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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (Sept, Vol 29 #9)
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Pg01- Refreshed Mission, Clear Vision for The Joint Commission FYI: JCSC. LDR. The new mission statement is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."
Pg03- New Field Review for Staffing Effectiveness Requirements FYI: JCSC. Survey of the staffing effectiveness standards, PI.04.01.01 for hospitals remains suspended (see August 2009 Perspectives, page 1). However, The recent field review on two of the Staffing Effectiveness EP (PI.02.01.01 EP#12 and #13) has had two outcomes. Proposed EP#12 will be revised to better define the use of outcome data. Things were less clear for proposed EP#13. Respondents were "unclear on what an annual data evaluation should include and what analysis would be required and presented to leadership if no staffing issues were identified". As a result, this EP will be scheduled for a follow-up field review.
Pg03- Hospitals to Be Accredited in Line with CMS Certification Number FYI: JCSC, LDR. If your hospital has more than one CMS Certification Numbers (used to be called Medicare Provider Numbers), the new policy could be relevant to you. TJC says this only effects 300 hospitals and they are contacting them directly. Bottom line under the new policy is that each CCN'd hospital would now need to be individually accredited.
Pg04- Shorter Time Frame for Second Survey Under the Early Survey Policy FYI: JCSC. LDR. Hospitals undergoing first time TJC accreditation can now request the second survey in that process to occur within 4 months. The article provides full text of the change. Note CMS deemed status is not granted until successful completion of the second survey.
Pg06- New Target for Speak Up Campaign: Prevent Errors in Your Child's Care FYI: PtAd. The latest Speak Up Campaign, Prevent Errors in Your Child's Care, focuses is on educating and encouraging parents and guardians to safeguard the care of their children.
Pg08- Get News from The Joint Commission via Social Media FYI: JCSC. TJC is now on:
• Twitter: http://twitter.com/JCommission
• Facebook: http://www.facebook.com/pages/The-Joint-Commission/104533371063
• YouTube: http://www.youtube.com/user/TheJointCommission
This is an interesting excursion by TJC into social media for those with that inclination. Unclear at this point how this might contribute to your compliance efforts or survey preparations. Share your thoughts about this on our discussion board (or maybe we should also start a tweet :)
Pg09- Free Help for Meeting Infection-Related NPSG [••REF••] TJC allotted one year (with quarterly milestones) for the full implementation of HAI-related NPSG 7 by January 1, 2010. Longer lead times usually suggest a greater effort is needed to comply. It can also be the basis for greater accountability once the measure is fully in effect. With that in mind, IC and RN should take advantage a free online education program offered by TJC to support compliance and implementation for NPSG 07.03.01, 07.04.01 and 07.05.01. Just be aware that the 76-slide webinar with narration by Louise Kuhny, RN, MPH, MBA, CIC and Barbara Soule, RN, MPA, CIC lasts a little over 58 minutes. You will need to log on to your TJC Connect website to access it.
Pg10- Round 2 of the JCR Flu Vaccination Challenge: More Than 1.1 Million Health Care Workers Participated in 2008 FYI: IC, HR. Whether your hospital formally takes the Flu Vaccination Challenge or not, the encouragement to increase the percentage of staff vaccinations is worth receiving and the associated support materials are worth reviewing. The original target (2007) was only 43%, but with an average increase of 14% last year, TJC has established three tiers of achievement for the 2009-10 flu season at 65%, 75% and 90% respectively. Consider these targets for your own organization.
[Index] [Blog] The Source (Sept Vol 7 #9)
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Pg01- Steam Sterilization Strategies Subhead: Complying with Joint Commission Requirements [••REF••] This is the first of two articles presented in separate TJC publications (see related Pt Safety article below) on the topic of steam sterilization. Although it was later clarified, one of our hospitals received a sterilization-related citation during its June 2009 survey. It was attempted by a physician who is used by TJC to conduct a relatively large number of state hospital surveys. As such, we think IC and Dentistry should review this article. At the very least, review the special panel entitled 'What Surveyors Are Looking For?"
Pg02- 5 Sure-Fire Methods: Identifying Unanticipated Adverse Events FYI: JCSC, RM. To better comply with LD.04.04.05 (formerly PI.3.20) and reduce adverse events, this article encourages the use of annual, pro-active risk and safety assessment process.
Pg05- Spending to Treat Mental Disorders on the Rise, Study Reports FYI: LDR. " The number of Americans treated for depression and other mental disorders nearly doubled between 1996 and 2006, according to the Agency for Healthcare Research and Quality. Total spending for mental disorders rose by nearly two-thirds over that 10-year period…" A chart also depicts the increases in the 4 other most costly conditions: heart conditions, cancer trauma-related disorders and Asthma.
Pg08- Voices From the Field: Cynthia Cisneros: Tracer Coordinator FYI: JCSC, LDR. This is a Q&A piece on the experience of a 'Tracer Coordinator' for a mid-sized military hospital. Although you may not be able to afford such a position, the concept and the value of educating, training and practicing staff on tracer methodology are worth noting. A sample tracer form is included but only addresses a few generic issues such as presence of ID Badges and knowledge about fire extinguishers.
[Index] [Blog] Patient Safety (Sept Vol 9 #9)
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Pg01- Helping Patients Stand Tall A Primer on Fall Prevention in Health Care [••REF••] RNx, RN and other clinical LDR should find value in several aspects of this article. It provides useful examples of risks factors and suggests some scales for evaluating them (e.g., Morse Fall Scale, Hendrich Fall Assessment. It gives a reference to the VA's tool for fall prevention and mentions some creative approaches to increasing staff awareness of patients at risk. However, the most useful part of the article may be the pointers it provides on using simple statistics to evaluate and guide your fall prevention program. It gives easy formulas for establishing fall rates and also encourages looking at the subsequent rate of injuries related to those falls. See also SHCC Risk of Falls
Pg08- Preventing Surgical Site Infection How to Use Rapid Cycle Sterilization of Surgical Instruments [••REF••] Ordinarily we would not review an article highlighting issues related to surgical sites. However, given the context referenced in the related Perspectives article above, we think IC and Dentistry should review the special panel entitled 'What Will Joint Commission Surveyors Consider?"
[Index] [Blog] Environment of Care News (Sept Vol 12 #9)
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Pg01- Clearing the Air Before Construction Begins: Preconstruction and Other Risk Assessments Pave the Way for New Pediatric Facility in Minneapolis FYI: E&M, SFT. Although state hospitals are more likely to experience renovation instead of new construction there is still a need to perform a “preconstruction risk assessment,” as required by Joint Commission Standard EC.02.06.05, Element of Performance (EP) 2. While sharing the experience of new construction for a pediatric facility the article provides useful insights and a side bar in which TJC outlines the areas that should be considered in a preconstruction risk assessment.
Pg04- Designing and Maintaining Buildings to Minimize the Effects of Fire: Examining the "Life Safety" (LS) Chapter, Part 4 [••REF••] This 4th article in a series on the Life Safety Chapter focuses on LS.02.01.10. It provides a good overview of the requirements related to A - height, construction and sprinklers, B - building separations/penetrations and C - fire door features (e.g., closing, latching, gaps, protective panels, decorations). This is well worth reading by E&M, SFT.
Pg06- Involving Staff in the Environmental Tours Process: Advocate Illinois Masonic Medical Center Gets Everyone Onboard FYI: LDR, SFT. For many hospitals, the Safety or Environmental Rounds/Tours have become a perfunctory and ineffective process. This case study shares the success one hospital had in re-invigorating the process by expanding and broadening staff involvement (and training).
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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INTERNET HIGHLIGHTS
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Joint Commission Online (JCO) & Website
- 9/2/09 TJC E-mail: The Joint Commission is seeking comments on candidate measures for assessing and treating tobacco, alcohol, and other drug use and dependence. Specifically, these eight measures address screening/assessment; treatment including brief interventions and if applicable, medication; and follow-up after hospital discharge. The measures will be posted for a 30-day public comment period beginning September 1. Click here to review and comment on the measures.
- Aug 27, 2009 News Release: SE Alert #43 - Leadership Committed to Safety
- TJC continues to advocate for greater involvment of leaders (i.e., execs, senior managers, admin/clinical leaders, and governing body) in issues of hospital safety. The latest SE Alert recommends a series of 14 specific steps leaders shoud take to improve patient safety.
▪ Stroke Panel advises no change to t-PA measure
▪ Volunteers needed to test blood management candidate measures
▪ Volunteers needed to pilot test draft osteoporosis measures
▪ Hospital campuses going smoke-free: what’s the trend?
▪ Take the Flu Vaccination Challenge
▪ Hospital Executive Briefings
▪ 2009 Annual Conference on Quality and Patient Safety
▪ Call for presentations for 2010 Annual Conference on Quality and Patient Safety
▪ Briefings for hospitals, critical access hospitals and ambulatory organizations
▪ Free briefing on HCSS Certification in D
By January 1, 2010, hospitals and other accredited organizations are expected to be in full compliance with the three National Patient Safety Goals pertaining to health care-associated infections (NPSG.07.03.01, NPSG.07.04.01, and NPSG.07.05.01). To help organizations prepare for and understand how to meet the requirements of the HAI NPSGs, The Joint Commission has developed a complimentary education program, now available on The Joint Commission Connect extranet. The presentation covers:
▪ What organizations need to do to prevent HAIs for multidrug-resistant organisms, central line-associated bloodstream infections, and surgical site infections
▪ How the three NPSGs, the Infection Prevention and Control standards, and the Leadership standards work together to help organizations put systems in place to reduce HAIs
▪ Resources for “targeting zero” HAIs and other major infection prevention initiatives
▪ Characteristics of high reliability organizations, The Joint Commission’s vision for health care
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 sixteen state hospital members that have experienced full unannounced Joint Commission surveys (see below). A preliminary analysis of 2009 survey dates in comparison to the previous full survey confirmed the previous trend of most (64.3%) surveys occurring before the 3-year mark (average = 104.5 days or approximately 34.9 months). Top survey findings specific to state hospitals are now available at PSQ Data (Jan-June 2009) (XLS)
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)
