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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (April, Vol 29 #4)
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Pg01- Field Urges Focus on Three "Burdensome" Requirements FYI: JCSC. Back in January we encouraged state hospitals to respond to the TJC survey requesting feedback the 2009 NPSG. As a result of our request TJC extended the deadline to allow your participation. That survey has resulted in 3 NPSG being identified as 'burdensome' and consequently scheduled for review and possible refinement. The 3 requirements in question are Universal Protocol, Medication Reconciliation and Staffing Effectiveness. Scoring for Medication Reconciliation has already been placed on hold. Please stay alert for upcoming field review on proposed changes. Your input can make a difference.
Pg03- Approved: Revisions to the Public Information Policy FYI: LDR, JCSC. Previously, TJC could only release info to 'appropriate authorities' if it were denying accreditation as a result of an Immediate Threat to Health and Safety. The revised policy allows disclosure whenever there is "public risk even for individuals not currently receiving care from the organization". Text of the specific revisions is provided.
Pg06- Update: Number of New and Revised Requirements Reduced as Part of CMS Deeming Authority Application FYI: ALL. See related review in the Internet section below.
Pg07- Are You Getting the Most from Your New E-dition? FYI: JCSC. This snippet of an article is basically an advertisement for the E-dition and the site vs. the complementary single-user version. However, it raises a good question to which we have been receiving mixed feedback. Please share a brief word about your experience with E-dition (either version).
Pg10- Clarification: The Effect of Disruptive Behavior on a Culture of Safety [••REF••] This article provides useful TJC perspective on the definition of disruptive behavior in general and intimidation in particular. This further clarification of 2009 Leadership Standards is a worthwhile read for LDR and anyone needing to fine-tune their code of conduct.
[Index] [Blog] The Source (April Vol 7 #4)
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Pg01- Assessment and Documentation: Important Details Needed at Admission FYI: UrUm, IM. The article is a reminder of the importance of good admission documentation with an included checklist of key elements and some recommendations for assessing the need for improvement in this area.
Pg02- 5 Sure-Fire Methods: Complete and Accurate Medical Records FYI: IM, UrUm, JCSC. The requirement for maintaining complete and accurate medical records (now Standard RC.01.01.01) has been a significant survey compliance challenge for a number of years. One of 5 recommendations provided is to " Designate a person or a group to review and revise policies based on regulatory changes"
Pg04- Edition for Beginners: This Month's Tip: History Tracking FYI: All. The history tracking feature identifies changes to an EP that may have occurred between the current and previous version of the EP. These changes are displayed in a side by side comparison using one of three icons. The icons and how to manage the display are described in the article.
Pg06- Tracer Methodology 101: Staff Training for Tracers [••REF••] The 'how to' series on tracer methodology continues with this installment actually including a bit of a behavioral health care organization scenario. We believe all hospital LDR and JCSC should conduct practice tracers for improvement purposes as well as survey readiness. This article suggests useful tips, steps and strategies for training staff to conduct tracers. Key concepts include focusing on process improvement vs. staff competency and conducting tracers on a regular basis as part of a culture of safety. The latter practice not only prepares staff but also improves the skills of those who conduct tracers.
[index] [Blog] Patient Safety (April Vol 9 #4)
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Pg01- Spell It Out: Ensuring Compliance with Do-Not-Use Abbreviation Policies [••REF••] JCSC, MD, P&T, PHRM. There is some concern that compliance with NPSG 0202.01 may have fallen off since its implementation in 2004. We are reminded that between 2004 and 2006 almost 30,000 abbreviation-related medication errors were reported to the U.S. Pharmacopeia (USP) MEDMARX program and most of those originated with the prescriber. [Pearl] Some real life examples are provided along with 10 recommended strategies you should read for improving/maintaining compliance. Download free DNU list, brochure, poster, slide show and training video (3.5 min).
Pg02- Endorsing a Framework and Preferred Practices for Measuring and Reporting Cultural Competency FYI: LDR, HR, StEd. NQF has now completed a study of cultural competency that produced an evidence-based framework, 4 guiding principles and 45 recommended practices. See also: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care by the Institute of Medicine (IOM) that was part of the impetus for this NQF study.
Pg02- Patient Safety Pulse: Your Patient Safety News FYI: P&T, Phrm, MD. The Feb 19 2009 issue of the New England Journal of Medicine includes and article entitled Estimation of the Warfarin Dose with Clinical and Pharmacogenetic Data. This study by the International Warfarin Pharmacogenetics Consortium reports the development of an algorithm for estimating Warfarin dose based on clinical and genetic data that improves the estimation of initial dosing.
Pg05- Preventing Never Events: Pressure Ulcers Although the focus of this topic is on longterm care, state hospital RN, StEd with elderly and/or longer term patients may also find it useful to review the strategies and tips presented. The chief recommendation is for early identification of at-risk patients. These would include "those who are older, immobile, incontinent, malnourished, dehydrated… and those who have sensory deficiencies, multiple comorbidities, or circulatory abnormalities such as diabetes mellitus". Remember that 'Never Events' are clinical care issues that should never occur. See also CMS IMPROVES PATIENT SAFETY FOR MEDICARE AND MEDICAID BY ADDRESSING NEVER EVENTS Note: CMS will no longer pay health care organizations for any extra costs associated with Stage III or IV pressure ulcers.
Pg08- Assessing Patients' Potential Suicide Risk The best line in this NPSG.15.01.01 article is, "Suicide is a permanent solution to what is in most cases a temporary problem". The best resource in the article is a listed reference to the CDC's Violence Prevention section (includes suicide) of their National Center for Injury Prevention. [Pearl] StEd and PtEd may want to take advantage of their 2-page fact sheets (e.g., 'Understanding Suicide and 'Suicide Facts At A Glance'), podcasts and other free resources listed there.
Pg10- Is This an Outbreak? Identifying New Influenza Cases FYI: IC, StEd. We still have another month in Flu season (Nov to April). Although this article also focuses on longterm care, it contains relevant principles for our state hospitals as well. For StEd there is a brief review of the classic signs and symptoms of the Flu. For IC there is a listing of most common reasons for employee refusal of vaccination and strategies for overcoming them.
[Index] [Blog] Environment of Care News (April Vol 12 #4)
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Pg01- Facing Down Hurricane Ike: University of Texas Medical Branch Plans, Executes, and Recovers from an Evacuation FYI: E&M. Our SHCC members from Louisiana could probably have written this article. In other states where hurricanes may not be likely, you can still find useful insights on the management of evacuations in this article. There is a useful sidebar on 'Getting Help From the National Weather Service…' and a 3-page Checklist* for Hospitals Planning to Reopen After Hurricane and Flooding. *Note: The checklist is available in the electronic version of this month's EC News or in hardcopy in the Jan 2006 issue of EC News, pg 6-9.
Pg06- Help for When the Sky Is Falling and You're Facing Evacuations: The National Weather Service and Severe Weather Events [**REF**] E&M can find additional assistance from the National Weather Service (NWS) in making the important decision about the need to evacuate. Hospitals can consult with a 'warning coordination meteorologist' (WCM) by calling your local NWS office*. [Pearl] WCM resource persons not only provide weather warning information, but are also available for outreach, education and training exercises, especially for administrative staff and professional development (free of charge). Hospitals (e.g., Louisiana) subject to hurricanes or flooding should also take advantage of the advance warning provided in a new NWS tool, 'Tropical Cyclone Impact Graphics'. An example of the latter is provided in the article. *Note: The person listed with each local office is usually the WCM and is often at extension 223
Pg08- Managing Outside Maintenance Contractors: Keeping an Eye on Who's Minding the Shop [**REF**] EOC Ldr should review the TJC expectations in this article related to contract management. A chief recommendation is that contracts be structured to define performance expectations. For example, you can stipulate that documentation of any test explain what was done to demonstrate that the equipment or system passed the evaluation. E&M should also consider developing a “dashboard” matrix of equipment that is being maintained by contractors. This could be monitored by the Safety Committee (SFTcom)
Joint Commission This Month For State Hospital Associations (April 2009 - PDF)
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Note: The last published edition was February. Review is pending. Check back.
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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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Joint Commission Behavioral Health Update (Newsletter from Barrins & Associates)
Joint Commission
National Association of Psychiatric Health Systems (NAPHS)
National Association of State Mental Health Program Directors (NASMHPD)
SHCC Additions (Note: During March the SL1 library will begin converting to 2009 Standards/terminology)
2009 Member Surveys (SL5)
If you anticipate a survey soon, please click here
This year is off to a challenging start. We really need your 2009 feedback! Go to www.shccPSQ.com or send us a copy of your survey report.
Reviews by Sara Virginia Knight, RN, PhD and Richard Fields, MD
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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, UrUm: Utilization Review/Management, X: Exec, Dir or Chief (e.g., MDx = Medical Director)
