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: Culture of Safety Eval, Inpatient Room Suicide Prevention, HAI Compendium MD Role in Med Rec,
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations (November 2008)
[Note: All of the 2008 issues of this publication have been significantly delayed. November 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 go toSHCC Calendar for date of missed call. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
[Index] Perspectives (December, Vol 28 #12)
Pg01- Update: The Joint Commission's Hospital Deeming Authority Application FYI: JCSC, LDR. This article provides an update and some more details on the fact that TJC will no longer enjoy a 'unique statutory' deeming status. They will now need to apply, be reviewed and approved. They are confident of retaining their deeming status, which remains in effect until 7/15/2010. [**ALERT: JCSC **] Be sure to download 'Hospital New and Revised Requirements in Response to CMS DeemingApplication' (PDF)
Pg03- Approved: Remaining Component to the Accreditation Decision Methodology for 2009 FYI: JCSC. The Joint Commission has just announced the eagerly awaited, final component of the 2009 accreditation decision methodology in the December 2008 edition of Perspectives. As a result, the use of “thresholds” (a set number of not-compliant Direct Impact standards) as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA) have been eliminated.
Consequently thresholds of RFIs will only serve as “screens” for identifying organizations whose survey findings should be subject to a more intensive review by Joint Commission Central Office staff, rather than serve as “automatic” determinants of CA and PDA decisions. This review will be in addition to the review conducted for organizations that meet a Situational Decision Rule for an adverse accreditation decision or for which an Immediate Threat to Life has been declared.
The screens for the Central Office review, based on the number of not-compliant Direct Impact standards, adjust for differences in size and complexity of surveyed organizations (“bands”). These bands are based on statistically significant differences in the number of RFI's associated with various survey lengths (surveyor days).
The JC Central Office internal review of survey findings will focus on identifying and resolving instances in which pre-established “situational” rules for CA or PDA were actually met but not recognized at the time of survey. This revised process will also evaluate the magnitude and nature of the survey findings to determine if “systemic” problems exist across the organization (that is, similar issues identified across multiple departments or key systems), or if the findings would result in a “Condition” level deficiency. The Central Office review would result in one of 3 possible outcomes: (1) Identification of RFI's to be addressed via the submission of Evidence of Standards Compliance (ESC), (2) Recommendation for CA as an exception to rules, or (3) Recommendation for PDA.
Finally, according to Perspectives, the revised process and results from 2009 surveys will be closely monitored by The Joint Commission. Depending on the results, thresholds for determinants of CA and PDA decisions may be established for 2010. by Glenn D. Krasker, MHSA
Pg05- Joint Commission Resources Launches 2009 Manual E-ditions FYI:JCSC. As promised, TJC has now made E-ditions (electronic versions) of its manuals available and all currently accredited organizations should now have their free single-user license. The key advertised features are 1 - Three click access to most standards, 2 - History tracking, 3 - Full text searching and 4 - Service profiles and filtering (only standards applicable to your organization are displayed). One can also purchase an upgrade of the E-dition that includes AMP self-assessment functions. We're looking for tips, tricks, pros/cons for the E-ditions vs. the AMP. Share your feedback in our Suggestion Box
Pg07- Letter from Dr. Chassin: The Use of Standing Orders in Hospitals Although every hospital was sent this letter, JCSC should make sure that it is reviewed and its implications are fully understood by Phrm, P&T and MDx. CMS and TJC are now in synch on this issue so there is no room for error here. See alsoS&C-09-10 (PDF) : “Standing Orders” in Hospitals.
Pg11- Update: The Joint Commission Urges Patients to 'Speak Up' about Pain: New Speak Up™ Materials Focus on Pain Management Reviewed in Nov RTP
Pg11- Update: 2009 Universal Protocol FAQs Now Available Online FYI: MD, RN. These may be accessed online in the TJC Universal Protocol FAQs or downloaded in PDF format
[Index] The Source (December Vol 6 #12)
Pg01- New E-dition: Flexible, Interactive Access to Joint Commission Standards FYI: JCSC. [Pearl] This is probably the best overview of the new E-dition manual so far because it includes more explanation (e.g., the Service Profile) of features, their uses and includes some screenshots. For example, one of the advantages of a full text search is that "After users enter a topic of interest, the tool shows all standards and EPs that relate to that topic in order of relevance."
Pg04- Evaluating Your Culture of Safety—Knowing and Growing: Compliance Strategies and Tips for Standard LD.03.01.01 [**REF**] LDR, PI and JCSC should note that "at least a baseline cultural evaluation" is to be completed by 1/1/09. Previously, TJC had avoided identifying 'valid and reliable tools' for performing cultural assessment. [Pearl] However, in this article they reveal the following two, free tools that will apparently meet their requirements:
1. Agency for Healthcare Quality and Research: AHQR Patient Safety Culture Surveys. (accessed Oct. 20, 2008).
2. Sexton J. B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 6:44, Apr. 2006.
Pg06- Restraint Reduction at Fort Sanders Regional Medical Center: Best-Practice Notes from the Hartford Institute of Geriatric Nursing Although this 'Spotlight on Success' for PI.01.01.01 is from a med-surg hospital, its focus on geriatric patients and restraint reduction may still be useful to those PI or LDR considering new or additional reduction efforts.
Pg09- The Joint Commission Develops New Accreditation Standards: Culturally Competent, Patient-Centered Care in the Spotlight FYI: LDR, JCSC. TJC has a new grant from the Commonwealth Fund to continue its ongoing study of Hospitals, Language and culture* as a basis for new standards (expected in 2011) addressing culturally competent patient-centered care. As part of this process , TJC will also collaborate with the National Health Law Program (NHeLP) a "national public interest law firm that seeks to improve health care for America’s working and unemployed poor, minorities, the elderly, and people with disabilities". * Also see the study: Hospitals, Language, and Culture: A Snapshot of the Nation (PDF), (TJC Info) (Summary)
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[index] Patient Safety (December Vol 8 #12)
Pg01- The Physician's Role in Medication Reconciliation FYI: P&T, Phrm, MD. A prescribing physician is ultimately responsible for knowing his or her patient's current medications. However, this article acknowledges some benefits to multi-disciplinary approaches to this task and some specific timesaving strategies for physicians. It also emphasizes the importance of having a respected physician champion involved. A useful flow chart is included.
Pg02- Patient Safety Pulse: Your Patient Safety News:Health Care Groups Develop Infection Control Compendium. [**REF**] The compendium was contributed to by the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, The Joint Commission, the American Hospital Association, and the Association for Professionals in Infection Control and Epidemiology. The focus is on acute care hospitals, but the principles are still valuable and… it is available for free. IC should at least review the following:
• S12 Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals Abstract- Full Text- PDF Version
• S62 Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals Citation- Full Text- PDF Version
• S81 Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals Citation -Full Text- PDF Version
[Index] Environment of Care News(December Vol 11 #12)
Pg01- Reviving and Managing Your Contingency Plans: Being Prepared for Equipment, Utilities, and Emergency-related Failure or Disruption George Mills, senior engineer in TJC's Standards Interpretation Group (SIG) provides insights that E&M and SFT would be wise to be aware of. He strongly encourages reviewing, updating and actively testing contingency plans on a periodic basis. This should also include a re-examination of related agreements/MOU with other agencies. Apparently, it is not uncommon for such hospital plans to go unscrutinized for many years, become outdated and leave the facility vulnerable during a disaster. He specifically advises hospitals expecting survey [FYI: AL:NARH, IL:CMHDC, KS:LSH, LA:CLSH-SEH, NY:BPC, PA: ASH-CSSH-DSH-NSH-SMRC-TSH-WaSH-WeSH] to pay attention to standard EC.02.05.01, EPs 7-13.
Pg04- Top EC Standards Compliance Issues: Emergency Management, Life Safety Code® Compliance Among RFI Leaders for 2007 FYI: EOC, JCSC. They are:
• EC.5.20 (29%) Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®.
• EC.5.40 (18%) The hospital maintains fire-safety equipment and
building features.
Pg05- The FACT on FICTION: Don't Use Expanding Foam to Repair Fire, Smoke Barriers FYI : E&M. According to George Mills (and contrary to a recent non-TJC publication) foam " does not have a UL system for use as a smokestop or firestop application." and is therefore not allowed by TJC.
Pg05- Keep Current on the Standards Improvement Initiative: New Web Site Gives Latest Information FYI: JCSC. Reviewed in November RTP (Perspectives)
Pg06- Evacuating an Iowa Hospital in a 500-Year Flood: Mercy Medical Center Moves Patients as Waters Rise FYI: E&M, EOC. This case study providing a day-by-day log and insights into a hospital's flood experience may be preaching to the choir for our LA hospitals but others who have not been through such a disaster could find the vicarious knowledge useful.
Pg08- Suicide Prevention and the Inpatient Room: Bricks and Sticks and Beyond [**REF**] David M. Sine, ARM, CSP, CPHRM and James M. Hunt, AIA are co-authors of [PEARL] Design Guide for the Built Environment of Behavioral Health Facilities, the bible for in-room furnishings that help prevent suicide. In this article they share updates on some of the latest materials and approaches used to reduce the environmental risk of suicide. Did you know that all bathrooms do not have to be ADA compliant? (refer to Code of Federal Regulations at 28 CFR 36.301(b).) SFT, EOC and E&M should definitely read this article and download a free copy of their Design Guide to help better address EC.1.10, EC.1.20 andEC.8.10
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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Mid-Quarter Instructions
What's New
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S&C-09-10 (PDF) : “Standing Orders” in Hospitals
INTERNET HIGHLIGHTS
National Association of State Mental Health Program Directors(NASMHPD)
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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.
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Obesity Reduction & Prevention Strategies for Individuals with Serious Mental Illness (pdf)
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Suicide Prevention Efforts for Individuals with Serious Mental Illness: Roles for the State Mental Health Authority (pdf)
SHCC Additions (Note: This section may be updated throughout the month)
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SL3: S&C-09-10 (PDF) : “Standing Orders” in Hospitals [2124 - §482.24 Medical Record Services}
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SL2: 2004:2008 Medical Staff Crosswalk (PDF) - HCPro Credentialing Resource Center
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SL2: 2004:2008 Gov Body Crosswalk (PDF) - HCPro Credentialing Resource Center:
Recent Member Surveys (SL5)
Please help. Pending PSQs are needed ASAP for conduct of our first trend analysis of state hospital-specific survey experience in January 2009. If the outstanding PSQs were submitted, it would almost double the size of our survey data base and dramatically enhance the analysis.
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2008/11-tjc-Arizona State Hospital (AzSH)_4Ad1Ca4Fr [PSQ - pending]
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2008/08-tjc-Manhattan Psychiatric Center (MPC)_??????*Viol*Polydip*Hisp [PSQ - pending]
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2008/07-tjc-Kirby Forensic Psychiatric Center (KFPC)_3Fr [PSQ - pending]
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2008/07-tjc-Bronx Children's Psychiatric Center (BCPC)_2Ca*Clozaril [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-Mid-Hudson Psychiatric Center (MHPC)_6Fr [PSQ - pending]
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2008/04-tjc-Ancora State Psychiatric Hospital (ASPH)__15Ad+ [PSQ - pending]
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