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THE JOINT COMMISSION (TJC and JCR)
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[Index]  [Blog]                                Perspectives (Mar, Vol 30 #3)

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Pg04-  Correction: Scoring Impact and Criticality for Accreditation Requirements FYI: JCSC, PPR.  There were three sets of errors in the January Perspectives.
1) The following requirements were assigned level 2 criticality (Situational Decision Rules), but should be level 3 (Direct Impact)
      • PC.02.01.0X, (EPs) 1 and 2 -  Effective after 1/1/11
2) The following requirements were assigned level 3 criticality (Direct Impact) but should be at level 4 (Indirect Impact)
      • RI.01.01.01, EPs Y and Z*  (effective 7/1/10)
      • PI.02.01.01, EPs 12, 13, and 14 (effective 7/1/10),
3) The following requirements were not assigned scoring categories but should be category A
      • LD.04.03.01, EP 26
      • LD.04.03.07, EPs 1 and 2,

Pg05-  Correction: National Patient Safety Goals on Labeling Medications and Multidrug-Resistant Organisms FYI: JCSC, PPR, Phrm.  Effective immediately, NPSG.03.04.01 has been modified so that 'preparation date' is no longer required as part of medication labeling.  The word 'prevention' was omitted and has now been added to NPSG .07.03.01 with regard to providing education on multi-drug resistant organisms.

Pg06-  The Joint Commission/JCR Release New "Smart Parent" Book for the Public   FYI: PtEd.  The Smart Parent's Guide is said to feature" 'insider' recommendations about how to protect your child’s health—in the emergency department, pediatrics unit, pharmacy, and doctor’s exam room and at home".  Needless to say, one point of emphasis is "looking for the Joint Commission’s Gold Seal of Approval™ when choosing a health care organization for your child and for your family".  Needful to say, there is a price of $16.00.

Pg07-  Sentinel Event Alert: Preventing Maternal Death  [REF: MDx, RMx, P&T]  Although rare, we sometimes have patients who are or (unfortunately) become pregnant during hospitalization.  While we are unlikely to be involved in the delivery process, our care of such patients could be a significant factor in the delivery outcome.  In that context, MD and RN should be aware of Sentinel Event Alert 44: Preventing Maternal Death.  In particular, review the common causes of such deaths that might be influenced by our care (e.g., management of hypertension) and suggested actions that might be relevant (e.g., identifying triggers for responding to changes in a mother’s vital signs and/or clinical condition as might be required by PC.02.01.19).

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[Index]  [Blog]                                                  The Source (Mar, Vol 8 #3)

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Pg01-  Leaders Should Be Champions Against Disruptive Behavior: Strategies to Comply with Standard LD.03.01.01  [REF: LDR, HR. JCSC]  Compliance with LD.03.01.01 requires leaders to create and maintain a culture of safety and quality.  This must involve managing disruptive and inappropriate behaviors.  A key part of this process should include creating a code of conduct that will discourage disruptive behavior.  The article provides useful guidance for the creation of an effective code, includes examples of disruptive behavior, a sample code of conduct policy (PDF) from Stanford1003 and advice for managing its implementation.  Most likely you already have a code, but make sure your definition of disruptive behavior properly covers more subtle issues such as intimidation.  You might even consider refining your current code with additional staff input and some of the suggestions included in this article. 

Pg08-  An Interview with a Joint Commission Hospital Surveyor FYI: JCSC.  The interview is with Susan Hill, R.N., M.A.  who has surveyed at least two of our member organizations in the past 3 years.  Her insights are fairly routine, but do provide useful confirmation of some survey topics that staff should be prepared for.  For example she specifically advises hospitals to anticipate questions about the survey of the culture of safety.  A word to the wise.  [Note:  If you have additional information on Ms. Hill not included in our profile database, please send us your input. Thank you.]

 

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[Index]  [Blog]                                                  Patient Safety (Mar Vol 10 #3)

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Pg07-  Error Prevention in a Just Culture: Avoiding Severity Bias [REF: LDR, GB] Severity bias is a phenomenon in which our managerial response to risky staff behavior is influenced by the severity of the outcome related to it.  For example, staff use an unapproved physical hold technique during a restraint process. In Scenario A the result is no patient harm.  However, In Scenario B, the patient suffers a broken arm.  Would you/your management respond differently to the scenarios?  The point of the article is to encourage and underscore the importance of 'consistency of response whenever a risky behavior is recognized'.  [See also Patient Safety, Dec '09,Pg08-  [REF: GB, LDR] Column: The Growth of a Just Culture]

 

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[Index] [Blog]                                              Environment of Care News (Mar Vol 13 #3)

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Pg01-  Understanding Fire and Smoke Protection Features Examining the “Life Safety” (LS) Chapter   [REF: EOC, SFT] This is the third article addressing Health Care Occupancies in a continuing series on the LS Chapter.  The specific focus is LS.02.01.30 with a useful overview (by George Mills, M.B.A., F.A.S.H.E., C.E.M., C.H.F.M., C.H.S.P., senior engineer, Standards Interpretation Group)  of key compliance issues for vertical openings, hazardous areas, wall and floor coverings, and compartmentalization.  It should be noted that 38% of hospitals in our 2009 PSQ analysis received survey citations on this standard.  As such, this article might well benefit those responsible for PPR review of this standard and those involved in environmental safety rounds/tracers.

Pg04-  Six Facility Design Strategies Shared by Top Children's Hospitals FYI: LDR, GB, E&M.   The six strategies focus on children with general medical or surgical needs.  Still, there may be value in the concept of 'positive distraction' and other suggestions for those who have distinct areas for child and/or adolescent populations and an opportunity to design or renovate them.  

Pg06-  It's All on the Surface: Establishing Protocols for Cleaning and Disinfecting Environmental Surface Areas [REF: LDR, EOC, RN, HSKP] The CDC makes it clear that cleaning and disinfecting environmental surfaces in health care facilities is "fundamental in reducing the potential contribution of those surfaces to the incidence of HAIs".   This article advises organizations to have specific protocols for different areas of the hospital (as well as the different environmental surfaces within them) that are developed with multi-disciplinary input (and involvement).  It also suggests that it is useful to differentiate between surfaces requiring frequent vs. non-frequent cleaning and clearly defined cleaning schedules.   See also: 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities1003 •• Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (PDF)1003

Pg08-  The Violence Tracer A Behavioral Health Care Requirement That Can Also Benefit Other Settings FYI: JCSC, LDR.  This is the same article printed earlier in The Source, July, 2009 under the title Tracer Methodology 101: The Violence Tracer.

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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

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. Quarterly Provider Updates

• QPU July-September 2010
• QPU April-June 2010
• QPU January-March 2010
  

Mid-Quarter Instructions

• January 2010 Mid-Quarter Instructions [PDF, 32 KB]
  • F&B: Annual Update Inpatient Psychiatric Facilities (IPF) PPS Rate Year 
  • F&B: Inpatient Prospective Payment System (IPPS)…Inpatient Psychiatric Facility (IPF) Pricer –Annual Update 

What's New

• What's New Page - January 2010 [PDF, 29 KB] 
  
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INTERNET HIGHLIGHTS

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Inside the Joint Commission  (DecisionHealth) 

• Put performance criteria into your contracts, or expose leaders to RFIs. FYI: LD.  Compliance with LD.09.03.09 (especially EP 4-6) requires the determination and utilization of performance criteria for direct care services provided under contract.  Make sure your contracts include them.
• Get emergency response letters in order, surveyors may want to check yours. FYI JCSC, MDx.   EM.02.02.07, EP8 requires communication 'in writing' to all LIP about their role and to whom they would report during an emergency.  The article provides a sample letter, but compliance could also be achieved via an annual e-mail or newsletter. Make sure MDx is aware of this.

Joint Commission Behavioral Health Update (Newsletter from Barrins & Associates) 

• Make Sure You Have a Process for High-Alert Meds1003: [REF: Phrm, P&T, RN, MD] Provides a concise, useful overview with practical strategies for compliance with MM.01.01.03.

• Take Note: New PI Requirements for Behavioral Health1003: FYI: PI.   Under BHC standard PI.01.01.01, EP#16, organizations/programs will need to specifically ask their clients about their treatment goals/needs and if they were met.  The article advises the fundamental step of clearly defining patient involvement in treatment planning.  It also suggests incorporating the required questions into client satisfaction surveys.

Joint Commission Online (JCO) & Website

• JCO 3/10/10: 
  

  • In celebration of Patient Safety Awareness Week, TJC has posted an 11-question safety quiz for patients designed to test/reinforce their knowledge of how to keep themselves safe and informed in treatment situations.  FYI: PtEd
    

National Association of State Mental Health Program Directors (NASMHPD)

• Medical Directors Council Paper entitled, "The Role of the Medical Director in a State Mental Health Authority: A Guide For Policymakers December 2009". Includes recommendation that "State Mental Health Authorities should have a fulltime Medical Director".  FYI: GB

Forensic Hospital Conference Call  

• On March 10^th,  two of our SPHCC members (ELMHS and LaSH), participated with three other hospitals in a conference call discussion of in-patient forensic issues.  The call was sponsored and facilitated by former member, Western State Hospital (WSH).  The focus was primarily on general forensic/judicial (e.g., discharge limitation, competency rates) matters and concerns related to seclusion and restraint (e.g., reduction strategies, debriefings).  Member hospitals with forensic populations are encouraged to stay tuned for the next conference call. FYI: For

 

SPHCC Library Additions 

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. 

• 2009/12-tjc-Barrins Psychiatric Hospital-LA_1Ad  {New}
• 2009/12-tjc-Central Louisiana State Hospital (CLSH)  2Ad1Ca2Fr*S&R {New}
• 2009/11-tjc-Searcy Hospital (SH)_7Ad1Fr {New
• 2009/09-tjc-Southeast Louisiana Hospital (SELH)_3AD1Ca*S&R*AdolNeuro¥ 

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!