.
THE JOINT COMMISSION (TJC and JCR)
.
[Index] [Blog] Perspectives (June, Vol 29 #6)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg03- Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This article addresses two key questions regarding LS.01.02.01. When is it necessary to conduct and fire watch and who can/should do to. A useful checklist defines 'Out Of Service' responsibilities.
Pg05- Release of Revised 2010 National Patient Safety Goals Delayed FYI: JCSC. Because of the special review currently in progress, 2010 NPSG will not be published in Perspectives until October (instead of the usual July). [ALERT: JCSC] Potential revisions to the National Patient Safety Goals and the Universal Protocol are only available for field review through June 23, 2009
Pg05- Updated Sentinel Event Statistics FYI: JCSC. SE statistics have been updated through March 31, 2009.
Pg06- Revision: Hospital Definition of Physician [ALERT: MDx, MD] TJC standards now include a broader CMS definition of physician (to include doctors of dentistry, podiatry optometry and Chiropractor) but for some requirements will still utilize its more narrow designation of doctor of medicine or osteopathy. As a consequence, 14 EP (2 MM, 5 MS, 6 PC and 1 RI as listed in a provided table] are being revised and become effective July 1 of this year.
Pg08- Update: Additional Scoring Changes for All 2009 Accreditation Manuals [ALERT: JCSC, EOC, SFT, P&T, PPR] Last month and now again this month, TJC has found the 'need for additional' scoring changes. Effective 7/1/09 most of the latest changes (14 EP in EC, 17 In LS, 6 MM, 2 PC, 3 PI, 1 RI and 1 in LD) will be applicable to hospitals.
Pg10- Q&A: Understanding Hospital Deemed Status Accreditation Reports [••REF••] JCSC should review the Q&A on deemed status surveys. Among the explanations is that different levels of CMS deficiencies found during TJC surveys will require differing types of follow-up. Specifically, a standard-level deficiency will require an ESC (in 45 or 60 days) while a condition-level deficiency will require an ESC and unannounced follow-up survey. Note: TJC has standards with subordinate EP whose scoring has a precise, pre-defined relationship to the determination of compliance with its related standard. CMS has Conditions of Participation (CoP) with subordinate standards whose scoring does not have a pre-defined, precise or consistent relationship to determinations of compliance at the related condition level. Determinations are made case-by-case based on the deficiencies impact on “the provider’s . . . ability to furnish adequate care or . . . adversely affect the health and safety of patients” (42 CFR 488.24(b)).
Pg11- Status Report on Restraint and Seclusion Requirements for Hospitals FYI: JCSC. Last month TJC announced replacement of its Restraint and seclusion requirements with those of CMS for any hospital using TJC survey for deemed status purposes. Other hospitals would continue to use the current TJC standards. In this article TJC indicates it will be 'reviewing its current restraint and seclusion requirements (standards PC.03.02.01 through PC.03.03.31 and RC.02.01.05) and the new CMS requirements (standards PC.03.05.01 through PC.03.05.19) for similarities and differences among various accreditation programs." A time frame is to be set for potential revisions and announced in a future issue of Perspectives. [ALERT: JCSC] The go-to-person for this is identified as Mary Brockway, MS, RN, Associate Director of the Division of Standards and Survey Methods. In a brief conversation with her, she recognized significant difference in the psychiatric hospital setting and was encouraging of our input. Please e-mail her about any concerns you may have for complying with the new R&S standards at mbrockway@jointcommission.org. Alternately, send your comments to SHCC and we will combine and submit them in the aggregate.
[Index] [Blog] The Source (June Vol 7 #6)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Featured Standard: Handling Infectious Patients: Is Your Organization Prepared to Respond to an Influx? FYI: IC. This month's featured standard is Standard IC.01.06.01 that requires organizations to prepare to respond to an influx of potentially infectious .patients. The article recommends staying currently informed (e.g., via CDC listserv), performing a risk assessment, ensuring good communication/coordination with the community as well as considering table top exercises to test preparedness.
Pg04- Edition for Beginners: This Month's Tip: Searching Supplemental Content FYI: JCSC. To search the non-scored chapters of the E-dition (e.g., Accreditation Process, ACC), type an appropriate term into the search box in the upper left corner of the screen and click on the symbol of the magnifying glass. More details available in the article.
Pg05- Effective Pain Management: Tips for Undergoing a Complex Task FYI: RN. The article provides a general review of compliance issues for standard PC.01.02.07 largely by reviewing the classic characteristics of pain (e.g., location, intensity, etc). The most useful information provided is probably the included check sheet for assessing your organization's pain management policy and/or program. JCSC should consider sending a copy of this to the appropriate PPR chairperson/team.
Pg06- Tracer Methodology 101: The Fall Reduction Tracer [••REF••] Although this is officially a program-specific tracer for home care, JCSC are strongly encouraged to incorporate this as a practice tracer for survey preparation/standard compliance (i.e., NPSG.09.02.01) and an RN/ PI strategy for the reduction of patient falls. The article includes a scenario and sample questions that can be adopted to your setting.
[index] [Blog] Patient Safety (June Vol 9 #6)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Patient Safety Pulse: Are You Prepared for Swine Flu? FYI: IC. Joint Commission Resources (JCR) prepared a Statement on Pandemic Preparedness, with an emphasis on A(H1N1). The statement includes links to a number of other useful resources (e.g., articles from JCR publications and guidance documents from the CDC and WHO).
Pg08- Power of Communication in Health Care: Four Simple Ways to Adjust Your Mind-set and Avert Bad Outcomes FYI: HR, StEd, MDx. "In a health care setting, every miscommunication is a potential crisis. Poor communication can compromise patient safety, as well as lead to staff upheavals, burdensome lawsuits and irreparable reputation damage. Individuals who are insensitive to the impact of their words and actions invite adverse outcomes" As the foregoing suggests, this is a different and interesting piece written by communication experts on the risk management importance of effective communication. MDx, HR and StEd might find this article a useful resource and reading assignment, especially for staff with difficulties in this area.
[Index] [Blog] Environment of Care News (June Vol 12 #6)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg05- Top Standards Compliance Issues for the First Half of 2008 FYI: JCSC, EOC. The most frequently cited EC standards for hospitals from January 1, 2008, through June 30,
2008 are:
• EC.5.20 (46%) @ compliance with LSC and
• EC.5.40 (28%). @ fire-safety equipment and building features
Pg06- Function 3: Emergency Safety and Security: Keeping Patients and Staff Safe and Secure During a Disaster [••REF••] EOC and SFT should review this 3rd installment of articles providing compliance guidance for requirements related to the six critical functions of emergency management. This one focuses on four aspects of safety and security.
1 - Defining the roles of community security agencies and such issues as what law enforcement agents are to do with their weapons when they come on to hospital grounds/buildings.
2 - Disposing of hazardous materials and waste or where they could be stored if regular pickup services were disrupted for significant periods of time.
3 - Controlling movement of potentially increased numbers of persons (not just patients) within the hospital and with the community
4 - Controlling vehicles that access the facility and dealing with accidents, abandoned vehicles or other traffic flow concerns.
Note that as a result of their hurricane experiences in recent years, two of our Louisiana members (ELMHS and CLSH) have special insight into some of these issues. Refer also to EC News January and March (or our reviews in Reading Tips for January and March) for the first two articles in this series.
Pg08- Authoritative Answers to Common Questions About the Environment of Care FYI: EOC, E&M, JCSC. Frequently asked questions related to EC topics are addressed. They include wheeled carts in the hallway, evacuation maps, PFI extension and change requests, time frame for correcting SOC Deficiencies, management plans, security sensitive areas, ID badges and hazardous materials/waste.
Joint Commission This Month For State Hospital Associations (TMFSH)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
TMFSH May
- TMFSH Becomes Weekly Newsletter: Beginning with the July issue, This Month for State Hospital Associations and Joint Commission Online will be combined and become a weekly electronic newsletter. As such, we will no longer review it in a stand-alone section, but rather include its relevant updates in our 'Internet Highlights' section below.
- RPI making progress at The Joint Commission: The Joint Commission began an internal Robust Process Improvement (RPI) initiative in mid-2008 to "improve the efficiency and effectiveness of internal processes." A “power pack” of resources on how to comply with complex standards and National Patient Safety Goals will be available to customers in the fall.
- Physician and nurse executives team up to fight disruptive behavior" (Refer to ACPE in the internet section below)
TMFSH June (Review Pending TJC Release)
.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
.
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
INTERNET HIGHLIGHTS
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
The Joint Commission (TJC)
- 6/8/09 - Field Review: Effective Communication, Cultural Competence, and Patient-Centered Care - [Alert: JCSC, LD, HR, MDx, StEd, PtAd] Although implementation would not be expected before January 2011, "The Joint Commission is (developing and) proposing accreditation requirements to help hospitals better address effective communication, cultural competence, and patient-centered care." Although this will require setting aside some time, within the next six weeks when the field review ends (7/20/09), JCSC and LD really should:
- 6/10/09 - Field Review: Staffing Effectiveness - [Alert: JCSC, HR, RNx] TJC has acknowledged the field's concern about the value of current staffing effectiveness requirements. They have proposed two new EP as part of a transition to a more useful approach and are requesting feedback by 7/10/09 if possible, but no later than 7/22/09 (when the field review officially closes). State and public psychiatric hospitals are strongly encouraged to review the proposed staffing effectiveness requirements (5 min) and then complete the questionnaire (10 questions, 5 min) online or via email to ensure more appropriate requirements for our specialty.
American College of Phyisician Executives (APCE)
National Association of State Mental Health Program Directors (NASMHPD)
Joint Commission Behavioral Health Update (Newsletter from Barrins & Associates) - Click the preceding link for the B&A website to sign up for the full newsletter.
- Effective July 1, 2009: New Restraint and Seclusion Requirements for Hospitals Take Full Effect: June Newsletter provides answers to the following questions and is excerpted as a Discussion Board Special Topic:
- What are the new requirements?
- What current requirements are not included in the new standards?
- What has not changed?
- Do the changes apply to Behavioral Health Organizations?
- Periodic Performance Review Pitfalls and Strategies
SHCC Additions (Note: The SL1 library is in the process of being converting to 2009 Standards/terminology)
2009 Member Surveys (SL5)
If you anticipate a survey soon, please click here
SHCC has determined that in the first six months of 2009, ten of our state hospital members experienced full unannounced Joint Commission surveys (see below). A preliminary analysis of 2009 survey dates in comparison to the previous full survey revealed the following:
- Average time since last survey: 1055.6 days or approximately 35.2 months
- Percent of 10 hospitals having 2009 surveys earlier than 36 months: 70%
Members who have not submitted PSQ feedback are implored to do so as soon as possible.
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 and surveyor photos/feedback.
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, UrUm: Utilization Review/Management, X: Exec, Dir or Chief (e.g., MDx = Medical Director)
