• New Members:South Florida Evaluation & Treatment Center (SFETC), South Florida State Hospital (SFSH) and Treasure Coast Forensic Treatment Facility (TCFTC)
Pg01-Joint Commission Anticipates More Discussion on PhysicianFYI: MD. As part of its process of re-application for deeming authority, TJC was required to align its definition of 'physician' with that of CMS. That revised definition presented in this article is now in the TJC glossary and footnoted in those EP that correspond to a Medicare COP. That definition originates in the Social Security Act (Sec. 1861.[42 U.S.C. 1395x]) and was developed for purposes of reimbursement. Apparently, since this was announced in the June 2009 Perspectives (effective 7/1/09), some physician groups have expressed concern.However, TJC gives assurance that " The use of this definition by The Joint Commission does not either expand or contract any health care practitioner’s license or scope of practice, nor is it meant to have any other purpose than that related to the specific EP in which it appears." The article contains the definition and a listing of all EP that refer to Physician or Doctor. See also: Revised Definition of "Physician" (MM, MS, PC, RI)PDF1002
Pg01-Get the Most Out of the Periodic Performance Review: Do You Know About Your Organization Service Profile Report?[ALERT: JCSC] TJC reminds us of the Organization Service Profile Report (OSPR) within your PPR tool that displays just those standards that are actually applicable to your organization. Be aware that the OSPR automatically updates when changes to the e-App are made and that this can cause some previously scored EP to show up as 'Not Scored'. Therefore, be sure to check the Scoring Summary Page after any update. In addition, AMP users should know that its upload function only sends data into the PPR tool and not the PPR itself, unless you go into the PPR tool and click on the submission button. Additional tips are provided in a sidebar.
Pg02-5 Sure-Fire Methods Identifying Risks for InfectionsFYI: IC. The article offers 5 strategies to comply with IC.01.03.01: 1 - Don't use generic risk-assessment templates. Make your risk-assessment plan specific to your organization 2 - Use a meaningful analysis of collected surveillance data to direct the IC plan and risk-assessment approach 3 - Use a defined criteria to prioritize identified risks 4 - Establish a tickler system to avoid forgetting, omitting or being late with required annual evaluations… 5 and obtain varied staff input.
Pg03-Get a Jump Start in 2010 on Meeting the Top Compliance Challenges, Tips and Strategies for Dealing with the Hot Buttons from 2009FYI: JCSC, P&T, MD, Phrm, The article identifies 3 standards, NPSG.02.03.01, MM.03.01.01 and MS.08.01.01 as being particularly challenging during the first half of 2009 for TJC hospitals in general. It then offers brief compliance tips such as flow-charting your critical test processes. In our analysis of 21 state hospital post survey questionnaires (PSQ) from last year, more than half of our members also had difficulty with NPSG.02.03.01 as did almost a quarter with MM.03.01.01. However, MS.08.01.01 did not make our list of the SPHCC TOP 15 most frequently cited standards
Pg06-Tracer Methodology 101: The Fall Reduction Tracer[REF: RN]We count this as the 11th installment in this series and the 2nd time Fall Reduction has been the focus. This article uses the same picture as in the Source article of June 2009 on fall reduction, but the tips have been refined and there are more/different sample questions. The setting for the scenario is again in a home care organization. However, the description of the basic surveyor approach and more than 20 sample questions should still be valuable to psychiatric hospital efforts to comply with PC.01.02.08 (where a number of 2009 NPSG.09.02.01 EPs were moved to).
Pg05-Communicating with Adult Patients About Influenza Vaccinations: A Conversation with Kristin L. Nichol, M.D., M.P.H., M.B.A.FYI: IC, PtEd. The authors of Barriers to Adult Immunization (Full Txt)1002 (Am J Med 121: S28–S35, 2008) found that in their study, 80% of consumers said they would receive a vaccination if their health care providers recommended it. In addition, many people do not get influenza vaccinations because they do not know they should be immunized. Based on such reasons, the discussant in this article recommends that health care providers make direct recommendations to patients—especially those in high-risk categories—to receive the vaccine. “It’s not enough to simply provide hand sanitizer and display posters about protecting yourself from influenza,” Staff should also consider making discussion of the flu and vaccinations a topic of community meetings and care education.
Pg08-Multidisciplinary Morbidity and Mortality Conferences: Improving Patient Safety by Modifying a Medical Tradition[REF: MDx, LDR] The first page of this article describes a bit of the history and purpose of the morbidity and mortality (M&M) process. It notes the early 1900 origins of the process at Massachusetts General Hospital. It also points out the fact that the Accreditation Council for Graduate Medical Education (ACGME1002) considers morbidity and mortality review a part of the core competencies of system-based improvement (one of the six general competencies also encouraged by TJC for all medical staff members). The rest of the article provides the rationale for its key recommendation that the M&M process be improved by making it more multi-disciplinary. In this article, the focus is upon the traditional confinement of M&M within hospital departments (e.g., surgery, medicine, etc). However, there is often a similar restriction of the process to the Medical Staff in psychiatric hospitals that leadership may want to reconsider in light of this article's arguments. MDX should also consider formally using M&M in the monitoring and evaluation of general competencies. See also: Integrating Clinical Practice, QI, and the Competencies into the M&M Conference1002, See also: Morbidity and Mortality Conference, Grand Rounds, and the ACGME’s Core Competencies (PDF)1002
Pg04-Meeting the Security Needs of Individuals Affected by Mental Illness and Developmental Disabilities[REF: StEd, SFT, RN]. This is a brief, basic, but useful review of communication and de-escalation techniques for security staff and others that might be called upon for early intervention, prevention and/or management of dangerous and disruptive behavior. It provides a reminder to speak clearly and calmly using smaller quantities of information/words while displaying calm body language. A straightforward six-step de-escalation strategy is also described.
Pg08-Function 6: Patient Clinical and Support Services: Meeting Patient Needs in a Crisis[REF: EM. EOC, MDx, RNx, Psych, SW, AT, IM] This article briefly reviews and provides compliance tips and strategies for the 8 EPs of Standard EM.02.02.11 in the 6th and final critical function of emergency management. In particular, there should be some anticipation of increased stress during any emergency and a plan (as required by EP6) to manage the resultant effects on the mental health service needs of your patients.
Field review of revised Medication Reconciliation NPSG postponed: A field review of NPSG.08.01.01 was planned for February, but has been postponed. A revised version is expected to go to the TJC’s Standards and Survey Procedures Committee for approval this spring.
The Multi-state Disaster Behavioral Health Consortium ensures that State mental health authorities are represented in disaster and emergency response planning and preparedness activities at the national level… FYI: GB, LDR
SPHCC Library Additions
SL1a: PSQ Analysis: 2009 (Full Year)Most frequent citations by rank order and chapter.
January Mini-WebNR: Active Treatment Compliance Strategies (MP3 & Slides)
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 contributions in advance.
