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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (Nov, Vol 29 #11)
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Pg01- Joint Commission Launches Center for Transforming Healthcare FYI: LDR, MDx, RNx. TJC is again announcing its new center identifying the following 8 "leading hospitals and health systems" as participants: ● Cedars-Sinai Health System, Los Angeles ● Exempla, Lutheran Medical Center, Wheat Ridge, Colorado ● Froedtert Hospital, Milwaukee ● The Johns Hopkins Hospital and Health System, Baltimore ● Memorial Hermann Health Care System, Houston ● Trinity Health, Novi, Michigan (specifically St. Joseph’s Hospital) ● Virtua, Marlton, New Jersey ● Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina. More details are provided in our review of this announcement also found in Patient safety below.
Pg04- Top Standards Compliance Issues for First Half of 2009 [••REF••] 6 of TJC's top 10 are also among the most frequent citations found in our 09 PSQ analysis for the same period. However, JCSC should note that the rankings and percentages are quite different. Click here to compare: Top Deficiencies (Jan-Jun 09): SHCC vs. TJC. As usual, tear out cards are available in the print edition.
Pg05- Accreditation and Certification Manuals and Updates Have Mailed FYI: JCSC. If you do not have your 2009 Update 2 for CAMH and CAMBHC by 12/1/09, contact your account representative. Remember, the complementary print version of the manuals is now a 'portable' 9"x9" 3-ring binder. The article also describes other format changes in content.
Pg06- The Trend: Smoke-Free Hospital Campuses FYI: LDR, GB. Smoke-free hospital campuses increased from 3% in 1992 to more than 45% in 2008. A new TJC study, “The Adoption of Smoke-Free Hospital Campuses in the United States (Abstract, 2-Min Podcast),” projects that "a majority of U.S. hospitals will have a smoke-free campus by the end of 2009".
Pg07- Changes to the 2009 Survey Fee Schedule FYI: LDR, F&B. The change defines fee structures for the Follow-up Survey related to a Condition-level deficiency and an On-site Evidence of Standards Compliance. The rate is $4,130 per surveyor day for the first day, and $1,945 per surveyor day for the second and subsequent day(s). A table is provided.
Pg08- 2009 Eisenberg Award Recipients Announced FYI: RN, RNx. One of this year's awardees won for their development of a Modified Early Warning System (MEWS) that helps nurses evaluate a patient's likelihood of deterioration. It is essentially based on a scoring system of key vital signs. We could not located the specific version by Cincinnati's Mercy Hospital Anderson cited in the article. However, for more insight/detail, click on this IHI article that also describes MEWS entitled: Early Warning Systems: Scorecards That Save Lives.
Pg10- ORYX Requirements for Three Programs Rescinded for 2010 FYI: JCSC. [ALERT: BHC, JCSC, PI] With the most recent revisions, APR.04.01.01 and its EP will no longer apply to BHC thereby eliminating ORYX requirements for BHC programs. Performance measurement and improvement would be addressed via relevant PI standards.
[Index] [Blog] The Source (Nov Vol 7 #11)
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Pg01- Redesigning the Process The Joint Commission Uses Lean Six Sigma for Robust Improvements [••REF••] In this article, TJC confirms its commitment to the concept of Robust Process Improvement (RPI). TJC has defined 4 levels of champions and sponsors for the process and actually implemented its own training program for what it calls green belts, black belts and change agents. Reported examples of RPI application to internal TJC processes include improving the e-App, reducing the post-survey report turnaround time to 10 days and development of 'BoosterPaks' for problematic standards. There is currently no requirement for an organization to use RPI in its PI processes, but GB, LDR, PI and JCSC are encouraged to familiarize themselves with RPI. See also Making Health Care a High-Reliability Industry: The Joint Commission Launches Center for Transforming Healthcare in Patient Safety below.
Pg02- 5 Sure-Fire Methods Planning a Patient's Care FYI: TxTm. Although PC.01.03.01 is not on the TJC or SHCC list of most frequently non-compliant standards, treatment plan development, documentation and implementation is still a challenge to do well. The article suggests the following 5 strategies to increase success:
1 - Multi-disciplinary approach
2 - Clear, well-defined update/review process
3 - Easy, simple updating process
4 - SMART* goals
5 - Patient inclusion
The SMART acronym stands for Specific, Measurable, Attainable, Relevant, and Timely.
See also: What is a SMART Goal?, SAMSHA S.M.A.R.T. Treatment Planning (with ASI), Treatment Plans Using the S.M.A.R.T. Model, Writing S.M.A.R.T. Goals
Pg03- E-dition for Beginners This Month's Tip: Managing Passwords FYI: JCSC. Article provides steps for resetting your password and/or using the "Forgotten Password" link.
Pg06- Spotlight on Success Minimizing Restraint Use FYI: RNx, MDx. The setting for this spotlight on success is a 779-bed level 1 Trauma Center. The chief challenge apparently was to discontinue the use of vest restraints. Staff education (especially of physicians) on the dangers of restraint and idea sharing were key approaches used. These approaches and the efforts of their Restraint Reduction Team produced a reduction in both restraint use and falls. Nothing new here for psych hospitals.
[Index] [Blog] Patient Safety (Nov Vol 9 #11)
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Pg01- Special Report! 2010 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them [••REF••] Although there are no new NPSG for 2010 there have been a significant number of refinements. JCSC and PPR may want to pay particular attention to the numerous changes in EP criticality and scoring. Remember, no matter when your survey occurs, scoring is based on continuous compliance from the first of the year. The article also provides a brief review of NPSG scoring and confirms the 'on hold' status of NPSG 8 while it's re-evaluation continues. Surveyor findings related to NPSG 8 will not affect accreditation decisions or generate RFI.
Pg04- Summary of Changes to the National Patient Safety Goals FYI: JCSC. Concise, tabular summary of 2010 NPSG changes. It adds info on criticality and scoring changes but is not as complete as the summary of changes provided in the October Perspectives (Pgs 20-21). For example, this chart does not include NPSG 16 that has now moved into the standards. The chart does indicate that 12 NPSG have criticality icon changes and another 4 have scoring changes while 7 were moved into standards. 11 EP in 5 requirements were deleted and 2 requirements are no longer an NPSG.
Pg06- The 2010 National Patient Safety Goals, Rationales, and Requirements FYI: JCSC, PPR. 4-page full text of the new NPSG with rationales. Useful as printout.
Pg10- Making Health Care a High-Reliability Industry: The Joint Commission Launches Center for Transforming Healthcare FYI: JCSC, PI, IC, RN. TJC's new Center for Transforming Healthcare began in September of 2009. TJC says "The center brings together the leading hospitals and health systems in the United States to identify specific underlying causes to patient safety problems and develop targeted solutions to solve those problems, and then share those solutions with health care organizations nationwide." Essentially, its mission is to reduce the occurrence of key preventable errors in healthcare. [PEARL] To that end they will be employing a process utilizing tools and methods from Lean Six Sigma called Robust Process Improvement. LDR and PI should increase awareness of these approaches as TJC announced last year its intent to adopt this new change strategy. These approaches are thought to be more effective than PI/QI in producing and maintaining excellence, particularly in challenging, improvement-resistant work processes. The Center's first project addressing hand hygiene and HAIs has already begun to identify important causal factors and recommended solutions. One of its next projects will target patient handoffs with a report expected in December 2010. A word to the wise. The article says you may expect to hear and see more about the findings/recommendations from the centers projects on TJC's intranet and even as a part of surveyor process. For more on RPI and TJC see: Sustaining the Improvement We Need by Mark R. Chassin, MD (11/6/08) [especially slides 16-21] [HTML] (PDF) For more info on Lean, Six Sigma and Lean Six Sigma goto our SL1 library page on PI & Data Management Tools
[Index] [Blog] Environment of Care News (Nov Vol 12 #11)
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Pg01- Art in Health Care Facilities: Designing Sights for Sore Eyes FYI: LDR, GB, EOC, SFT, PtAd The idea of evidence based art and its potential contribution to patient care outcomes as well as staff morale are reviewed and worth noting. Despite a primary focus on the integration of artwork during construction and discussion of rules of thumb for a line item artwork budget, there are relevant references to the impact of art on psychiatric populations as well. Consider this article useful encouragement to go beyond the color of wall paint when considering ways to improve the environmental contribution to safe, quality care. Useful advice is also provided for those who might be able to afford art consultants and art committees. See also A Guide To Evidence Based Art and the Pyschiatric Patient section of Therapeutic Art Programs For Special Patient Populations.
Pg03- The End of "Art for Art's Sake": M.D. Anderson Cancer Center at the University of Texas Medical Center Uses Art to Help Heal LDR, GB, EOC, SFT, PtAd This case study provides insights into the 10-year experience of the M.D. Anderson Cancer Center's in purposely using art as part of the healing process.
Pg05- Function 5: Utilities Management: Avoiding Utilities Failure During a Disaster [••REF••] This is the fifth in a series of articles on the six critical functions of emergency management, EM.02.02.09. The compliance suggestions for 6 of this standard's EP are worth reviewing by EM and LDR.
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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
- JCO 10/30/09:
- PDA accreditation decision rule changes: FYI: JCSC, LDR. PDA07 has been eliminated. PDA06 (having a license) now allows avoidance of PDA when your organization is found without a required license during survey, if you obtain or apply for it as soon as you learn of the need. Instead, you would now receive an RFI and an "… Accreditation decision pending the receipt of an acceptable Evidence of Standards Compliance showing that the organization has obtained its license, certificate or permit."
- New on the Web! NPSG 7 webinar on health care-associated infections: FYI: StEd, IC, RN, RNx. This free JCR Webinar on NPSG 7 that we reviewed in Sept was at that time only available via the secure TJC intranet. Health Care-Associated Infections, From the bedside to the C-Suite is now available in an improved form and accessible directly on the TJC website if you have Adobe Flash Player. Just remember the presentation is 76 slides long and runs a little over 58 minutes.
- New! Speak Up coloring book about infection control: FYI: IC, C&A. Free download coloring book for kids entitled "Stay well and keep others well"
- JCR Live video streaming and conferences on demand:
National Association of State Mental Health Program Directors (NASMHPD)
- 2009 Meeting Presentations and featured
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) as well as a comparison of Top SHCC vs. TJC Deficiencies (XLS)
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.
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)
