••ALERTS: Revised Scoring, Telemed Requirements, H1N1,CMS Teleconf, ••REFS: Target Analysis, Med Mgt Eval, Continuity Tracer, LS Chapter Part 2, H1N1, Hand Hygiene, Verbal Orders
••Downloads: Target Analysis Aids, Safe Practice Guide, Hand Hygiene Measurement, ••Free E-Course: Pandemic Influenza Preparedness
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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (May, Vol 29 #5)
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Pg01- UPDATE: Summary of March Changes from CMS Hospital Deeming Application: [ALERT: JCSC, MD]. This is the Perspective update promised by TJC in the March 26 conference call. As most of you know by now, TJC has been bringing its standards more closely in line with relevant CMS Conditions of Participation (COP). This is a long needed process that has been 'inspired' by TJC's need to re-apply and be re-approved for deeming privileges with CMS. The latest refinement of standards reduced the modified number of new and revised requirements from 165 to 87. And, of that remaining number, TJC assures us that " In most cases, Joint Commission standards already covered these topics, just not in the specificity now required by CMS". However, there are about 37 new EP in 4 areas that would be exceptions to that statement. 2 of these areas apply to our hospitals. The first has to do with seclusion and restraint (27 EP). If you use TJC accreditation for deemed status (as most state hospitals do) then revised Standards PC.03.05.01 through PC.03.05.19 will replace PC.03.02.01 through PC.03.03.31. The second area of exception relates to the history and physical exam (3 EP). The article includes a chart of CMS-Related Changes Scheduled for Implementation April 6, 2009. Audio replay (until the end of this month) and a transcript of the March 26th Deeming Status Teleconference are available. Support materials (e.g., AMP, automated PPR, E-dition) for accredited hospitals will be updated by July 1, 2009
Pg03- Update: Revised Scoring for All 2009 Accreditation Manuals FYI: JCSC. The changes involve 16 requirements relevant to state hospitals that are spread over the EC, IM, MM, PC, RC and RI chapters., Most of the revised scoring is about changes in EP type from C to A with the addition of an MOS. The article includes a table listing of the specific requirements and their changes.
Pg04- Update: Target Analysis Methodology for Assessing Hospital Performance [••REF••] Yes, this new methodology for assessing hospital PI will be applied to psychiatric hospitals and their new core measures. That said, JCSC and PI should dig into this enough to be able to properly read and interpret their next set or ORYX reports. A sample report page is included, but more details will be available in an updated version of The ORYX Performance Measure Report User Guide that should soon be available under the “Performance Measurement (ORYX).” section of your TJC Connect website. However, on 5/1/02, Frank S. Zibrat (Associate Director, ORYX Implementation) was kind enough to provide two explanatory documents and permission to share them with our members: • Target Analysis Methodology (revised 3/12/09) • Using ORYX Data Target Analysis
He and his statisticians are also available to answer questions by email (hcooryx@jointcommisssion.org) or phone (630)792-5085)
Pg06- Update: Comparing Joint Commission and CMS Telemedicine Requirements [ALERT: JCSC, LDR, MDx] Bottom line: CMS (S&C-05-04) requires full credentialing and privileging of the LIP by the medical staff at the hospital where the patient is being treated. However, TJC (MS.13.01.01 and LD.04.03.09) can allow a hospital/medical staff to rely on the C&P decision another accredited hospital where that LIP provides similar care. Currently you could be found in compliance by TJC and out of compliance by CMS for the same approach. TJC says they are working on this matter with CMS and further updates will be provided in a future issue of Perspectives. See also the recent SHCC Discussion Board Special Topic: New TJC Rigor On C&P.
Pg08- Approved: An Extension for Extension Surveys FYI: LDR, JCSC. The time frame for conducting extension surveys is generally 4-6 months. However, that time frame has now been increased to 12 months for surveys occasioned by a new service or site. Other conditions requiring extension survey will continue with the old time frame.
Pg09- Errata: All 2009 Accreditation and Certification Manuals FYI: LDR, JCSC. EOC, PtAd, Details are provided in the article. Although the changes are relatively minor, relevant staff should apprise themselves (and the PPR) of corrected requirements applicable to hospitals in: • APR.03.01.01, EP 3 • APR.09.01.01 • LS.03.01.30, EP 7 • PC.03.03.15, EP 4 • RI.01.03.03, EP 8
[Index] [Blog] The Source (May Vol 7 #5)
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Pg01- Featured Standard: Improving Medication Safety: How Effective Is Your Medication Management System? [••REF••] This is s good overview of TJC recommended approaches for compliance with MM.08.01.01. The article recommends six specific steps for evaluating the effectiveness of your medication management system and further suggests examples of data to monitor and relevant online literature resources (all of which are monitored for relevant updates by SHCC in this newsletter). P&T, JCSC and relevant PPR teams should read this article.
Pg02- 5 Sure-Fire Methods: Receiving and Recording Verbal Orders [••REF••]The requirement for having only qualified staff accept/transcribe verbal or telephone orders given by appropriately authorized persons shifted from standard IM.6.50 (2008) to standard RC.02.03.07 (2009). Although it did not make the top 10 in our analysis of state hospital-specific deficiencies for last year (PSQ Analysis 2007-2008) , TJC found 40% of all hospitals were non-compliant at survey time. This makes the 5 compliance strategies they recommend for RC.02.03.07 worth reviewing by P&T, RN and MD. There is an encouragement to distinguish between VO and TO and discouragement for use of the former. Note the possibility of additional staff (e.g., Dieticians) being able to receive/record VO/TO and the requirement for LIP to date, sign AND time such orders. Remember 48 hours is now the minimum standard unless your state statutes provide more leeway.
Pg04- Edition for Beginners: This Month's Tip: Using Service Profiles FYI: JCSC. Bottom line: "the Service Profile feature tailors the content display based on those services that are relevant to you". If your facility has programs for multiple service groups consider utilizing this feature. A 'how to' series of nine steps are described.
Pg06 Tracer Methodology 101: The Continuity of Care Tracer [••REF••] Essentially this is a program tracer that evaluates the process of ordering and following through on diagnostic testing. Although this tracer is primarily 'applicable' to ambulatory health care (AHC) organizations, but TJC leaves itself options to apply it "organizations that provide complex services across the continuum of care". Interpret that to mean if your organization is found to have problems with any aspect or phase of diagnostic testing, you could be subjected to this tracer. JCSC would be wise to consider incorporating this tracer into their practice tracer methodology. The article provides 16 sample questions for the process.
Pg08- Spotlight on Success: Educating Staff as Part of the Survey Process FYI: JCSC, LDR. An AHC organization describes its success in using "Daily Joint Commission Tidbits" sent via e-mail to its staff. This was used to update staff on hospital policies, new forms, TJC standards and other regulations in short, practical messages that staff were responsible for checking 15 minutes before their shift. JCSC and LDR might consider a modification of such an approach (e.g., weekly vs. daily) building in part on the brief mid-month compliance reviews (SHCC Pearls) already being e-mailed to you. Two samples of 'Survey Preparation Emails' are included
[index] [Blog] Patient Safety (May Vol 9 #5)
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Pg02- National Quality Forum Updates Safe Practices Guide FYI: LDR, MDx, RNX, PI. Most of the safe practices first released in 2003 and previously updated in 2006 are applicable to psychiatric hospitals. There are now 34 practices including 7 new ones. 4 of these (i.e., Multi-drug resistant organisms, Patient falls, Care of the caregiver, Organ Donation and Glycemic control) are relevant to typical psychiatric populations. Safe Practices Guide for Better Helathcare (2009 Update) was designed to bring attention to key clinical issues for the reduction of risk of error and harm to patients. A few of these issues are not specifically addressed in CMS or TJC standards and as such are worth being familiar with as a reference for quality improvement activity.
Pg03- Case Study: Creating a Safer Anticoagulant Therapy System Through Communication FYI: MD, RN, Phrm, FdDt, P&T. Psychiatric hospitals are subject to NPSG.03.05.01 even though use of anticoagulant therapy (most often Warfarin) is generally quite limited. However, it is this infrequent use (in addition to the inherent risks of the medication itself) that makes attention to safe management all the more important. In this case study three issues are emphasized: 1 - Ensuring a baseline INR, 2 - improving communication between relevant clinicians (e.g., MD, nurse, pharmacist, dietician) and 3 - Pharmacist involvement in INR monitoring.
[Index] [Blog] Environment of Care News (May Vol 12 #5)
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Pg01- Completing the Statement of Conditions™: Examining the "Life Safety" Chapter, Part 2 [••REF••] This article focuses on LS.01.01.01, the first of two administrative standards in the LS chapter and its four associated EP.
In EP#1 management responsibilities for the individual (or individuals) assigned to manage LS compliance is detailed in 3 areas (i.e., assessing LS compliance, resolving LS deficiencies and managing the SOC).
There is a particularly useful discussion of EP#3 that confirms the automatic 6-month grace period for meeting PFI deadlines and when extensions need to be requested.
It should also be noted that under EP#4 organizations are now required to have documentation (e.g., when/where inspections occurred and the report's location) about state or local fire inspections
Pg04- OSHA's Role in Disaster Response and Recovery: Because All Disasters Are Local FYI: SFT, HR. This article is designed to raise awareness about the health and safety of the providers and other responders to emergencies. And, it provides some descriptions of Occupational Safety and Health Administration (OSHA) resources and supports for this purpose. The sidebar listing of related resources (now incorporated into the SL3 Links Library) alone is worth a read.
Pg08- Learning from an Explosive Situation: Spectrum Health United Hospital Decontaminates After Local Bomb Incident FYI: SFT, LDR. This case study provides useful insights into an Emergency Operations Plan (EOP) exercise related to a young man in the community having a homemade explosive device blow up in his face. Of course, there is an emphasis on issues related to communications.
Joint Commission This Month For State Hospital Associations (TMFSH)
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TMFSH April
- Updated hospital COP-related requirements: Updated version with scoring information is now available.
- July 1, 2009: Update 1 to the Comprehensive Accreditation Manual for Hospitals (CAMH), PPR, AMP and E-dition technology will be updated
TMFSH May (Review Pending TJC Release)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- The Care Transitions Project: This is a new CMS Pilot program funding 14 communities to reduce rates of hospital re-admission and the fragmentation of care.
INTERNET HIGHLIGHTS
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CDC
Joint Commission
- TJC Announcement: [••REF••] After two years of work with major infection control leadership organizations (e.g., CDC, IHI, WHO and others), the Joint Commission has released a 232-page monogram entitled Measuring Hand Hygiene Adherence: Overcoming the Challenges, It was developed " to help health care organizations (IC, PI) target their efforts in measuring hand hygiene performance"
Essential Learning.com
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)
