Pg01- The Joint Commission to Include Patient Satisfaction Data on Quality Check®—Web Site Provides New Information to Help Patients Make Decisions FYI: JCSC, IM, PI. As the title suggests, TJC has begun (Jan 2009) including patient satisfaction data on their Quality Check report… if you report such data to the CMS Hospital Compare database. The latter is the source for the reporting. It does not appear that state hospitals are participating in this database. We sampled hospitals from all the states in our membership and none had the referenced satisfaction data included on their Quality Check.
Pg03-Approved: "Unlinking" Accreditation Decisions in Tailored SurveysFYI: JCSC. Effective immediately, if you have a tailored survey, "each organizational component’s accreditation decision will neither directly affect another component’s decision, nor will an organization’s overall accreditation decision be generated as the result of surveys of each of the organization’s required components."
Pg03-Update: The Joint Commission's Hospital Deeming Authority Application [**ALERT**] In order to successfully apply for renewal of its deeming authority (TJC accreditation affording deemed status for certain CMS requirements), the Joint Commission has had to bring its standards into fuller alignment with CMS. In most cases this has meant a refinement of language, but in some instances, it has meant new standards or elements of performance. Although the modifications and/or additions are still in draft status for the next 6 months, JCSC should definitely obtain, review and distribute them now. Those revisions that are not further refined will need to be implemented (and will be surveyed/scored) starting in July of this year. If you have not already done so, download New & Revised 2009 Accreditation Requirements in Response to CMS Deeming Application
Pg04-Update: The 2009 Decision Process FYI: JCSC. The main point of this article appears to be the announcement that the decision process for CON and PDA is changing. TJC survey results warranting consideration for CON or PDA are going to be based on something called 'programatic bands'. The article includes a chart showing 5 bands and the number of surveyor days that define each band for each program (e.g., HAP). So, if you are a hospital that required 1-4 surveyor days,you are in Band 1. How bands get translated into CON or PDA was not clear to us from this piece, but at the end of it, TJC promises "additional information" in an upcoming issue of Perspectives. For now, stay tuned… and wait for more details. Also note that survey reports will no longer (started Jan 2009) include a preliminary accreditation decision.
Pg05-Errata: 2009 Accreditation Manuals, All Programs [**Alert**] Two and a half pages of corrections are provided. Those relevant to psychiatric hospitals include standards in IC, LS, MM, NPSG, UP and PC. Since the corrections are effective immediately, those JCSC expecting survey soon should review the details.
Pg10-Update: Accreditation and Certification Deposit and Fee Information FYI: LDR, JCSC and FB. The TJC fee policy sections addressing Forfeiture of Survey Deposit and Survey Fees has been revised. The first issue is primarily a concern for initial customers/first-time surveys. The full revision to include details for making credit card payments is provided in the article.
Pg01-Interviewing with Ease Staff interviews during Joint Commission surveys can be less stressful if staff members know what to expect. Surveyors usually focus their questions on how each individual provides treatment and his/her role in the treatment team. When a staff member does not know an answer, the appropriate reaction is to tell the surveyor that he/she knows where to find the answer and then proceed to do so. Management and supervisory staff who hover over staff and surveyors during interviews are distracting and anxiety provoking for staff. JCSC may want to consider this article as a reassuring handout for unit staff.
Pg02-5 Sure-Fire Methods: Verifying New Staff's Identity[**REF**] Standard MS.06.01.03 EP5 requires hospitals to verify that the person who applies for medical staff membership and the person who shows up to provide care are both the same actual person named in the application. Five excellent strategies are listed for checking the applicant’s picture on his/her government-issued ID and comparing this with his/her appearance. Your hospital (especially MDx and MEC) is expected to determine the best strategy(ies) and the most appropriate staff to accomplish this and set a process in place. Five staff members suggested for this duty are: medical staff clerk; security officer; a specific member of the medical staff; a specific staff member in an off-site location where the applicant will be working; or a designated staff member who interacts with the applicant prior to the first day of work.
Pg03-The Summary Report: The Next Steps for OrganizationsFYI: JCSC, LDR. A change that began January 1, 2009 involves the report that surveyors provide to your hospital at the end of a Joint Commission survey. The Summary Report starts with a list of the not compliant standards and elements of performance that have a direct impact on your accreditation decision (Note that “direct impact” standards in the accreditation manual are marked with a triangle icon with a 3 inside it). Next is a list of not compliant standards that have an indirect impact. The Summary Report does not include the accreditation decision. The Joint Commission Central Office staff reviews the findings and posts an official accreditation report on your organization’s extranet site.
Pg04-Edition for Beginners: This Month's Tip: Advanced SearchingFYI: JCSC, PPR. The target audience for this article are those who use JCR’s E-dition, an electronic version of the standards manual. Clear, specific steps provide guidance for searching items such as how many standards or EP’s mention discharge planning.
Pg05-Featured Standard: Integrating Leaders Into Activities [**REF**] Standard LD.04.04.05 emphasizes the need for leaders to ensure that patient safety activities throughout the organization are integrated, rather than operating in compartments or “silos”. [Pearl] JCSC, LDR and PI should note that surveyors will be looking for evidence of the following as they survey this standard:
1. An effective connection of all activities that may have something to do with patient safety and quality so that safety is promoted, problems are reported, and failures are corrected.
2. Example of an RCA (preferably proactive), including effectiveness of follow-up that has generated learning throughout the hospital which is integrated into practice.
3. A blame-free internal reporting system so that staff members are comfortable reporting what seems to be sentinel event.
Pg06-Tracer Methodology 101: The Medication Management Tracer This article describes how to conduct a Medication Management Tracer with a Pediatric Focus. However, JCSC, Phrm and P&T can find information useful for any Medication Management Tracer including a list of sample tracer questions and a sidebar “Tips Checklist” of tracer strategies.
Pg01-Preventing Never Events: Stopping Air Embolisms During Surgery: [**ALERT**] No, embolisms are not particularly relevant to state hospitals, but Never Events are! CMS defines them as “serious and costly errors in the provision of health care services that should never happen”. The National Quality Forum (NQF), has defined 28 Never Events that include concerns for psychiatric hospitals such as death or serious disability associated with: elopement; medication error; fall; attempted suicide; restraints or bed rails. Also on the list is any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider; abduction of a patient of any age; and sexual assault on a patient within or on the grounds. JCSC, LDR and PI are strongly encouraged to obtain the full list and consider data collection and intensive analysis of such events just as you would asentinel event. NQF says such events “… indicate a real problem in the safety and credibility of a health care facility” and CMS is moving to discontinue payment for them. Note: On 1/15/09 CMS published final decision memos that discontinue payment for ("no longer cover") the following medical errors (never events): Wrong procedure, Wrong part, Wrong patientSee also:
MEDICARE AND MEDICAID MOVE AGGRESSIVELY TO ENCOURAGE GREATER PATIENT SAFETY IN HOSPITALS AND REDUCE NEVER EVENTS (CMS Press Release),
CMS IMPROVES PATIENT SAFETY FOR MEDICARE AND MEDICAID BY ADDRESSING NEVER EVENTS 202-690-6145, 8/4/08
Pg08-Establishing a Patient Advisory Council[**REF**] LDR, PtAd and SFT should seriously consider involving patients and their families in performance improvement work as one approach to address National Patient Safety Goal 13. The Patient Advisory Council (PAC) is a mechanism to structure this involvement utilizing a group of volunteer patients/family and staff who meet on a regular basis to address key hospital issues. The article provides a fairly detailed description of how to create the Advisory Council and how to use it to improve safety. A sidebar also delineates items to include on the hospital’s application form for Advisory Council membership.
Pg01-The New "Life Safety" Chapter: What It Applies to and How Organizations Can Comply with It : [**REF**] This is a good review for E&M, EOC and SFT of occupancy types and approaches to comply with the new separate chapter devoted to fire safety, as required by the National Fire Protection Association (NFPA) Life Safety Code. Occupancies include not only health care and ambulatory, but also the occupancies often maintained by state hospitals as group homes (usually lodging and rooming house occupancy) and residential facilities for 17 or more occupants (hotel and dormitory occupancy).
A concise outline of the Occupancy Types is provided in a sidebar. For freestanding business occupancies, the TJC does not require compliance with the Life Safety Code or LS standards; however, these occupancies, like all others, must comply with EC.02.03.02, EP4, which requires the organization to maintain free and unobstructed access to all exits.
Approaches covered in the article are Resolution of LSC deficiencies and creating a Building Maintenance Program. To resolve each LSC deficiency identified by your organization or others, your organization has three options: 1.) Correction within 45 days through a management process or corrective maintenance program. 2.) Obtain a LSC equivalency approved by TJC; or 3.) Create a Plan for Improvement (PFI).
The Building Maintenance Program (BMP) is an optional, proactive way to manage specific features of the hospital’s life safety program. The article provides an overview of various items included in a BMP, such as specific types of doors, grease-producing devices, horizontal exit doors, prohibition of combustible decorations, etc.
Pg04-Emergency Planning for the Long Haul: Mercy Health Partners Creates "96-Hour Operational Impact Chart" FYI: E&M, EOC and SFT. The standard that requires each hospital to manage without local community support for at least 96 hours (EM.02.01.01,EP3) requires diligent, ongoing planning. To prepare for extended sustainability, TJC encourages exercises that rehearse and plan strategies for escalating scenarios . One example is to begin an exercise with a community power outage scenario that escalates to an outage for the power grid of the community that will take several days to fix. To organize this type of drill and to guide the processes involved, one hospital developed a detailed, 96-Hour Operational Impact Chart. The chart and a discussion of the experience of the hospital that developed it are provided.
Note: This publication is now being provided in PDF format only).
Overview of accreditation changes for 2009 FYI: LDR, JCSC.
Although the following changes have been previously discussed, The Joint Commission’s decision to announce these 3 again stimulates us to make sure that JCSC are aware. The following are direct extracts from the TJC publication:
1) The Standards Improvement Initiative (SII) resulted in the elimination of some elements of performance and the “unbundling” of other elements of performance The SII process did not create new requirements but there is an increased number of EPs to improve clarity and measurability. … any increase in EPs cited as RFIs will not automatically indicate that there are more significant problems than found during surveys prior to 2009. …
2) …Instead of thresholds, program-specific “screening bands” will be used to identify organizations whose survey findings should be subject to a more intensive review by Joint Commission Central Office staff. … based on the number of noncompliant direct impact requirements, which pose an immediate risk to patient safety or quality of care.
3) … language changes have been made to the hospital standards to meet CMS requirements …. Compliance with any potential new deeming-related requirements, including compliance with the areas of specificity added to meet CMS regulations, will be reviewed by surveyors beginning January 1, 2009, but will not impact an organization’s accreditation decision until July 1, 2009. Non-compliance with these new CMS expectations will be reported to the surveyed organization after the survey in a separate document, for informational purposes. The changes scheduled for July 1, 2009 are subject to some modification pending further Joint Commission discussions with CMS. … These changes are being made to ensure conformity with Medicare’s Hospital Conditions of Participation, which all deemed accrediting bodies must assess. … the hospital deeming application process may necessitate additional changes during 2009.
Joint Commission appoints Mark G. Pelletier, RN, MS, Executive Director, Hospital Programs, Accreditation and Certification Services FYI: LDR, JCSC.
…Mark G. Pelletier, R.N., M.S., (has bee appointed) as the executive director for Hospital Programs and Accreditation and Certification Services. Pelletier is a health care executive with more than 20 years of experience in hospital operations, performance and quality improvement, process redesign and program development. He was most recently the senior vice president and chief operating officer of Condell Medical Center, Libertyville, Illinois.…
TJC What's New (2/5/09) -Medication reconciliation National Patient Safety Goal to be reviewed, refined [**Alert** JCSC] "…effective January 1, 2009, survey findings on National Patient Safety Goal 8 (Accurately and completely reconcile medications across the continuum of care) will continue to be evaluated during the on-site survey… (but) … survey findings from NPSG 8 will not be factored into the organization’s accreditation decision… (,) will not generate Requirements for Improvement (RFIs) and will not appear on the accreditation report".
