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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (Aug, Vol 29 #8)
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Pg01- Staffing Effectiveness Standard Suspended for Hospitals and Long Term Care [ALERT: JCSC, HR, PI] We first alerted you to this in our July RT review of This Month For State Hospitals. It is now confirmed and made official by publication in Perspectives. Effective immediately, survey of the Staffing Effectiveness standards (PI.04.01.01 for hospitals and HR.1.30 for long term care organizations) has been suspended. Two interim elements of performance, EPs 12 and 13 at PI.02.01.01 (PI.2.10 for Long Term Care) were field reviewed until 7/22/09. See Field Review: Staffing Effectiveness in our June RT.
Pg03- Errata for 2009 Accreditation Manuals [ALERT: EOC, E&M] Effective immediately, there is a correction to Standard EC.02.03.05, EP 18, (in the print manual and E-dition) that changes the frequency for operating fire and smoke dampers to "1 year after installation and then at least every 6 years" E&M should read the full text for complete details.
Pg05- Clarification: Contracting for Services with Accredited or Certified Organizations [••REF••] Given the confusion around this issue in surveys earlier this year, this is a timely article that should be read by HR and LDR. Key points are:
1 - There is no requirement to verify HR files for every contract service employee
2 - Contracted staff are not required to participate in every aspect of an employee orientation program (as some parts are irrelevant)
3 - Include contract language that defines required contract staff qualifications and requires contract organizations to provide only those staff that meet the qualifications
4- Perform due diligence even when contracting with other TJC-accredited organizations
[Note: These requirements do not apply to licensed independent practitioners.]
Pg06- Update: MS.1.20 Task Force Consensus FYI: MD, MDx. The controversial MS.1.20 from 2004 is now MS.01.01.01. The task force that has been wrestling with this for quite a while has decided that still further revisions are needed. These potential revisions are being informally reviewed for possible development into a formal field review down the line. In the interim, compliance with MS.01.01.01 is required except for EP19 that is still under indefinite moratorium.
Pg07- Approved: 2010 Updates to Accreditation and Certification Decision Rules [ALERT: JCSC] The effective date is Jan 1, 2010 and most of the changes are editorial. However, FOLL_U (which is actually a survey type and not a new decision category - See JCO below), is the requirement for follow up surveys to Medicare deemed status condition-level deficiencies and it became effective 7/1/09.
[Index] [Blog] The Source (Aug Vol 7 #8)
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Pg01- Improving Waived Testing Compliance: How to Conduct Quality Control Checks FYI: RN. This article addressing WT.1.60 reminds us of the need for a functional audit trail that ties patient test results to quality control results. The author also suggests using the same staff that perform waived testing to perform the quality controls and to ensure monitoring of the quality control results on an ongoing basis to improve reliability.
Pg02- 5 Sure-Fire Methods: Verifying Staff Qualifications FYI: JCSC, HR, C&P. Last year 22% of hospitals were found out of compliance with HR.1.20. Frequently this is due to a lack of primary source verification. The 5 suggested strategies are:
1 - Define staff tasks, competencies and performance expectations/goals
2 - Involve staff that perform the tasks in the defining process
3 -Document #1 above in a job description
4 - Base hiring on defined competencies and other objective criteria
5 - Be sure to document all verifications
Pg04- Edition for Beginners: Enhancements Implemented for E-dition FYI: JCSC. These previously announced enhancements include the CMS-related requirements, and the ability to e-mail a standard to more than one recipient at a same. Be aware there is a dedicated customer support line at 630/792-5420.
Pg06- Tracer Methodology 101: The Data Use System Tracer [••REF••] A scenario and sample questions are provided to help organizations, JCSC and IM conduct their own data use tracers. When doing so it is suggested you consider using a 'pinpoint data tracer' to focus on a particular aspect of data use such as infection control.
Pg08- Featured Standard: Assessing Effective Communication: Complying with LD.03.04.01 FYI: LDR. As a part of complying with LD.03.04.01, this article encourages regular assessment of your facility's communication processes and efforts. To that end, a series of strategies and some suggested questions are provided.
[Index] [Blog] Patient Safety (Aug Vol 9 #8)
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Pg01- The Bottom Line: Is Patient Safety Recession-Proof? FYI: LD, F&B. The National Patient
Safety Foundation (NPSF) thinks the recession is putting patients at increased risk. If, like many states, you are involved in budget and/or staff reductions, be sure your planning efforts seriously consider the impact of such reductions on patient safety and how you can mitigate them.
Pg02- Patient Safety Pulse Your Patient Safety News: Joint Commission Releases Influenza Monograph FYI: IC, HR. With the collaboration of APIC, CDC, SHEA, NFID and support of Sanofi Pasteur (vaccine maker), TJC has released a 104-page monogram entitled “Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies from Research and Practice”. 3 of its 4 chapters discuss vaccine administration, staff immunization and immunization rates while the fourth provides an overview of existing guidelines and other references.
Pg05- A New Role for Nurses: Making Room for Clinical Nurse Leaders: Robert Rosseter, M.B.A., M.S.M. FYI: RNx, LDR. The Clinical Nurse Leader (CNL) is a new nursing role being developed by the American Association of Colleges of Nursing (AACN) since 2003. The article announces that this is the first new nursing certification in 35 years. A CNL is described as a masters prepared advanced generalist whose focus on coordination of care, clinical outcomes, risk analysis, patient safety and communication place them in an 'air traffic controller' type role for a unit. The VA hospital system has already begun to embrace CNL's and considers itself at the forefront of this movement. We also noted that Alabama, Illinois and New Jersey have Master of Science in Nursing degree programs that prepare Clinical Nurse Leaders . Click here for additional CNL information, FAQ, a fact sheet or copy of the ACCN White Paper on the Education and Role of the Clinical Nurse Leader (80 pages). See also discussion board special topic: Cinical Nurse Leaders (CNL) in St. Hospitals???
[Index] [Blog] Environment of Care News (Aug Vol 12 #8)
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Pg01- How to Use Social Media to Manage Emergencies: Twitter, Facebook, YouTube, and More [PEARL: LDR, IT, IM. Louisiana] This is a fascinating 'Spotlight on Success-type article that should expand one's thinking about the use of modern social media to enhance communication. The focus here is on its use in disasters/emergencies, but the potential application in other communication efforts such as marketing, recruitment and even staff moral are easily apparent. Just don't forget that social media tools require two-way communication and therefore a willingness and commitment to a certain amount of responsiveness. Get your 'techies' to read this article and then discuss the implications and potential with them in a leadership group. The article also refers to a white paper called Social Media … Here to Stay: Effective Technologies for Reaching Audiences that may be a useful primer and background read.
Pg04- Staff Responsibilities in a Disaster: Examining the Six Critical Functions of Emergency Management [••REF••] JCSC. The following five aspects or staff responsibilities in emergency management (as required by EM.02.02.07) are clarified:
■ Identifying and defining roles
■ Outlining a clear reporting structure
■ Ensuring staff and family support
■ Providing effective training
■ Implementing a standardized approach to identifying those who work in the organization
LDR is encouraged to review and assess the readiness of your facility staff in these same areas. Consider using them as points of reference in evaluating your next disaster drill.
Pg06- The Silent Killer of the Helpless: Avoiding Deadly Aspergillus Contamination in Health Care Facilities FYI: IC, E&M. Although our hospitals may only have a few patients from time to time with seriously compromised immune systems, those who serve more fragile populations (e.g., elderly, children), are located in humid environments (LA, AL) and/or have construction projects underway should at least peruse this article. Too often the issue of mold is taken lightly and this piece may help provide a more appropriate perspective and respect. Mold can kill.
Pg08- Standards Compliance Issues for All of 2008: Life Safety Still Tops the List, with Emergency FYI: EOC, JCSC, The most frequently cited EC standards for hospitals in 2008 are: EC.5.20 (50%) Life Safety Code®. EC.5.40 (34%) Fire safety equipment/building features. EC.7.40 (16%) Emergency power systems. EC.7.50 (13%) Medical gas and vacuum systems.
Joint Commission This Month For State Hospital Associations (TMFSH)
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TMFSH June
TMFSH July (Review Pending TJC Release)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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INTERNET HIGHLIGHTS
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Joint Commission Online (JCO)
- 8/5/09: Clarification of July 15 article: Accreditation and certification decision changes for 2010 - “Medicare Condition-Level Deficiency Follow-Up Survey.” This is not a new accreditation or certification decision; it is a new type of follow-up survey. This follow-up survey is required after an organization has one or more Medicare Conditions of Participation (CoP) assessed as a condition-level deficiency. The “Medicare Condition-Level Deficiency Follow-Up Survey” requires that an organization remedy the identified CoPs and subsequently undergo an on-site follow-up survey. This new follow-up survey should not be confused with “Conditional Accreditation” or “Conditional Certification,” which are accreditation and certification decisions. The adoption of this new type of follow-up survey is related to The Joint Commission’s application to the Centers for Medicare and Medicaid Services for continued hospital deeming authority. “
SHCC Additions
2009 Member Surveys (SL5)
If you anticipate a survey soon, please click here
Our database of surveys for the first half of 2009 has grown and now includes fourteen state hospital members that have experienced full unannounced Joint Commission surveys (see below). An updated preliminary analysis of 2009 survey dates in comparison to the previous full survey confirmed the previous trend of most (64.3%) surveys occurring earlier than 36 months.
- Average time since last survey for 14 state hospitals in the first half of 2009:
- 1045.9 days or approximately 34.9 months
This year's surveys are off to an exciting start. We really appreciate your 2009 feedback! Don't forget to e-mail copies of any policies or procedures that received compliments during your survey to share in our library.
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)
