Pg01-Approved: Revisions to Medical Staff Standard MS.01.01.01Alert: MDx, MD, LDR. GB. Yes, 'after three years of discussion and debate' there is an approved revision of standard MS.01.01.01 that is slated for full implementation/compliance a year from now on 3/31/11. The revised version provides more flexibility for governing bodies and medical staffs to determine what will be placed in the medical staff bylaws and what will be placed in other documents. An MS.01.01.01 FAQ is already available. Be on the lookout for the audio conference that is to be scheduled sometime in April.
Pg03-Clarification: Hospitals Can Still Use Credentials Verification Organizations [REF: MDx, HR] For hospitals that use TJC for deemed status purposes, revisions to standards, MS.13.01.01 and LD.04.03.09, have raised questions about whether an organization can continue to use a CVO to obtain credential information for privileging practitioners providing interpretive services (e.g., imaging, tracings or specimens) through a telemedical link. This clarification says there is essentially no change in a hospital’s ability to use information from a CVO if the hospital determines it meets TJC's CVO guidelines. See fuller explanation below in 3/31/10 JC Online.
Pg04-Sentinel Event Statistics for 2009FYI: JCSC, SFT, Phrm. TJC has been collecting SE data since 1995. At least three of the top 10 events are relevant to psychiatric hospitals. Suicide is #4 in 2009 and #2 overall. Patient Falls is #6 in 2009 and overall. Medication errors is #7 in 2009 and #5 overall. It is also interesting to note that the number of reported SE has been increasing steadily over the last decade.
Pg08-Update: Progress at The Center for Transforming HealthcareFYI: JCSC, LD, GB and PI. Since it began in September 2009, we have been following the Center For Transforming Healthcare (CTH) in TJC articles. CTH was announced in November and in December its first product, a 'Booster Pak' for MM.03.01.01 (Safe Medication storage/labeling) was unveiled. This article provides a brief update on three other projects currently in process related to Hand Hygiene, Hand-off Communications and Wrong-Site Surgery. In the third quarter of this year, fruits of the hand hygiene project should be rolling out. The article says this will include a free, new application that can customize a set of solutions based on your organization's specific demographics. The concepts of Robust Process Improvement (RPI) and Lean Six Sigma (L6S) were prominently featured. LD, GB and PI are again strongly encouraged to familiarize themselves with RPI and L6S.ALERT: IC. SPHCC conducted a phone interview with Rick Morrow (director of Business Excellence at The Joint Commission) and Paul Shuyve, MD, (psychiatrist and Sr. Vice President at TJC) about the center and its projects. There are no psychiatric hospitals currently involved in the center's projects. However, Mr. Morrow offered a special invitation to any of our members who might be interested in participating in the last phase of the pilot experience for the Hand Hygiene project. Contact him quickly to see if he can work you in. He and Dr. Shuyve were certainly open and interested in having psychiatric hospital participation. And, at the pilot level, it is not necessary for an organization to be particularly expert in RPI. Dr. Shuyve pointed out that the new application referenced above is designed to help organizations that may not necessarily have the expertise to take advantage of RPI technology . He says the application's database is cause vs. solution based. So, if an organization can identify the cause(s) of their issue of concern, the application can assist them in navigating to appropriate solutions. TJC is definitely moving deeper into RPI, but Dr Shuyve assures us that while RPI will be encouraged, it is not likely to be a requirement for accreditation. As a beginning point for greater familiarization with RPI, we have requested permission to obtain and share the center's RPI Roadmap. We should be able to let you know how to get a copy soon. You can contact Mr. Morrow at 630/792-5239 or rmorrow@jointcommission.org or learn more online about the Center For Transforming Healthcare.
Pg01-Conducting Ongoing Professional Practice Evaluations (OPPE) How to Improve Compliance with MS.08.01.03FYI: MD, MDx. MS.08.01.03 certainly caused consternation when it first went into effect 4 years ago. Although it has not been a frequent finding in surveys of our hospitals, TJC believes a significant number of organizations have yet to achieve full compliance. For that, your organization must collect and analyze relevant performance data (not necessarily all 6 general competencies) and be able to demonstrate use of that data in the privileging process. If you still have some questions or feel there is some fuzziness in your hospital's approach, this article is worth reviewing.
Pg04-New Hospital Standards to Improve Patient-Provider Communication Free Guide Offers “How-to”s and Other Resources Before Standards Go into Effect FYI: LDR, RNx, HR, PI. In January TJC announced 4 new and 4 revised standards in the HR, PC, RC and RI chapters that were to improve Patient-Provider communication. It came with an odd implementation date of "no later than January 2011". At that time an implementation guide was to be released in February. This update projects that release a little further out to some time in April and provides more insight into the examples and how-tos it will provide. Stay tuned and we will let you know as soon as the guide is available.
Pg06-Tracer Methodology 101 The Laboratory Integration Tracer[REF: P&T, MDx] As the other articles in this series have done, there is description of a tracer scenario with suggested questions and tips for conducting and being prepared for this tracer. Remember, the focus of this tracer is not on laboratory functioning, technical competence, quality control or proficiency. Rather, the point is the effectiveness of communication and integration between hospital and laboratory. Note: The entire series of Tracer Methodology 101 Articles to date (10) are listed in the SPHCC Compliance Library in the Survey Process/Technologies section.
Pg10-What's the Most Popular Type of PPR? FYI: JCSC. The 'Full PPR' option is the most commonly chosen…almost twice as often as the other 3 options combined.
Pg08-Systematic Screenings Crucial in Preventing Patient Suicides [REF: MD, RN, SFT, StEd] The article provides a brief overview of a fairly standard suicide screening approach. However, it also reminds us that suicide is the second most common sentinel event reported in hospitals. 75% of those cases involved hanging while another 20% involved jumping from a roof or window. It should be noted that an estimated 70% of those who attempt hanging die and that the physical environment (including structures that support hanging) is a root cause in 73% of reported suicides. The bottom line of the article is its advocacy of suicide screening as part of the risk assessment of every patient that is required by NPSG.15.01.01. StEd may find this a useful item for an annual review packet. [Pearl] One of the article's sources was Suicide in secure psychiatric facilities1004 (By Harvey Gordon Advances in Psychiatric Treatment 8:408–417, 2002) that contains useful lists of risk factors for various psychiatric illnesses and hospital settings.
Pg04-Emergency Management Focus: Stemming a Rising Tide Responding to an Influx of Infectious Patients, Part 1[REF: EM, IC, LDR, SFT] This is the first of a two-part series looking at emergency management of an influx situation. H1N1 is the primary example used. While much of the preparedness process is generic, the article attempts to point out some issues that are more specific to this particular type of emergency. This first installment looks at the first three critical areas of emergency management (communication, resources/assets and safety/security) as they might be applied to an H1N1 influx. Part 2 will be published next month.
Pg06-Bringing Home Fire Drill Training Santa Ynez Valley Cottage Hospital Uses Best PracticesFYI: SFT. A 10-bed acute care hospital in California shares three best practices used in their fire drills that makes their hospital safer and more compliant with EC.02.03.03. Those practices include performing a pre-drill walk-through with new and junior staff. They also require each participant to individually complete and sign an "action performed' form. Most interestingly, they always conduct a concurrent utility disruption drill along with their fire drills. A side bar reviews the RACE (Rescue Pt, Activate Alarm, Contain fire/smoke, Evacuate) and PASS (Pull the pin, Aim at the base of fire, Squeeze the handle, Sweep from side to side) mnemonic devices for staff response to fire and proper extinguisher use.
Pg08-Curing Corridor Clutter: How New York Hospital Queens Used the Statement of Conditions™ to Help Clear Its Hallways FYI: EC, SFT. According to TJC statistics, cluttered corridors (LS.02.01.20) was the most common compliance issue for hospitals during the first half of last year. 38% of our psychiatric hospital members also had difficulty with LS.02.01.20, but our concerns were more often related to EP 31 (Egress Integrity/Exit signs) as opposed to EPs 11-13 (corridors). There was also a pitch made for "The Benefits of Using the SOC to Cure Deficiency" as was done by this New York hospital.
The Patient Who Falls1004, JAMA. 2010;303(3):258-266. : ALERT: MD, RN. In 2005, IHI and JAMA joined forces under an RWJ Foundation grant to produce a series of free teleconferences entitled Author in the Room (AITR). AITR is billed as a "Teleconference Series to Accelerate Health Care Improvement". The concept behind the series is to have "the author of a study published in JAMA with the potential to change clinical practice" to present their work and then be available for interactive discussion with clinician participants. The presentations are currently being scheduled for the third Wednesday of each month from 2:00 PM to 3:00 PM Eastern Time. The April topic on falls is presented by author Mary Tinetti, MD. There is no fee involved, but enrollment is required. If you are unable to make the live presentation, be aware that recordings are available in the AITR archives as far back as March 2005. [Pearl] MD and RN should note that participation in the calls qualifies for 1 hour of continuing education credit. Full text of the JAMA article is also available.
Inside the Joint Commission (DecisionHealth) - March , Vol 15 Issue 6
Page 2: Put performance criteria into your contracts, or expose leaders to RFIs. FYI: JCSC, Ldr. Although we have not seen it in our psych hospitals yet, the article tells us that citations on LD.04.03.09 have risen 'nearly fivefold or 14%' for TJC hospitals overall between 2008 and the first half of 2009 (these are the latest TJC stats available). Based on advice given by Glen D. Krasker, MHSA, former director of TJC's Hospital Accreditation Program, you may want to pay particular attention to having performance critieria in those contracts that involve what TJC might consider critical patient safety issues. An article provides a Checklist for Contracted Services with suggested performance criteria by Mr. Krasker that IJC has been kind enough to make available to us.
Page 4: Get emergency response letters ready. FYI EM, SFT. Article contains a sample letter outlining a provider's role in emergency response.
Feedbackfrom Surveys: 1st Quarter 2010 - FYI: JCSC. B&A has identified the following 'themes' from their client surveys (BHC and HAP) so far this year:
·MS: FPPE and OPPE
·LD: Contracts
·RC: Dating and Timing of Entries, Authenticating Verbal/Telephone Orders
·PC: Treatment Planning, Nutritional Screening
·MM: High Risk/Alert Meds, Adverse Drug Reactions, Refrigerator Temps
·IC: Risk Assessment
The article gives more details about these trend areas along with helpful tips for compliance. To see the full article, just subcribe (no cost) to the B&A newsletter.
Assess your Environment of Care for Suicide Risks - [REF: EOC, SFT] In the author's experience, TJC survey citations related to suicide risks in psychiatric hospitals are often attributed to EC.02.01.01 as a failure to conduct a thorough risk assessment of the environment. The article provides 9 specific steps for conducting such a risk assessment. B&A has also developed a [PEARL] Patient Safety Risk Assessment Tool for that purpose and will share with those willing to request it by e-mail. They also recommend the Design Guide for the Built Environment that is in our library along with other resources in the section entitled Environmental Suicide-Related Assessment.
Assess your Environment of Care for Suicide Risks - [REF: EOC, SFT] The key point emphasized in this article is the need to label mulit-dose vials with an expiration date as required by MM.03.01.01. Basing that date on the 28 day guideline established by USP 797 (chapter <51>) is fine, but that actual date needs to be indicated on the label and not inferred from an opening date.
MS.01.01.01 audioconference scheduled for April 22, 1-2 PM. CT. NPSG.03.07.01 has TJC is providing a free audioconference on the controversial MS.01.01.01 (formerly Ms.1.20). The official sign up is via your TJC Extranet site (at the bottom of the page under 'Top Spots') but we were able to go directly to the registration page that is provided by a third party. Resources for the call (including a podcast) are already available.
Reinstatement of anti-discrimination requirements for hospitals. FYI: MD, MDX. Effective 7/1/10, an EP is being 'reinstated' to both MS.06.01.07 and MS.07.01.01 to ensure that decisions about medical staff membership and/or privileges are not based upon gender race, creed or national origin.
JCO 3/31/10: [ALERT: MDx, RNx,P&T, PHRM]The Joint Commission seeks input on revised medication reconciliation NPSG. NPSG.03.07.01 has now been revised to be shorter and more specific. It also focuses more on four 'risk points' of 1- obtaining current medication information; 2- comparing meds ordered to the patient’s current meds; 3- giving the patient updated med info at discharge or transfer; and 4- explaining the importance to the patient of maintaining accurate medication information. Since these changes are in field test status, there is still an important opportunity for psychiatric facilities to review and comment on the appropriateness of the planned NPSG.03.07.01 changes for our hospitals. You are strongly encouraged to do so by 4/30/10, but not later than the dealine on 5/11/10.
Suicide in secure psychiatric facilities1004 - By Gordon H.: Advances in Psychiatric Treatment 8:408–417, 2002. contains useful lists of risk factors for various psychiatric illnesses and hospital settings
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 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!
