date for submitting PPR Plans of Action you might want documented
11/1-12/30/08: No PPR Option 2 or 3 surveys during this period
1/1/09: PPR “Begin Submission” link first available for those with Jan, Feb or March 2009 PPR’s
1/1-31/09: PPR’s due in this period extended 90 days
2/1-3/31/09: PPR’s due in this period extended 60 days
For more detail, JCSC should review this article and/or go to: http:///www.jointcommission.org/Standards/SII
Pg04- Emerging Staff Qualifications and Performance Issues: Human Resources Standard HR.01.02.01: Top Compliance Issue for 2007 [**REF**] Because HR.01.02.01 is in the Top 10, HR and RN should review this article. It provides a useful reminder of the relationship of competency to staffing effectiveness and some suggestions for approaching issues of skill mix, task and job analysis.
Pg06- Storing Medications Properly: Complying with Standard MM.03.01.01 [**REF**] Medication storage, MM.2.20 (now MM.03.01.01) was also a Top 10 non-compliant standard. Phrm, RN and P&T should review this article in which TJC lays out the following expectations for compliance and provides additional considerations:
• Limit the number, doses, and strengths of medications stored (even in an automated dispensing cabinet)
• Eliminate the use of look-alike drugs whenever possible
• Empower staff members to report potential storage problems
• Store adult and pediatric medications in separate locations
• Monitor the temperature of refrigerators used for storing medications
• Allow only pharmacy professionals to restock a dispensing cabinet
• Discourage the storage of sample medications
• Remove patient-specific medications from storage as soon as patients are discharged or transferred.
•Store controlled (scheduled) medications to prevent diversion, in accordance with law and regulations.
Pg08- Nutritional Support for an At-Risk Population: An Effective Initial Assessment and Standard PC.01.02.01 The article tells us that 40% of older adults admitted to the hospital setting are malnourished on admission…60% will be discharged undernourished. In this context, Dietary and RN may find it useful to review this example of screening approaches to the elderly.
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[index] Patient Safety (November Vol 8 #11)
Pg05- Addressing Substance Abuse Among Health Care Professionals [**REF**] The article defines substance abuse as "misuse or overuse of a substance…by persons unable or unwilling to stop using". While any healthcare worker may be affected there are estimates that 8-12% of physicians and perhaps 32% if nurses may have a problem of this nature. The article reminds us of some of the common signs of the problem to include: Inattentiveness, Lack of concentration, Irritability, Frequent mood swings, Gradual decline in work performance, Frequent absences from work and Elaborate excuses for poor performance or workplace absence. A more detailed list of signs and behaviors of impairment from the AANA (see below) is included. There are also recommendations for the content of a comprehensive policy. MD may find this particularly useful in evaluating compliance with MS.11.01.01 (MS.4.80). RN may find a useful resource in the American Association of Nurse Anesthetists (AANA) that created "a peer assistance program to provide resources to individuals concerned about their own or a colleague’s substance abuse problem". See also: Signs and Behaviors of Impaired Colleagues
Pg08- Psychiatric Polypharmacy: Identifying Risks and Seeking Solutions FYI: MD, Phrm. Unless it is properly managed, the use of multiple medications can cause a variety of problems and increase mortality. Although the context of this article is more outpatient focused, it does underscore the importance of medication reconciliation. There is also a sidebar that provides a brief definition of four types of polypharmacy: same-class, Multi-class, adjunctive and augmentation. See also: Technical Report on Psychiatric Polypharmacy (PDF). NASMHPD Oct. 9, 2001
[Index] Environment of Care News (November Vol 11 #11)
Pg01- The 2009 Scoring and Accreditation Decision Processes: Standards Improvement Initiative Changes Effective January 1, 2009 FYI: JCSC. This is a 4-page review of the new scoring and accreditation decision process that has been previously described in 'Standards Improvement Initiative: An Overview' (PDF) and the March issue of 'This Month For State Hospital Associations'.
Pg04- EC Requirement: 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. {This is the same article published in last month's Perspectives}
Pg05- Joint Commission Resources Launches Flu Vaccination Challenge in the Name of Patient Safety: JCR Encourages Hospitals to Help Protect Patients by Promoting Flu Vaccinations for All Health Care Workers FYI: IC. JCR's Flu Vaccination Challenge seeks to get hospitals to achieve higher staff vaccination rates. Rates of 43% or more will be recognized. Obtain more information and/or register at http://www.fluvaccinationchallenge.com/ {Same article for last month's Perspectives and This Month…}
Pg06- Cleaning and Disinfecting Medical Equipment: A Renewed Focus on Enhancing Patient Safety FYI: IC. A key point of the article is that hospitals need to "ensure that the responsibility for cleaning and disinfecting medical equipment is clearly defined". It also advocates for more hospital involvement in updating/refining relevant guidelines such as those formulated jointly in 2007 by FDA, CDC, EPA and OSHA (i.e., Public Health Notification from FDA, CDC, EPA and OSHA*: Avoiding Hazards with Using Cleaners and Disinfectants on Electronic Medical Equipment)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- S&C-09-10 (PDF) : “Standing Orders” in Hospitals
INTERNET HIGHLIGHTS
National Association of State Mental Health Program Directors (NASMHPD)
- NASMHPD's Medical Directors’ Statement on Comparative Effectiveness of Antipsychotic Medications and Individualized Treatment (pdf) Includes 4 broad recommendations for best practice use and some excellent references with full text available.
- Obesity Reduction & Prevention Strategies for Individuals with Serious Mental Illness (pdf)
- Suicide Prevention Efforts for Individuals with Serious Mental Illness: Roles for the State Mental Health Authority (pdf)
- NASMHPD Issue Paper (December 9, 2005): Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) What Does It Mean for Practice and Policy? (pdf)
SHCC Additions (Note: This section may be updated throughout the month)
- SL2: 2113: S&C -8-18 [Info] (PDF) (04/11/2008) [**REF**] Restraint/Seclusion Interpretive Guidelines & Updated SOM Appendix A [More details @ 2101 Highlights]
- Public Health Notification from FDA, CDC, EPA and OSHA*: Avoiding Hazards with Using Cleaners and Disinfectants on Electronic Medical Equipment {HTML}
- SL3: S&C-09-10 (PDF) : “Standing Orders” in Hospitals [2124 - §482.24 Medical Record Services}
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- Lincoln Regional Center (LRC) [PSQ - pending]
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F&A
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