Welcome Sara Virginia Knight, RN, PhD as RTP Co-Reviewer.
**ALERTS: 09NPSG, SEA #42, PPR Repop, NY CLIA, New Waived Tests **REFS: Contract Services, Disruptive Behav, Pt Flow Tracer, Emerg Comm
Jump quickly to the Alerts, Reference Articles or a specific RTP Section with our new orange Jump Links!
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THE JOINT COMMISSION (TJC and JCR)
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[Index] Perspectives (January, Vol 29 #1)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01-Update: National Patient Safety Goals Undergoing Review During 2009—No New NPSGs for 2010 Based on compliance difficulties and feedback from the field, TJC has decided to perform 'an extensive review' of NPSG during 2009. Using the Standards Improvement Initiative (SII) process, NPSG will be clarified, revised and some redundant ones may be eliminated. No new goals are to be developed for 2010 when SII recommended changes would take effect. State hospital JCSCand LDR are encouraged to participate in the current survey… Today (1/12/09) we learned that the survey the article invites you to participate in actually ended on 12/30/08. We are exploring options for SHCC members to still have an opportunity for input. [**ALERT: JCSC **] 1/15/09: In response to our request, TJC has re-opened the 2009 NPSG survey until 1/30/09. Please make sure there is state hospital input on the goals. Click here and take the survey!
Pg03- The Joint Commission Releases Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety, 2008: Report Shows Gains in Safety, Quality FYI: JCSC, LDR. The report describes the results of tracking hospital performance on 25 quality measures reflecting evidence-based treatment. The primary focus is, of course, on primary healthcare issues such as heart attack and surgical performance along with some data on NPSG compliance. Needless to say, TJC accredited hospitals have 'steadily improved the quality of patient care over a six-year period. However, the article/report acknowledges the need for significant additional progress. See the full report at: www.jointcommissionreport.org
Pg04- The Joint Commission Names 2008 Ernest Amory Codman Award Recipients: National Health Care Award for Performance Measurement FYI:JCSC. Winners in the hospital category were:
• Carolinas Medical Center, Charlotte, North Carolina;
• Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
• Mission Hospital, Mission Viejo, California
None of the featured programs were psychiatric in nature.
Pg06- The Joint Commission's Latest White Paper Urges Major Changes for Hospitals: "Hospital of the Future" Report Proposes Principles, Actions to Guide Future Development FYI: JCSC. This latest white paper from a TJC-sponsored expert panel 'contends that hospitals must respond in new ways to challenges' such as older and sicker patients, patient safety and quality of care, economics, and the work force. Guiding principles and actions are offered in the following five core areas:
1. Economic Viability (E.G., Use process improvement tools to increase efficiency and reduce costs)
2. Technology Adoption (E.G., Widespread adoption of health information technology)
3. Patient-Centered Care (E.G., Make adoption of patient-centered care values a priority)
4. Staffing (E.G., Create workplace cultures that can attract and retain health care workers)
5. Hospital Design (E.G., Improve safety with evidence-based design principles)
You can download or get more info on the report from TJC.
Pg08- The Joint Commission Names Five New Members to Board of Commissioners FYI: JCSC, LDR. The five new members include three physicians (no psychiatrist), an oral surgeon and a university hospital COO/attorney.
Pg09- Reminder: Manual E-ditions Now Available FYI: JCSC. Don't forget to take advantage of your one free single-user license for a manual E-dition. For more details on the features and benefits of the new E-dition, see the December 2008 issue of The Joint Commission Perspectives®, page 5. or go to: http://www.jcrinc.com/e-dition. Note: Additional licenses for Single Users Hosted = $469 while a Site License Hosted would cost $2,345. If you have begun to use your Edition, please share feedback on your experience via our Discussion Board
Pg10- Sentinel Event ALERT: Safely Implementing Health Information and Converging Technologies [**REF**] This article is essentially a reprint of Sentinel Event Alert #42 which focuses on the prevention of 'technology-related adverse events. Although most of the 13 recommendations are pro-active new implementation strategies, a number are specific to the post-implementation phase making this a must read for IT and LDR. In addition, if like approximately 83% of hospitals in the US, you have an automated dispensing cabinet (ADC), your P&T, RNx, MDx should also download and review a copy of the Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets (PDF). This contains an additional 12 guidelines on such issues as ADC location, number, security, stocking procedures, inventory, etc.
Pg14- Joint Commission Requirement: Clarification: Pediatric Emergency Medications and Immediate Threat to Life Few state hospitals have Pediatric crash carts. However, if your hospital does, P&T should attend to this refined definition of Immediate Threat to Life. Bottom line: "The only time that the patient is at risk of significant harm (Immediate Threat to Life) is when only the higher (or adult) strength of a medication is stocked in a crash cart, and the organization’s policy, protocol, dosing charts, or routine practice in handling pediatric codes is based on the less concentrated pediatric strength."
Pg15- Update: 2009 Standards FAQs Now Available Online FYI: MD, RN. To access the 2009 Hospital FAQ, click here.
[Index] The Source (January Vol 7 #1)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Your Refreshed Re-Source FYI: JCSC. The Source currently is considered to be the Joint Commission’s most practical publication, and this article outlines plans to increase its emphasis on “how-to” information and tools to assist with compliance requirements. In 2009, several new features will be covered in each issue, including Tracer Methodology 101, which will feature a tracer scenario each month with sample questions and checklists.
Pg02- 5 Sure-Fire Methods: Leadership's Responsibility for Contracted Services [**REF**] Many of our hospitals contract with outside services for staffing and compliance with LD.04.03.09 is challenging. To provide the foundation for monitoring such contracts, this article emphasizes the necessity of establishing clear service expectations and how they will be evaluated as part of the contract. Tips include avoiding a tendency to assume that an agency provides safe and quality care simply because it is accredited. LDR and HR should note the specific strategies covered that include: performing routine, unannounced observation visits; monitoring of patient and staff satisfaction with performance; and auditing of documentation by contractors. Although not a requirement of LD.04.03.09, keeping a copy of the current license for each contracted staff member can help address HR.01.02.05, EP 1 and HR.01.02.07, EP 1.
Pg03- Featured Standard: Storing Medications Safely This is a discussion ofMM.03.01.01, which surveyors scored as not compliant in 43% of hospitals in 2007. Phrm, P&T and PPR should be aware that this standard has 18 EPs beginning in 2009, and noncompliance with any one of them means that an organization can be scored as not compliant. The article provides several recommended strategies, including: rounds by leaders; active involvement of supervisors; increased attention to security of medications at all times; training for staff on the regulations; and methods to ensure monitoring of temperatures in medication refrigerators. See also: SL1 MM Highlights: Source Nov 08 Vol 6 #11 Pg06 Storing Medications Properly: Complying with Standard MM.03.01.01 [**REF**] and TJC FAQ on Medication Refrigerator Temperature Logs, Sample Policy: Refrigerator Temperature Monitoring (from University Of Kentucky Hospital, Chandler Medical Center (Aug, 2007)
Pg04- E-dition for Beginners: This Month's Tip: "Filtering" Since late November of 2008, one leader within each accredited hospital has been provided a number that allows access to the E-dition, the electronic standards manual that applies to the whole organization. This article provides steps for use of the filter tool to reduce and focus the number of standards and elements of performance displayed to only those that apply to the organization’s services. This should be useful for JCSC and PPR. See also related article in Perspectives above.
Pg05- Repopulating Your PPR [**ALERT: JCSC **]. Due to changes in the standards manuals for hospitals, ambulatory, and home care, Periodic Performance Review (PPR) tools for these services now require steps to “repopulate” their PPR. This article provides guidance and encouragement to complete the steps as soon as possible so that staff can use their PPR to assist with continuous compliance. Note that behavioral health care, long term care, and laboratory accreditation programs will need to evaluate only those standards labeled as requiring an update. For a summary of key dates/deadlines see also: Nov RTP[**ALERT: JCSC **] - Source Nov 08 Vol 6 #11 Pg03- Going Offline, Staying on Course: What You Can Do When the PPR Is Down
Pg06- Tracer Methodology 101: The Patient Flow Tracer [PEARL] Again, we want to remind you that, this issue is relevant to state hospitals. JCSC should review this month’s column that explores one example of how to conduct a patient flow tracer and includes sample questions that may be asked of representatives from various departments and services. A sidebar “Tips Checklist” includes several suggestions to consider when implementing your own patient flow tracer.
Pg08- Spotlight on Success: Successfully Sharing Tracer Data This article describes the approaches of a general teaching hospital that has firmly integrated tracers into its organization’s culture. The page included from a sample data collection tool may provide ideas for your JCSC and staff who design tracer tools.
[index] Patient Safety (January Vol 9 #1)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg02- Preventing MRSA in the Neonatal Intensive Care Unit at Beth Israel Medical Center Ensuring accuracy of medication reconciliation lists across the continuum as required by NPSG #8 is an ongoing challenge for psychiatric hospitals, P&T, MD. During internal patient tracer activities, most of our hospitals identify some significant inaccuracies on their lists. A close study of accuracy of emergency department medication lists revealed that 56% had omissions and 80% had dosing or frequency errors; 87% had at least one error.
Pg02- Patient Safety Pulse: Your Patient Safety News Although not directly applicable for most of our hospitals, Quality Managers and PI may want to stay informed of the recently released inventory of health care quality measures released by the Department of Health and Human Services recently, available at www.qualitymeasures.ahrq.gov.
Pg06- Part II. Providing Safe and Beneficial Enteral Feeding: Ensuring That Patients Tolerate Tube Feeding FYI: LDR, RNx. Consistent with the long held beliefs of most of us, a study in the September/October 2008 issue of the American Journal of Medical Quality found that the risk of patient harm increased when the number of areas in a hospital experiencing high volume increased. Ref: The Tipping Point: The Relationship Between Volume and Patient Harm. American Journal of Medical Quality 2008 23: 336-341. [Abstract]
Pg08- Managing Disruptive Behavior [**REF**] The concept of disruptive behavior spans beyond the overt behaviors that are familiar items which most hospitals cover in ethics and orientation programs, such as verbal abuse, harassment, condescending or berating behavior, lack of respect or physical abuse. Disruptive behavior that is identified most in hospital settings consists of more covert interference with communication, team performance, or safe patient care. Some examples are staff who constantly criticize other members of the patient care team, those who incessantly complain without taking any positive action, and those who obviously do not pay attention in meetings. The article outlines steps for LDR, HR, TxTm, MD, RN and others to take to address disruptive behavior and a side bar that encourages the proactive use of a Code of Conduct. See also a PDF of PowerPoint on Disruptive Behavior1001 by Sue Dill Calloway,RN, MSN, JD submitted by Phillip Ward (Bryce PI Director) and Pam Ward (ADMHMR) with useful references and special relevance for physicians.
Pg11- Educating Patients and Families About Infection Control: Practical Questions and Common-Sense Answers The Joint Commission expects hospitals to educate patients regarding infection control practices as a basic health practice, including hand hygiene and cough etiquette (PC.02.03.01). The article encourages more education, including providing handouts to visitors, such as the Joint Commission’s “Speak Up” campaign brochure called Five Things you Can Do to Prevent Infection. IC, PtEd and StEd should consider the suggested actions that include increasing awareness among staff members to identify visitors and staff who have signs of a potentially communicable infection
[Index] Environment of Care News(January Vol 12 #1)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Environment of Care® News: Broadens Focus - Emergency Management, Life Safety Given New Emphasis Joint Commission accreditation manuals for hospitals and ambulatory care (all Phase One programs) now have two new chapters: “Emergency Management” (EM) and “Life Safety” (LS). Behavioral Health Care for 2009 only has the new “Life Safety” chapter. This article delineates plans for 2009 Issues of EC News, which include expansion of coverage to provide specific, practical, and accurate advice on how to meet the requirements of all the EC-related chapters. An overview of Emergency Management expectations includes attention to the six critical functions during an emergency and evaluation of emergency planning. The summary of Life Safety emphasizes that format of the new LS chapter (applicable for both hospitals and behavioral health) incorporates the structure of the Life Safety Code, NFPA 101-2000. This also includes a brief mention of each specific standard that shifted from EC to other chapters for 2009. This is a good review for EOC and JCSC.
Pg06- Emergency Management's Six Critical Functions: Function 1: Emergency Communications - How to Keep the Lines Open [**REF**] The standard EM.02.02.01—Emergency Communications is discussed, including each Element of Performance. The article provides useful assistance for EOCand E&M to understand each EP. Sidebars include: ”Key Tips for Emergency Management Communications”; “Tips for Notifying Outside Staff of an Emergency”; “Tips for Notifying In-Building Staff of an Emergency” ; and “Tips for Backup communications Systems”.
Pg08- Universal Design for Health Care Facilities - Addressing Safety, Access to Care for a Diverse Patient Population The concept of Universal Design (UD) ensures that facilities, products, and services are usable by all people. For healthcare facilities, this means eliminating barriers to patient care while improving patient safety, going beyond the minimum requirements set by law. A sidebar lists the “Seven Principles of Universal Design”. For our hospitals, the best way for LDR and E&M to begin thinking in these terms is to pay closer attention to individuals who you identify as potentially receiving inadequate care, such as those who are hearing impaired, have language barriers, have physical or other challenges. For more info on UD, goto The Center for Universal Design (CUD)
Joint Commission This Month For State Hospital Associations (December 2008)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
[Note: All of the 2008 issues of this publication have been significantly delayed and as a result, information provided has often been provided elsewhere. For this reason, reviews of this publication will no longer lead off the RTP. December 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)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
- 12/22/08 Federal Register Notice E8–30452: New York CLIA Exemption - "CMS has granted exemption from CLIA requirements to laboratories located within the State of New York that possess a valid permit under Article Five of Title V of the Public Health Law of the State of New York and its implementing regulations at 10 N.Y. Comp. Codes R. & Regs., Title V, Part 58."
- S&C-09-10 (PDF) : “Standing Orders” in Hospitals
INTERNET HIGHLIGHTS
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
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)
SHCC Additions (Note: This section may be updated throughout the month)
Recent Member Surveys (SL5)
It is not too late to submit your PSQ! Go to www.shccPSQ.com or send us a copy of your survey report. Our first analysis of state hospital-specific trends will be reported later this month.
- 2008/11-tjc-Arizona State Hospital (AzSH)_4Ad1Ca4Fr [PSQ - pending]
- 2008/08-tjc-Manhattan Psychiatric Center (MPC)_??????*Viol*Polydip*Hisp [PSQ - pending]
- 2008/07-tjc-Kirby Forensic Psychiatric Center (KFPC)_3Fr [PSQ - pending]
- 2008/07-tjc-Bronx Children's Psychiatric Center (BCPC)_2Ca*Clozaril [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-Mid-Hudson Psychiatric Center (MHPC)_6Fr [PSQ - pending]
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- 2008/04-tjc-Ancora State Psychiatric Hospital (ASPH)__15Ad+ [PSQ - pending]
RTP Jump**Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
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)
