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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (Jan, Vol 30 #1)
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Pg01- The Joint Commission's Hospital Accreditation Recognized by CMS FYI: JCSC. TJC's deeming authority has now been officially approved/continued through July 15, 2014. The rest of the article recap's the organization's history as a deeming authority.
Pg03- Joint Commission, HHS Team Up in Language Access Education Effort FYI: GB, LDR, StEd. The effort being referenced is a 31-minute video entitled 'Improving Patient-Provider Communications'. This is another in a recent series of articles and resources calling us to attend to the important connection between patient safety and effective communication. Be aware that under Title VI of the Civil Rights Act of 1964, a failure to provide language access services for Limited English Proficient (LEP) persons may be considered discrimination on the basis of national origin. There are similar provisions for those who are deaf or hard of hearing under Section 504 of the Rehabilitation Act of 1973 See also: TJC Hospital, Language and Culture reference page
Pg04- New Process for Developing Accreditation Survey Agenda FYI: JCSC. For those organizations expecting survey in 2010, submission of your e-Application will now trigger communication from TJC that provides advance information about the on-site survey length and number of surveyors. Apparently there will also be opportunities before (with account reps) and during survey (with surveyors) for some negotiation of survey activity timing. However, the article assures us that "survey activities are not changing".
Pg04- Looking for a Few Good Surveyors FYI: ALL. TJC is looking for Home Care surveyors. If interested, call their HR department at 630.792.5615 or goto TJC Career Opportunities
Pg05- Approved: New and Revised Hospital EPs to Improve Patient-Provider Communication [REF: LDR, MDx, RNx, SW] It should be noted that the importance of effective communication to patient safety has now been underscored in 4 new and 4 revised standards in the HR, PC, RC and RI chapters. These changes address qualifications for language interpreters, language services and the data/information processes related to patient communication needs. The article provides requirement specifics but indicates an effective date "no sooner than January 1, 2011". However, if you recall the run up to the 2009 leadership standards, you may want to get a jump on this. An implementation guide is scheduled for release in February.
Pg07- Approved: Staffing Effectiveness Requirements for Hospitals and Long Term Care Organizations [REF: LDR, RNx, HR, PI] Be aware that effective July 1, 2010 there will be a set of interim staffing effectiveness requirements to replace PI.04.01.01, the previously suspended staffing effectiveness standard. The interim approach is a softer requirement for the evaluation of undesirable patterns and/or events to include consideration of staffing effectiveness with appropriate communication and reporting of the results. Staffing effectiveness indicators (e.g., National Quality Forum Nursing Sensitive Measures) are now suggested vs. required. Still, this is an interim requirement and more research and refinement of these requirements is expected during 2010.
Pg08- New Speak Up Coloring Book About Infection Control Available FYI: RN. For programs that serve children, there is a 2-page coloring book addressing key infection control principles. Stay Well and Keep Others Well is a free download.
Pg08- Free on the Web: Webinar on Health Care-Associated Infections FYI: JCSC. Refer to November 2009Review.
Pg09- Standards BoosterPak™ Now Available for MM.03.01.01 FYI: JCSC [DL] MM.03.01.01 BoosterPak. Refer to December 2009 review.
Pg11- Speak Up: How Patients Can Make the Most of a Visit to the Doctor FYI: PtEd. Last month TJC published “Tips for Your Doctor’s Visit” that might be a useful handout to offer as part of a patient discharge packet.
[Index] [Blog] The Source (Jan, Vol 8 #1)
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Pg01- What's New with Joint Commission Accreditation for 2010? Overview of Major Changes to Requirements for the New Year FYI: JCSC, MDx. The most significant changes are refinements in CMS-related requirements and the NPSG. We believe the best descriptions for both sets of changes was provided in the 2009 October, 32-page Special Edition of Perspectives (Vol.29#10). [PEARL] However, this article includes a 1-page table that provides a concise review of the changes. Those who credential and privilege for telemedicine are reminded that effective 7/15/10, the ability to do so by proxy will no longer be permitted under TJC standards as part of the CMS-related revisions. Also be aware that a new draft of the PC chapter for BHC is now available for review. See also: Perspectives v29#10 pg01- Approved: 2010 National Patient Safety Goals - Perspectives v29#10 pg16- Accepted: New and Revised Hospital Elements of Performance Related to CMS Application Process
Pg02- 5 Sure-Fire Methods: Monitoring and Evaluating Practitioner Performance [REF: MDx, C&P]. Although it was not a significant issue in our 2009 post survey questionnaires (PSQ), 16% of TJC hospitals failed to fully comply with MS.08.01.01 in the first half of 2009. Apparently the specific point of concern is EP#1 that requires a period of focused professional practice evaluation (FPPE) whenever privileges are initially requested. Since there is no longer a specific requirement for a provisional period, FPPE can be defined not only as a provisional period of time, but by a number of admissions or procedures related to the new privilege. Four more compliance strategies are suggested.
Pg03- Joint Commission Standards Are "Good Medicine" for H1N1 [REF: IC, EM] The article recommends compliance with IC.01.06.01 (the requirement to prepare to respond to an influx of potentially infectious patients) as a useful strategy for addressing the H1N1 virus pandemic. It also suggests several useful considerations for developing the required written plan and encourages working with EM staff in its development.
Pg05- The Joint Commission Launches H1N1 Electronic Forum FYI: IC. TJC has developed a free information exchange devoted to the peer sharing of information, tips and strategies related to the H1N1 pandemic. [PEARL] The H1N1 Electronic Forum is a part of TJC's WikiHealthCareTM site. Anyone can view the postings, but to participate in the discussion it is necessary to complete a free registration and have a valid e-mail address.
Pg06- Tracer Methodology 101: Learning from a Tracer 'Veteran': Main Line Health FYI: JCSC. The Main Line Health system of four acute care hospitals believe there are significant benefits gained by incorporating a schedule of ongoing tracers into the routine of their organization. In this piece they share their experience and some related suggestions. They use a two-person tracer team approach consisting of a clinical manager and a member of an ancillary department. As they describe it, one member often focuses primarily on the clinical issues while the other picks up on environmental concerns. A copy of their tracer worksheet is included.
[Index] [Blog] Patient Safety (Jan Vol 10 #1)
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Pg01- Using Six Sigma Methodologies: Creating a Revised Discharge Medication Reconciliation Process FYI: PI, MDx, RNx: The DMAIC steps of Six Sigma are lightly discussed as they were applied to a medication reconcilitation improvement effort that significantly reduced med errors over a 2-year period by a general medical hospital in Illinois. If you are still having difficulty with NPSG.08. some of their FMEA findings might be useful.
Pg07- Caring for the Delirious Patient: Preventing and treating delirium (Part 2 of 2) FYI: JCSC. [REF: MD, RN, StEd] This second part of the series provides useful advice and information on prevention and treatment. The prevention comments are largely drawn from the work of Dr. Sharon Inouye (Yale) and her Hospital Elder Life Program (HELP)1001 that is reportedly being implemented in 36 hospitals in the United States, Canada, and Australia, on medical and surgical wards. The article suggests one-third of delerium can be prevented, encourages early identification/intervention and discusses approaches to the six major risk factors. MD may find it noteworthy that the section on treatment encourages the use of Haldol as a last resort. See also Inouye S.K.: A practical program for preventingdelirium in hospitalized elderly patients1001. Cleve Clin J of Med 71:890–896, Nov. 2004
[Index] [Blog] Environment of Care News (Jan Vol 13 #1)
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Pg01- Creative Emergency Management Planning: Providence Health and Services, San Fernando Valley, Thinks Outside the Box FYI: E&M, EOC, LDR. A Southern California hospital system shares tips on Emergency Management in earthquake situations. A couple of the approaches described included their use of a trailer as a mobile emergency command center and a flexible oxygen tank hose.
Pg04- Putting the Brakes on Health Care "Road Rage": Recognizing and Opposing Disruptive Behavior to Help Maintain Safety and Security FYI: LDR, MDx, RNx, HR. Disruptive behavior and the SE Alert #40 (Behaviors that undermine a culture of safety) is the general focus here, but there is a more specific look at the issue of intimidating or bullying behavior. Some useful examples of such behavior are provided as are 13 suggested actions (largely from SE Alert #40) for dealing with them. The article also points out that intimidation can be considered a psychological form of workplace violence and that legislation to prohibit such behavior in the workplace is pending in nearly a dozen states.
Pg06- Keeping It Cool: The University of Wisconsin Hospital and Clinics Creates a Refrigerator Temperature-Monitoring Solution FYI: EOC, LDR. If your organization has trouble maintaining and/or monitoring refrigerator temperatures, as required by EC.02.04.03, EP 3 and MM.03.01.01, EP 2, this case study is worth reading. And, if you can afford it, the idea of remote temperature monitoring technology that is touted here is worth considering.
Pg08- Fire Safety in the Health Care Environment: Authoritative Answers to Common Questions About the Environment of Care FYI: EOC. This Q&A article looks at several questions related to temporary barriers, ILSM and other temporary measures taken during construction.
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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 12/30/09:
- Field review of proposed modifications to MS.01.01.01 (formerly MS.1.20): ALERT: LDR, MDx. Field review of MS.01.01.01 is open until Jan 28, 2010. Given the controversy around this requirement, we would encourage psych hospitals to weigh in.
- Submit your hospital’s practices for engaging patients and families in safety and quality: FYI: FB, LDR. TJC and AHRQ are seeking examples of effective practices being used in hospitals to engage patients and families in safety and quality. To make a submission send an e-mail to APFE@jointcommission.org describing how you engage patients and families and why you believe it is an example of an effective practice.
National Association of State Mental Health Program Directors (NASMHPD)
SPHCC Library Additions
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Note: All reference articles, Pearls and downloads will be added to the library by the end of the month.
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Take a look peak at the new Higlights Compedium and our 2010 TJC Compliance Library.
2009 Member Surveys (SL5)
If you anticipate a survey soon, please click here
Our database of surveys now includes twenty-one psychiatric hospital members that underwent full, unannounced Joint Commission surveys in 2009. Reported surveys for the last six months are listed below. The full set of surveys is available in the Survey Feedback Library. The latest analysis of PSQ for the full year of 2009 should be completed by the end of this month.
We really appreciate your 2009 feedback! Please 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. Our "thanks" to you for your contributioins in advance.
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)
