.
THE JOINT COMMISSION (TJC and JCR)
.

[Index]  [Blog]                                Perspectives (Oct, Vol 29 #10) SPECIAL 32-PAGE ISSUE

RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom

Pg01-  Approved: 2010 National Patient Safety Goals [••REF••] The 2010 NPSG were released on 9/25/09.  While there are no new goals, there are language refinements and a significant number of deletions (6) and movement of requirements into standards (18).  Much of the content is retained somewhere in the standards, but only five Goals (1-3 and 7-8) remain for hospitals/BHC.   [ALERT: JCSC]  "Effective immediately, during the on-site survey, surveyors will not evaluate compliance with requirements that have been deleted."  It should also be noted that NPSG 8, which is still being evaluated/refined, is not included in these changes and is not being scored during survey (refer to March RTP for more details).  The other changes will to into effect on January 1, 2010.  The article includes a useful table of changes and a full description of the goals themselves.  The pre-publication version of the 2010 NPSG chapter and outline are now available online at TJC.

Pg03-  Approved: Revised Universal Protocol for 2010 [ALERT: JCSC and MD]  Note that the protocol now applies to “all surgical and non-surgical invasive procedures.”  Although an update of the relevant FAQ has not yet been posted, SIG told us that minor procedures such as venipuncture would still be excluded. There are also changes in the site-marking process.  

Pg04-  Clarification: Reducing Infection Risks Associated with Medical Equipment, Devices, and Supplies FYI: IC, RN - Revisions to IC.02.02.01 now make a better distinction between low-risk processes (e.g., cleaning/disinfecting stethoscopes, blood glucucose meters ) addressed by EP#1, cat C and higher-risk processes (e.g., sterilizing endoscopes ) addressed by EP#2, cat A.  Full text of the revisions is provided.

Pg07-  Changes to the 2009 Survey Fee Schedule FYI: LDR, F&B.  The schedule has been amended to include two new survey events:
1 - Follow-Up Survey for a Condition-level deficiency - Cost is $4,130 per surveyor day for the first day and $1,945 per surveyor for the second and subsequent day(s).
2 - Onsite ESC - Cost is the same as rates for your routine full survey.  A table of these rates is included in the article.

Pg09-  A New Model for Customer Service at The Joint Commission FYI: JCSC, LDR.  To improve support, account representatives are now called account executives (AE) and are being 'teamed' with program-specific standards interpretation specialist and field directors.  This has involved some reassignments but no change in the handling of questions through SIG.  If your facility was effected you should have been notified last month.  Your AE's name and contact info is on the landing page of your Joint Commission ConnectTM site

Pg10-  Sentinel Event Alert: Leadership Committed to Safety [••REF••] TJC revised this SEA (#43) on 9/8/09 after we published our September review of the announcement in JC Online.  It now provides a clarification of staff acts requiring discipline based in part on the work of James Reason.  The article provides a summary of the SEA's 14 recommendations.  However, the actual SEA#43 is the reference we would encourage LDR to read. See also Assessing Unsafe Acts (A table Developed by the Missouri Baptist Medical Center based on Managing the Risks of Organizational Accidents by James Reason)

Pg11-  Special Section: Update on CMS Hospital Deeming Application: A Message from Ann Scott Blouin, Executive Vice President, Accreditation and Certification Operations FYI: JCSC.  This is basically a 1-page overview and introduction to the rest of the special issue articles on changes for hospitals that use Joint Commission accreditation for deemed status purposes…hereafter referred to here in as TJC/CMS-DS.

Pg12-  Changes in Content, Format, and Posting of the Accreditation Survey Findings Report FYI: JCSC.  New TJC survey reports (since 7/1/09) now include non-compliant Medicare requirements with a crosswalk of effected conditions of participation (COP) to TJC requirements.  The TJC section of the report has been updated to include levels of EP criticality (i.e., Direct or Indirect Impact).  There is also a category of Observed but Corrected on Site (OCO) for EPs found less-than-fully compliant but corrected before the survey ended.  In accordance with CMS requirements, survey reports will be posted within 10 business days to your JC Connect extranet site.

Pg12-  Clarification: Conducting Extension Surveys FYI: JCSC.  Effective immediately, an extension survey is to be conducted within six months upon acquisition of a new service, program or site any TJC/CMS-DS hospital.

Pg14-  Hospital Accreditation Award Aligned with CMS Certification Number FYI: JCSC, LDR, F&B.  If your facility has not been accredited in accordance with its CMS Certification Number (CCN) you will need to do so by 7/15/2010.  TJC says this only affects 300 hospitals that they have already been in contact with. See also Sept '09 RTP/Perspectives Pg03- Hospitals to Be Accredited in Line with CMS Certification Number

Pg14-  Revision to the ESC Tool on Secure Extranet [ALERT: JCSC]  The 'Who' sections of the electronic ESC now require more specificity.   Titles are to be entered for the person responsible for implementing corrective actions and/or approving newly developed or revised policies, procedures or processes.  

Pg15-  New Medicare Certification Recommendation Letter FYI: JCSC, LDR.  TJC now issues a Medicare recommendation letter along with its accreditation award letter for all TJC/CMS-DS hospitals.  The letter includes dates of survey, accreditation effectiveness, included locations and goes as a copy of notification to CMS

Pg16-  Accepted: New and Revised Hospital Elements of Performance Related to CMS Application Process  [ALERT: LDR, JCSC, MDx, HR, PI] & [••REF••]  In response to the need for more specificity to meet DMS deemed status application requirements, TJC has now released a third revision of EP for TJC/CMS-DS hospitals.  The article says "the majority of revisions are minor editorial changes…" A box is provided with  descriptions of  "More substantive changes…" made to 10 EP.  This includes 7 new EP for 1/1/2010 implementation (EC.02.04.03, EP 14 - HR.01.01.01, EP 28 - LD.04.01.05, EP 9  MS.03.01.01, EP 16/17 - PC.03.01.01, EP 10 - RI.01.07.01, EP 18), 2 revised EP for 1/1/2010 implementation, (LD.04.04.05, EP 13 - PI.01.01.01, EP 2) and 1 New EP for 7/15/2010 implementation (LD.01.05.01, EP 8).  There are also 3 revised EP related to telemedicine (LD.04.03.09, EP 4/9 - MS.13.01.01, EP 1), but TJC is still hoping to achieve allowance for credentialing and privileging by proxy that is currently not permitted by CMS.  Their implementation is delayed until 7/15/2010.  [Color code: relates to Nuclear Medicine,  Anesthesia]  See also full details in the 2010 Pre-Publication Standards [Info] {PDF}

Pg19-  Number of Inpatient Records Required for Initial Survey and Onsite Review FYI: JCSC, LDR.  Effective immediately, eligibility for an initial survey of "acute care hospitals" will require a number of records for review equal to 10% of the average daily census but not fewer than 30 inpatient records.   There will be a minimum sample size of 20 records for general hospitals with an average daily census of 20 patients or less, " provided the number of records is adequate to determine compliance". The article says this does not apply to surgical or other specialty hospitals, but in the past the term acute care hospital has applied to our state hospitals . As before, at least one inpatient must be in active treatment during the survey.  For the most part, the record reviews can be expected to occur as part of the patient/system tracer process.  However, surveyors can ask to review additional open and/or closed records if the minimum sample size has not been achieved

---

[Index]  [Blog]                                                  The Source (Oct Vol 7 #10)

RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom

 An error has delayed posting of the print and electronic version of this publication.  Our thanks to JCR for providing an advance copy for this review.  Title links will be provided once the publication is posted.

Pg01- Human Resources Challenges: Complying with Joint Commission Requirements  FYI: HR.  HR.01.02.05 was in the lower end of Top 10 Standards Compliance Issues for hospitals (and BHC) in 2008.  However, our PSQ analysis revealed it to be the 2nd most common citation for our reporting hospitals.  More than half of them (57%) were found non-compliant during 2009 surveys.  The article provides a few suggestions such as centralizing the process for primary source verification and doing spot checks of personnel files especially in areas that have had high turnover.

Pg02- Medication Orders Are Clear and Accurate FYI: MDx, RNx, JCSC.  Although MM.04.01.01 has not been a frequently cited standard for our members so far this year, it may help to be aware of the 3 common causes for its citation.  1 - Lack of written policy, 2 - consistent interpretation in the use of range orders and 3 - inappropriate use of standing orders/use of blanket orders.  5 recommendations for compliance are provided

Pg06- Update on the PC Chapter for BHC Programs: What’s New and What’s the Same [ALERT: JCSC] The 2010 CAMBHC is scheduled for delivery in early November.  What appears to be most significant is the fact that for BHC, the PC chapter, to include the restraint and seclusion standards (PC.12.10-12.190), has not yet been updated or significantly changed as part of the standards improvement initiative (SII).  TJC felt this chapter was more complicated and required more time for proper review and refinement.  A field review is expected by the end of this year. 

Pg08- Medication Management System Tracer: [••REF••] The article provides a list of 11 sample tracer questions for staff and another 5 for patients.  JCSC and staff conducting medication management tracers should consider incorporating these questions into their practice tracers and PI processes.

---

 

[Index]  [Blog]                                                  Patient Safety (Oct Vol 9 #10)

RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom

Pg01-  Without a Trace(r)… Your Organization May be at Increased Risk for a 'Never Event' [••REF••] This article generally encourages the use of tracer methodology as a pro-active  improvement and prevention strategy.  The particular focus is on the identification and avoidance of preventable serious incidents.  NCQF calls these Never Events and CMS developed a similar list that it calls Hospital Acquired Conditions )HAC).  The article includes tables listing each.  You will recall from our  review of a February Patient Safety article on  'Never Events' that CMS discontinued reimbursement for care related to such incidents in October 2008.  If not currently doing so, JCSC and LDR should consider a more deliberate use and incorporation of tracers into their overall hospital performance improvement and risk management processes.  This article provides useful suggestions, strategies and a sample tracer form.  Take note of the use of tracer teams with recorders vs. the less formal, undocumented  process conducted by one or two individuals.  See also Tracer Methodology 101: Staff Training for Tracers, Source, April 2009, Vol 7, Issue 4

Pg02-  Patient Safety Pulse: Your Patient Safety News: Pregnant Women Vulnerable to H1N1 Virus FYI: JCSC.  [••REF••]  There have been six deaths of pregnant women (April 15 - June 16, 2009) and a recent Lancet study[H1N1 2009 influenza virus infection during pregnancy in the USA, Lancet, Vol 374, Issue 9688] that suggests pregnant women may be more severely affected by HIN1.  IC should be aware of the recommendation that pregnant women with suspected or confirmed influenza infection receive prompt treatment with antiviral medication as published in CDC clinical guidance for treatment and prophylaxis in pregnant women.

Pg07-  Preparing for a Pandemic: Lessons from the H1N1 Outbreak FYI: IC.  Most of the lessons discussed are at the larger, perhaps national level.  However, IC may wish to note the issue of more effectively communicating, clarifying and motivating staff to take appropriate precautions (e.g., stay home when sick) for the future.

---

 

[Index] [Blog]                                              Environment of Care News (Oct Vol 12 #10)

RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom

Pg01-  Preventing Violence in the Emergency Department: Ensuring Staff Safety FYI: SFT, StEd, LDR.  This discussion of violence in emergency departments identifies a number of risk factors and strategies that are germane for psychiatric hospitals as well.  The article reminds us of environmental factors, the need for violence prevention (vs. reaction) training, effective violence response plans/mechanisms and the importance of post-violence debriefings.  Ideas such as defining security (safety) alert levels were particularly intriguing and made this piece worth reading.  

Pg04-  Dust Busters: Training Construction Workers to Build Safely in a Health Care Environment FYI: LDR, E&M.  If you need a construction company and have a choice, obtain one "whose workers have been trained to deal with the specific challenges of a health care environment".  This will help you manage your environment more safely and effectively during periods of renovation or construction as required by EC.02.06.05. A sample of two such companies and some of the training provided to their employees is shared.  LEED, an internationally recognized green building certification system, is also referenced.

Pg08-  Protecting Employees from Slips, Trips, and Falls: How Johns Hopkins Keeps Its Employees Safely on Their Feet FYI: HR, RN, SFT.  Hospital workers have a higher rate (67%) of injury from slips trips and falls (STF) than those in other industries. Although the hospital in this case study (Johns Hopkins Medical Institute) has a safety department with 30 staff, you may still benefit from results of the 10-year study they participated in to evaluate the effectiveness of approaches to reduce STF-related injuries.  The related  scientific paper, “Evaluation of a Comprehensive Slip, Trip and Fall Prevention Programme for Hospital Employees” (Ergonomics, Vol. 51, No. 12, pp. 1906-1925, Dec. 2008).  The article brings out a few of the findings and some recommendations from their post-study implementation experience.  Having an effective incident reporting and data collection process is one of the emphasized points.  OSHA forms.  See also our July review of EOC News July 09 Vol 12 # 7  Pg08-  Health Care-Associated Illnesses and Record-keeping: Using the OSHA Log 300

---

 

.
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

. Quarterly Provider Updates

• QPU January-March 2010
• QPU October-December 2009
  

Mid-Quarter Instructions

• July 2009 Mid-Quarter Instructions [PDF, 36 KB]
  

What's New

• What's New Page - July 2009 [PDF, 38 KB ]

INTERNET HIGHLIGHTS

RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom

Joint Commission Online (JCO) & Website

• JCO 10/14/09: 
  
  • Free Podcast [••REF••] : IC Beginning 10/15/09 TJC and CDC are offering a free educational 30-minute podcast (with accompanying 47-slide PowerPoint) to help organizations prepare for … the  2009-2010 influenza season. After listening, you can also e-mail questions about H1N1 or seasonal influenza.  The most frequently asked will be answered/included in an H1N1 FAQ
    

• JCO 9/30/09: 
  
  • Posting of prepublication versions of the 2010 standards FYI: JCSC
  • Free conference call on the Joint Commission Center for Transforming Healthcare - Overview of the center and its Hand Hygiene project with Dr. Chassin and others x 1 hr on Tuesday, October 6, at noon PT, 1 p.m. MT, 2 p.m. CT, 3 p.m  FYI: IC
  • Staffing effectiveness requirements available for second field review - A second field review of the most recent revisions/refinements available until 10/7/09  [ALERT: HR, RN, JCSC, LDR, PI]
  • Live streaming video and on-demand seminars and conferences
    

National Association of State Mental Health Program Directors (NASMHPD)

• Selected Presentations from the 6th National Summit of State Psychiatric Hospital Superintendents (in PDF format)
  
  • Morbidity and Mortality in People with Serious Mental Illnesses: Responding to the Epidemic, FYI: LD, MDx, PI, PtAd
  • Promising Practice Mid-Western Region: “Fulton State Hospital New Outlook Program for Behavior and Mood Self-Management” FYI: MDx, Forensic
    

  • Promising Practice Western Region: "Creating Your Own Internal Review Process - Consolidating CMS & Joint Commission Standards"  FYI: JCSC, LD, PI, UrUm
    

  • Hospital Disaster Preparation and Response:Like There Wasn't Enough To Worry About!  FYI: SFT, EOC, LDR
    

  • Mental Health Services for People Who Are Deaf or Hard of Hearing    FYI: PtAd, MDx

  • The Development of an Evidence-Based Best Practice: Preventing Violence and the Use of Seclusion and Restraint  FYI: MDx,RNx, LDR,
    

  • Developing National Core Competencies for State Hospital Superintendents: Removing the Mystery of Effective Leadership  [••REF••] LDR, GB   Principled Leadership for the State Hospital CEO/Administrator Toolkit 2009

  • Promising Practice Southern Region: “An Experiment in Community Reinvestment”  FYI: LDR, GB,

  •  Promising Practice Northeastern Region: "Achieving Real Transparency with Families and Consumers in New Jersey's State Hospital System"   [••REF••] LDR, GB, MDx,PtAd

  •  State Hospital Smoking Report  FYI: MDx, RNx, PtAd, LDR

  • From the Hospital into the Community: Technical Assistance and Dialogue on Going Tobacco Free  FYI: MDx, RNx, LDR
    

  • Trauma and Recovery  FYI: MDx,

  • In-SHAPE: Improved Health Status Through Social Inclusion for Persons with Severe Mental Illness by Mr. Jue and Dr. Bartels   FYI: LDR, MDx,RNx, PtAd
    

  •  Peer Support Whole Health  FYI: MDx,

  • Olmstead and CRIPA: Redefining the Standard of Care  FYI: GB, LDR, PtAd, MDx,

  • Preparing Your Direct Care Staff to Work in a Changing System of Care:  A Workforce Core Competencies Curriculum  FYI: LDR, HR, GB     Workforce Development Curriculum 2009

  

 

SHCC Additions 

2009 Member Surveys (SL5)

If you anticipate a survey soon, please click here

Our database of surveys for 2009 now includes sixteen state hospital members that have experienced full, unannounced Joint Commission surveys.  Reported surveys for the last six months are listed below.  The full set of surveys is available in the SL5-Survey Feedback Library.    Top survey findings specific to state hospitals are now available at PSQ Data (Jan-June 2009)   (XLS)

• 2009/09-tjc-Southeast Louisiana Hospital (SELH)_3AD1Ca*S&R*AdolNeuro¥ {New}
• 2009/07-tjc-Southeast Missouri Mental Health Center (SMMHC)  {New}
• 2009/07-tjc-Fulton State Hospital (FSH)_8Ad2Fr  {New}
• 2009/06-tjc-Torrance State Hospital (TSH)_5Ad1Sx*SexualResp&Tx  
• 2009/05-tjc-North Alabama Regional Hospital (NARH)_2Ad*HBIPS
• 2009/05-tjc-Danville State Hospital (WaSH)_5Ad1FR*HBIPS
  
• 2009/02-tjc-St. Louis Psychiatric Rehabilitation Center (SLPRC)   
• 2009/04-tjc-Metropolitan St. Louis Psychiatric Center (MSLPC)  
• 2009/04-tjc-Wernersville State Hospital (WeSH)_5Ad*HBIPS
  

This year's surveys are off to an exciting  start.  We really appreciate your 2009 feedback!  Don't forget to include surveyor feedback and e-mail copies of any policies or procedures that received compliments during your survey to share in our library.