••REFS: TJC Confidentiality, MM.03.01, Suicide Tracer, Part 1/2 Delirium, Just Culture, Fire Egress, Leadership Paper, SX Training ••PEARLS: Confusion Assessment Method (CAM)d, ••DWNLDS: CAM, MM.03.01 BoosterPak, Just Culture, Animal Assisted Tx , Leadership Paper
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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (Dec, Vol 29 #12)
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Pg02- 2010 E-dition to Be Released December 2009 FYI: JCSC. The release, expected in mid-December, includes new service profiles and interactive crosswalks between TJC and CMS standards. More details available at http://www.jcrinc.com/E-dition-20-Release-Notes
Pg03- Protecting Organizations' Confidential Accreditation Information [••REF••] GB, LDR and MD should find this a useful review of TJC's position on protecting confidential information (including that related to sentinel events/RCAs) from our hospitals. Those uncomfortable with sharing such information with TJC should note the following statements from the article. "The Joint Commission has never been compelled to produce confidential accreditation information in response to any state court–issued subpoena, whether issued by a court in or outside of Illinois". "The Joint Commission is aware of no case where the confidentiality of sentinel event–related information was lost because it was shared with The Joint Commission."
Pg04- Approved: Decision Rule for a Preliminary Denial of Accreditation Eliminated FYI: JCSC. The rule that would have triggered PDA as a result of Conditional Accreditation on two consecutive full surveys has been removed.
Pg05- National Patient Safety Goals and Provision of Care, Treatment, and Services Chapters Published in 2010 Comprehensive Accreditation Manuals FYI: Phrm, P&T, IC, MD. Changes to NPSG.03.05.01 (adding the word 'prescribers') and NPSG.07.05,01 (re; antimicrobials) are effective immediately.
Pg07- Approved: New Preliminary Denial of Accreditation Process FYI: JCSC, LDR. Decision rule PDA06 is triggered by the lack of a required license, certificate or permit. However, there are now provisions for immedicate actions that can avoid Preliminary Denial of Accreditation. See also_______
[Index] [Blog] The Source (Dec Vol 7 #12)
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Pg01- Joint Commission Now Giving “Booster Shots” for Standards Compliance First BoosterPak Focuses on Safe Medication Storage [••REF••] Last month in an article on Redesigning (Its) Process(es) with Lean Six Sigma, there was a brief mention of the development of BoosterPaks for problematic standards. The first BosterPak (BP) became available on 11/19/09 and is a well-designed compliance reference and resource for the Standard MM.03.01.01. This particular standard has been cited more in more than 30% of TJC hospitals every year since 2005. In the first half of this year 21% of our members also reported this citation. Although the article does not provide links, TJC says it sent announcements of the BP to all hospitals. JCSC, Phrm, P&T, RNx and MDx should at least review the first 22 pages of this 33-page compendium by going to BoosterPaks in the What's New section of your TJC Connect site or downloading BP_MM_03_01.pdf. The contents include implementation expectations (Pgs 2-11), the survey assessment process (Pg 12), FAQs (Pgs 13-15), key definitions (Pg 16), special issue discussion (e.g., Crash Cart Storage) (Pgs 17-22) and additional references and links.
Pg02- 5 Sure-Fire Methods Reassessing a Hospital Patient's Condition FYI: JCSC, MDx, RNx, TxTm. This article looks at PC.01.02.03 (Timely Assessment/Re-reassessment) primarily from the standpoint of surgery patients. 19% of all TJC hospitals and 21% of our members had difficulty with this standard in the first six months of this year. If compliance is a concern, they suggest determining more specifically whether the problem is a lack of assessment or of its documentation.
Pg04- E-dition: Helping Your Organization Navigate the 2010 Standards FYI: JCSC, PPR. This is a basic review of E-dition key features to include CMS Crosswalks, 'What's New Report. It briefly mentions the new Service Profiles (to see only those standards related to your organization) and the new E-dition Compliance Monitor (ECM) software that provides links to regulation sources like CMS, CDC or FDA.
Pg06- Tracer Methodology 101 The Suicide Prevention Tracer [••REF••] This program tracer is specifically applicable to psychiatric hospitals, hospitals with inpatient units and crisis stabilization units that are part of a behavioral health care program. It is designed to evaluate the effectiveness of organization's suicide prevention strategies/efforts and issues/processes that might contribute to suicide attempts. JCSC, RNx, MDx, Psy and TxTM should note the emphasis on staff education/competency, take advantage of the suggested sample questions and incorporate this tracer into survey prep and ongoing risk assessment efforts.
Pg08- Spotlight on Success Making Accreditation Training Fun! FYI: JCSC, StEd. The idea is to reinforce and maintain compliance knowledge and survey readiness through the use of edifying and entertaining games. Adaptations of The Amazing Race, Jeopardy and crossword puzzles are given as examples. If your facility culture is one that tolerates and enjoys good-natured competition, these ideas (and others) are well worth trying.
[Index] [Blog] Patient Safety (Dec Vol 9 #12)
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Pg01- The Pressure's On: JCR's Nursing Safety Scholar-in-Residence Works to Stop Pressure Ulcers FYI: JCSC. JCR has partnered with medical equipment manufacturer Hill-Rom to create a new Nurse Safety Scholar-In-Residence program. It is designed to help bring evidence-based patient safety best practices out of the literature and to the patient’s bedside. Those facilities with longterm patients may find the summary care recommendations and the reminder for 'all' staff vs just nursing to play a roll useful.
Pg02- Patient Safety Pulse: Your Patient Safety News: Federal Government Offers New FluResources FYI: IC. Designed to provide one-stop access, "Flu.gov provides comprehensive government-wide information on seasonal, H1N1 (swine), H5N1 (bird) and pandemic influenza for the general public, health and emergency preparedness professionals, policy makers, government and business leaders, school systems, and local communities". A new H1N1 self-evaluation guide for adults that includes sections on myths and fact sheets.
Pg05- Caring for the Delirious Patient, Part 1 of 2: Assessing for Risk Factors and Signs of Delirium [••REF••] MDx and RNx (especially those at facilities with geriatric populations) will find this article a good review. It reminds us that not all delirium are agitated and that mortality rates for delirium are as high as those for myocardial infarction. The article also includes a useful table of risk factors. Because it presents in multiple forms and can not always be accurately evaluated in basic conversation, there is a suggestion for the use of formal assessment tools like the [Pearl] Confusion Assessment Method or CAM {Info} (PDF) . The authors encourage all patients over age 70 to be formally assessed regardless of their risk factors. An e-mail address for requesting CAM permission is also provided.
Pg08- Column: The Growth of a Just Culture [••REF••] This is an edifying introduction and overview of 'Just Culture'. If you have ever wrestled with the appropriate management response to staff error, system failure or near misses, the emerging concepts and tools that are part of 'Just Culture' are worth becoming familiar with. GB and LDR should read this article before the next serious incident or sentinel event occurs. See also: The Perception of Just Culture Across Disciplines in Healthcare, Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability, Our long journey towards a safety-minded Just Culture
Pg10- The Role of Leadership in Patient Safety: Joint Commission Recommendations FYI: GB, LDR. The 14 recommendations of SE Alert #43 "Leadership Committed to Safety" are re-presented in summary form.
[Index] [Blog] Environment of Care News (Dec Vol 12 #12)
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Pg01- Ensuring Appropriate Means of Fire Egress: Examining the "Life Safety" (LS) Chapter, Part 5 [••REF••] Part 5 in this series of LS Chapter reviews focuses on the 32 EP of LS.02.01.20. The EP are divided into 5 groupings covering Doors/Exits, Corridors, Suites, Travel Distances and Exit Illumination/Signage. It is a useful review for EOC and SFT.
Pg04- When Comfort Has a Cold Nose: Balancing Animal-Assisted Therapy and Health Care Facility Infection Prevention and Control FYI: IC. This article informs us that "more than 30,000 therapy dogs are at work in health care facilities." For those programs currently offering (or considering) animal-assisted therapy, it also provides a helpful reference, Guidelines for animal assisted interventions in health care facilities.
Pg06- Animal-Assisted Therapy at Edward Hospital: Cleanliness Is Next to Canine-ness FYI: IC. This is a companion piece and case study of animal-assisted therapy at a 317-private bedded full-service, regional healthcare facility in Illinois.
Pg10- Steam Sterilization in the Spotlight: The Role of the EC Professional FYI: EOC. If your hospital uses steam sterilization then your EC staff may want to review the roles and responsibilities suggested in this article for more effective alignment with TJC's recent position statement on steam sterilization that went into effect with its announcement in the July 2009 Perspectives.
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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 12/2/09:
- The Joint Commission’s Hospital Accreditation Recognized by: FYI: JCSC, GB, LDR. As of 11/27/09, CMS has approved the continuation of deeming authority for The Joint Commission’s hospital accreditation program through July 15, 2014.
- The Joint Commission to offer electronic payment of deposits and fees: FYI: FB, LDR. Beginning in mid-December, organizations can pay their deposit, annual fee or on-site fee electronically by going to the “Invoice” page of the “Subscription Billing” site and select the “Pay Now” button within the TJC Connect extranet site. More details are provided in the article and questions can be answered by Pat Hall, phall@jointcommission.org or (630) 792-5665.
- “Leadership in Healthcare Organizations” white paper now available: [••REF••] The white paper is entitled “Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards”. It was Paul Schyve, M.D., senior vice president of TJC, as a publication of the Governance Institute, a membership organization serving not-for-profit hospital and health system boards of directors, executives, and physician leadership. The 35-page document is a solid review of 2009 Leadership Standards with supportive rationale and references. GB, LDR should find it a useful resource.
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National Association of State Mental Health Program Directors (NASMHPD)
- 2009 Winter Commissioners Meeting: Sunday, December 6, 2009 in Arlington, VA
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)
