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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (March, Vol 29 #3)
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Pg01- Approved: Will Not Score Medication Reconciliation in 2009: The Joint Commission Plans to Review, Refine NPSG 8 for 2010 FYI: JCSC. Due to difficulties meeting the complex requirements of NPSG #8, changes in scoring are retroactive to January 1, 2009. Surveyors’ findings on NPSG #8 will not contribute to an organization’s accreditation decision and will not appear on accreditation reports. Surveyors will continue to evaluate compliance with NPSG #8 to collect data for Joint commission process improvement efforts. TJC plans to create an improved NPSG #8 to be implemented in 2010.
Pg03- Approved: Additional Unannounced Survey Exceptions and Advanced Notice Provision FYI: JCSC. These behavioral health care programs now will receive seven days of notice in advance of their survey: All methadone programs, if not part of a hospital; All in-home behavioral health, case management, or ACT programs, if not part of a hospital; All freestanding organizations with 10 or fewer staff or a total average daily census of less than 100; and all community-based, freestanding programs.
Pg04- Update: MS.1.20 Task Force FYI: JCSC, MEC. There is an indefinite moratorium on the implementation of EP 19 of the current MS.1.20/MS.01.01.01. Surveyors will survey EP’s 1-18 to determine if each topic is addressed in the bylaws. Surveyors also will determine if necessary detail is addressed either in bylaws, rules or regulations, or policies.
Pg05- Clarification: Notification to Organ Procurement Organization FYI: JCSC, PtAd, Chp. Your policies and procedures related to notification of the OPO regarding a death should be checked and revised as needed to comply with the revisions to standard TS.01.01.01, EP 9. The major changes are that the OPO is not required to be notified of imminent death unless the patient is mechanically ventilated and notification ideally is within one hour of death.
Pg06- Top Standards Compliance Issues for First Half of 2008 [ALERT:JCSC, PPR, E&M, P&T] Standards most frequently identified in surveys as “not compliant” are listed for each program. Forty percent (40%) or more hospitals received RFI’s for EC.5.20regarding Life Safety code compliance; NPSG #2C regarding measurement and improving timeliness of critical tests, results and values; and IM.6.50 regarding verbal and telephone orders.Download 17 Most Challenging Standards for First Half of 2008
Pg07- Update: Sentinel Event Statistics Available Online FYI: JCSC. Six of the top ten sentinel events as of December 31, 2008 are concerns for State Hospitals: #2 Suicide; #4 Medication error; #5 Delay in treatment; #6 Patient fall; #7 Assault, rape, or homicide; #9 Patient death or injury in restraints. To view the report, visit www.jointcommission.org/SentinelEvents/Statistics. Compare these to the findings of our recent PSQ Analysis.
Pg07- The Joint Commission to Develop Hospital Standards for Culturally Competent Patient-Centered Care: Commonwealth Fund Grant to Support Initiative FYI: HR, PtAd. The new standards are not expected to go into effect until 2011, but stay alert for the implementation guide that is to proceed this. (More info)
[Index] [Blog] The Source (March Vol 7 #3)
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Pg01- Spotlight on Success: Hospital Built 'All-Digital': Training supports paperless system FYI: IT, LDR. The experience of implementing an electronic medical record as shared in this article may be useful for those hospitals heading in the same direction. This Wisconsin hospital's decision to develop a completely electronic system (i.e., paperless) added some special dimensions to the implementation and training processes.
Pg02- 5 Sure-Fire Methods: After-Hours Medication Needs FYI: Phrm, P&T. The five suggested strategies are:
1 - Limit the supply of medications outside the pharmacy
2 - "Develop a process that minimizes the risk of retrieval errors"
3 - Develop a "decision tree' to guide after hours calls to the pharmacist
4 - Pharmacist reviews off-hour orders when pharmacy opens
5 - Be sure to address both MM.05.01.01 and MM.05.01.13
Pg03- Featured Standard: Collecting Data to Improve Safety FYI: PI. This article about compliance with Standard PI.01.01.01 reminds the reader to involve line staff and patients in the data collection process as well as the development of data collection tools.
Pg04- Edition for Beginners: This Month's Tip: Bookmarking FYI: JCSC, PPR, ALL. For those who have obtained an E-dition of the standards manual, it is suggested that you use the 'My Favorites' feature to achieve bookmark-like access to your most frequently needed standards. The steps for setting this up are described.
Pg06- Tracer Methodology 101: The MRSA-Related Tracer Given the increasing significance of MRSA and articles like this, IC and JCSC should be prepared for an MDRO-focused tracer. A basic scenario for such a tracer is provided as are sample questions. The latter should be considered a heads up for those expecting survey and a useful basis for conducting one's own practice tracers.
[index] [Blog] Patient Safety (March Vol 9 #3)
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Pg02- Patient Safety Pulse: Your Patient Safety News [*ALERT: IC*] The US Department of Health and Human Services has established a set of five-year “national prevention targets” to prevent HAIs. The plan targets some infections that many state hospitals have experienced, including MRSA, Clostridium difficile, and catheter associated infections The HHS plan includes prioritized, recommended clinical practices and can be accessed atwww.hhs.gov/ophs/initiatives/hai/index.html. Also remember that the Joint Commission NPSG #7 requires management of identified HAI cases as sentinel events.
Pg02- Top 5 in the News: Agency Advises Organizations About Antiviral Drugs: FYI:IC. This article describes a new recommendation that may have implications for your current hospital emergency planning. The recent HHS recommendation is to continuously provide antiviral medication during an influenza pandemic for health care workers and patients who have weakened immune systems. [Pearls] The new guideline is available athttp://www.pandemicflu.gov/vaccine/antiviral_use.html. Additional HAI References, checklists, toolkit, and guidelines are available at www.pandemicflu.gov/plan/healthcare. See also theCDC's Pandemic Influenza Course with free 186-page Pandemic Flu Course Book.
Pg05- Strategies for Eliminating Catheter-Related Urinary Tract Infection [**REF**]IC, RN. Some state hospitals that have long term care or medical units allow the use of urinary catheters. For such facilities, this article is a good review of the risks involved. It also notes the fact that CMS will no longer pay for the extra costs associated with catheter-associated urinary tract infections. To guide catheter use, four clear strategies and a decision tree are presented.
Pg08- Preventing Home Fires Associated with Long-Term Oxygen Therapy FYI:SFT. This article addresses fire hazards involved with ambulatory patients who require oxygen. These individuals usually have COPD and may continue to smoke if possible in any setting. Several of the precautions described may be applicable to state hospital patients who require oxygen.
[Index] [Blog] Environment of Care News(MarchVol 12 #3)
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Pg01- Emergency and Security Planning for a VIP Event: When a Convention Attracts the Unconventional FYI: SFT This is a review of the detailed planning and actions taken by two hospitals in St Paul to achieve readiness for the Republican National Convention in 2008. Both hospitals used their Emergency Management Plans to guide their activities. Careful planning, coordination of efforts both internally and throughout the community, and communication were key. A sidebar displays some frequently asked questions that one of the hospitals addressed in handouts for patients, families, and visitors.
Pg04- EM's 6 Critical Functions: Function 2: Resources and Assets: Securing Supplies for Disaster Survival [**REF**] JCSC. As part of the planning process for securing supplies, five major steps are discussed in this article: Identifying Medication and Supply Needs; Working with Suppliers to Develop Emergency Supply Plans; Working with Other Organizations; Maintaining a List of Supplies; and Planning for Evacuation. Creation of a multidisciplinary team to accomplish each of these steps is recommended and highlighted in a sidebar. See alsoEmergency Management's Six Critical Functions: Function 1: Emergency Communications - How to Keep the Lines Open or review in RTP 0901
Pg08- When All Is Calm: AnMed Home Care Prepares for Disaster Before the Storm FYI: JCSC. When planning for disaster, community programs affiliated with State Hospitals face many of the same challenges as the home care agency featured in this article. An organization that has 110 employees describes their construction of an all-hazards emergency plan, including risk assessment, drills, and advice based on lessons learned. A sidebar clearly outlines this small agency’s main challenge, solutions, and outcome of emergency preparation and management.
Joint Commission This Month For State Hospital Associations (March 2009 - PDF)
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Note: Significant informaton from the March edition has been covered elsewhere. Click PDF above for a copy.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- What's New Page - January 2009 [PDF, 110 KB]
- CMS-2274-CN, entitled “Medicaid Program; Fiscal Year Disproportionate Share Hospital Allotments and Disproportionate Share Hospital Institutions for Mental Disease Limits,”
System (IPPS), … and Inpatient Psychiatric Facility (IPF) PPS Changes. FB
INTERNET HIGHLIGHTS
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Centers for Disease Control and Preventions (CDC)
- The Crisis and Emergency Risk Communication Course (CERC)
- Free online course with possible education credit
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Webinar: Crisis and Credibility Communication (PDF). The presentation focuses on crisis and emergency risk communication, reputational risk, and delivering difficult news. Crisis and Emergency Risk Communication (PDF), full text, 277-page course book
- Additional Resources available from CERC include:
- Training Curricula & Tools
- Course Books (free downloads)
National Association of State Mental Health Program Directors(NASMHPD)
SHCC Additions (Note: During March the SL1 library will convert to 2009 Standards/terminology)
Recent Member Surveys (SL5)
If you anticipate a survey soon, please click here
Reviews by Sara Virginia Knight, RN, PhD and Richard Fields, MD
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)
