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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (May, Vol 30 #5)
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Pg01- Joint Commission Expands Access to e-App Now “Open” Every Day, 24/7 FYI: JCSC. In the past, the e-App could only be updated once during the survey cycle, but now it can be modified at any time. Whenever changes are made, TJC will acknowledge this with an e-mail confirmation.
Pg03- The Joint Commission Seeks Input on Revised Medication Reconciliation Goal FYI: JCSC, MD, P&T, Phrm. Under proposed refinements, requirements from the current NPSG.08.01.01 through 08.04.01 would be re-located and condensed under NPSG.03.07.01. The remaining components of that goal would be covered under other existing standards. Unless the field review that ended on 5/11/10 reveals a need for more revision, the goal is likely to be implemented on 1/1/11.
Pg05- Top 10 Standards Compliance Issues in 2009 Challenging Requirements Identified [REF: JCSC] TJC has now updated its listing of challenging requirements to include the full year of 2009. A comparison with the frequency of citations reported on our post survey questionnaires for psychiatric hospitals over the same period is quite interesting. Only 3 of he TJC top 10 are in the SPHCC Top 10. TJC's most frequent compliance concern for hospitals (RC.01.01.01) was found in 49% of TJC hospitals surveyed, but only cited in 24% of our reporting psych hospitals. In contrast, the number one compliance concern reported in PSQs (NPSG.02.03.01) was a finding for 57% of our psychiatric hospital members, but only 27% of TJC hospitals. See the full comparison of SPHCC vs. TJC Top 10 Standard Challenges.
Pg12- Approved: Suspension of "Automatic" Sentinel Event Adverse Decision FYI: JCSC, PI, LD, GB. If in response to a sentinel event, an organization failed to submit an acceptable RCA or MOS in a timely manner, there were TJC provisions that would automatically trigger an 'adverse decision' (e.g., provisional or conditional accreditation). Although an adverse decision is still possible (under decision rule PROVO2), it is no longer automatically triggered. Instead, the determination is to be based on whether or not the organization has "undertaken serious improvement efforts". The article interprets such efforts as making "measurable and observable efforts to improve and mitigate a risk of recurrence". The article also includes the full text of the related changes to the sentinel event chapter.
[Index] [Blog] The Source (May Vol 8 #5)
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Pg01- Strategies for Complying with Interim Staffing Effectiveness Requirements FYI: JCSC, HR, LD, GB. Last year, TJC suspended the staffing effectiveness standard, PI.04.01.01. On July 1st, interim staffing effectiveness standards will go into effect in the form of refinements to standards LD.04.04.05 (EP 13) and PI.02.01.01 (EP 12-14). The article contains a useful summary of the revisions. It also suggests five compliance strategies and some recommendations for what to do if cited on the revised standards. Be advised that simply collecting data is not sufficient. The data needs to be properly analyzed and reported to the appropriate persons/leaders.
Pg03- Addressing the Confusion about Contracted Services Subhead: How to Comply with Standard LD.04.03.09 [REF: HR] One particular point of confusion that is addressed is what/how much personnel data must be on file for contract employees. The author of this piece declares it is the intent of LD.04.03.09 to ensure that the level of care throughout the organization is consistent and equal, including that provided by contracted services. To that end the reader is provided a series of strategies for better monitoring, partnering with and communicating with contractors. Some of the suggestions such as shorter more focused orientations for contract employees and establishing mechanisms for rapid access to contractor personnel data (vs. keeping full sets of such data on site) are worth considering. For example, in this latter case, TJC indicates that a surveyor request for a contracted staff member's personnel file can be satisfied if the file is requested and received from the contractor before the survey ends*. However, most important is the need for clear, up front contract/performance provisions. Note this provision only applies to contracted services that directly affect patient care. [*Note: This option is further explained in the 4/8/10 TJC FAQ on Contracted Services and applies only to staff and independent contractors of accredited or certified organizations and not to licensed independent practitioners.]
Pg05- PPR TIP: The Last Reviewed Date FYI: JCSC. It should be noted that when you review or revise a standard in the PPR, the 'Last Reviewed Date' does not automatically update itself. By design, the form requires manual entry of the new date and then a save. An illustration and picture of where the new date should be entered is provided.
Pg08- Tracer Methodology 101: The Elopement Tracer [REF: JCSC, SFT] As a program tracer, elopement is specifically applicable only to behavioral health care organizations with 24-hour treatment programs (e.g., residential). However, psychiatric hospitals and other organizations with elopement risks are encouraged to utilize this survey technology for PI purposes. This article , like others in the 'Tracer Methodology' series contains a scenario with sample questions and compliance tips. This time, the setting is a residential treatment program for youth.
Pg10- How Long Will That Tracer Last? FYI: JCSC. TJC reports that surveyors generally spend 50-60% of their time conducting tracers. On average, system tracers for both BHC and HAP are lasting 60-90 minutes. However, the average for individual patient tracers is 60-120 minutes.
[Index] [Blog] Patient Safety (May Vol 10 #5)
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Pg01- Patient Safety and Alternative Medicine: How to Answer Patients' Questions FYI: MD, RN, FdSv. Complementary and/or alternative medicine (CAM) contains a wide variety of care measures not considered a part of conventional medicine. Some of the potentially effective examples given were yoga, meditation, biofeedback, massage, chiropractic, reflexology and dietary supplements such as St. John's Wort. The real point of the article is that CAM use is significant and growing. Even hospitals are reported to be offering CAM services. In light of this, we are encouraged to begin asking about CAM use during routine history taking. Staff, especially MD and RN should also be prepared to discuss and/or refer patients to reliable sources of CAM information. Some resources/references including the National Center for Complementary and Alternative Medicine are provided.
Pg05- Stop "Borrowing" Medications: Protecting Patients from Harmful Medication Errors FYI: RNx, Phrm. In at least two recent studies, it was reported that despite the use of automated dispensing cabinets (ADC), almost half of all nurses surveyed admitted to borrowing medications. Whether to replace a missing dose or to provide the first dose of a new medication, borrowing bypasses important safety checks and as a result can expose patients to unwarranted risk of harm. RNx is encouraged to explore the extent of this issue within your facility. Then, as needed, eliminate the temptation (e.g., unused medication not returned to pharmacy ) and underlying causes for borrowing as suggested in this article.
Pg08- Patient Safety Organizations: Forging Ahead to Protect Patients FYI: JCSC, LD, GB. PI. The Patient Safety and Quality Improvement Act of 2005 (PSQIA) authorized the creation of patient safety organizations (PSOs). Like ORYX, PSOs were designed to encourage "clinicians and health care organizations to voluntarily report and share quality and patient safety information without fear of legal discovery". The PSO program is operated by the Agency for Healthcare Research and Quality (AHRQ). Currently, only 1 (PsychSafe) of the 84 listed PSOs across the country appears to focus on patient safety information for psychiatric hospitals. By 2011, AHRQ hopes to list 100 PSOs and have in place a national patient safety database (NPSD) . To learn more about PSOs, go to PSO Information.
[Index] [Blog] Environment of Care News (May Vol 13 #5)
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Pg05- Better Safe Than Sorry: Conducting a Security Risk Assessment FYI: SFT. EOC. Three security experts are interviewed about the general approach to the assessment of security risks. The article identifies a number of potential risks and suggests some assessment approaches. For example, to obtain a fresh perspective, use the security expert (or most expert person) from a sister facility to conduct the annual risk assessment.
Pg08- Considering Emergency Staffing, Utilities, and Patient Care Issues: Responding to an Influx of Infectious Patients, Part 2 [REF: IC, EM, EOC, LD] Last month in the first part of this series, a potential influx of infectious patients was examined from the perspective of the needed responses from the first three critical areas of communication, resources/assets and safety/security. This month the same event is considered in light of the remaining critical functions of staff responsibilities, utilities management and patient care. Staff should be prepared for the possibility of different responsibilities during an influx and increased staffing levels may need to be considered. Advance training should also have made them knowledgeable about the symptoms, assessment, transmission and containment of the infection. As a part of utilities management, thought should be given to the potential for an increase in infectious wastes and how its disposal would be accomplished. Leaders should also anticipate its capacity for treating infected and non-infected patients during such a situation. At some point, a discontinuation of admission or even closure may need to be considered. Mock drills are strongly recommended.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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INTERNET HIGHLIGHTS
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Institute for Healthcare Improvement Audio & Web Programs
Inside the Joint Commission (DecisionHealth) - March , Vol 15 Issue 6
- Medication reconciliation: New goal gives hospitals more latitude: The new requirements for medication reconciliation have not been finalized. If you did not review the proposed changes during the field review, this article provides a brief overview of what is likely to change (i.e., the hospital decides what medication information to collect, whether to use a separate list and may no longer be required to reconcile upon transfer) and what is likely to remain the same (admission and discharge remain the key points of focus). Just remember, the changes HAVE NOT BEEN FINALIZED. FYI: JCSC
- Psychiatric Emergency Response Team helps de-escalate patients: Tewksbury Hospital has implemented an S&R reduction approach using a Psychiatric Emergency Response Team that so impressed TJC surveyors that the facility was invited to apply for a Codman award. Although Tewksbury is described as a 750-bed longterm acute care hospital, the principles utilized in PERT are worth noting. For example, PERT is designed to encourage and provide intervention by 2 team members at the first sign of a patient escalation to de-escalate with less restrictive interventions. Additional, specially trained team members are used for more advanced escalations that may require more restrictive measures. Consider how your hospital might adopt the idea of very early R&S intervention. FYI: RN, PI.
Joint Commission Behavioral Health Update (Newsletter from Barrins & Associates) - May 2010
- Psychiatric Hospitals: Get Ready to Implement Core Measures: FYI: JCSC, PI. Based partly upon a recent conversation with Frank Zibrat, TJC Associate Director for ORYX Implementation, B&A says it is anticipated that all accredited freestanding psychiatric hospitals will be required to implement the 7 new core performance measures for inpatient psychiatry by the end of this year. Final endorsement of the measures by the National Quality Forum is still pending. More details are available on TJC's HBIPS homepage and in the latest HBIPS Specifications Manual (January 2010).
Joint Commission Online (JCO) & Website
- JCO 5/12/10
- Most challenging requirements for 2009 - This issue contains a compact listing of the top 5 non-compliant standards for each program
- Joint Commission webmaster encourages organizations to upgrade Internet Explorer 6. In order to use all of TJC's web features upgrade to one of the following: • IE 7 and above • Firefox 2 and above • Safari 3 and above • Google Chrome 4 and above
SPHCC Library Additions
- Midwest Association of Mental Health Organizations (MASMHO) - Spring Conference, May 11-12, 2010. Selected presentations and highlights will be added to the library over the next two weeks.
2010 Member Surveys (SL1a)
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!
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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)
