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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (June, Vol 30 #6)
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Pg01- Standards Project Focuses Attention on High-Value Standards, Cuts 16 EPs [ALERT: JCSC, LDR, GB] If your PPR is due after July 16th, it could be a little easier to complete. In response to TJC's request, 60 sources representing more than 300 hospitals identified 52 EPs they believed to be of questionable value. 16 of those (EC x 3, LD x 7, MM x 2, PC x 3, RI x 1) will be removed from the CAMH effective July 16. A number of the remaining 46 EP are being revised, including 5 under Standard RI.01.07.07 (patients who work for or on behalf of the hospital) that will only be applicable to psychiatric hospitals providing longer-term care. A full listing of eliminated and revised requirements is included. See also TJC raises expectations for 15 EPs,expects 100% compliance below.
Pg03- Update: Deleted Measures of Success and Revised Scoring Categories for 2010 [ALERT: JCSC] If your organization is in the MOS phase of your last survey you could also be getting a break. Effective April 26, 2010, 33 hospital MOS (EC x 19, IM x 2, MM x 1, MS x 1, PC x 4, PI x 2, RC x 4) were eliminated. A number also changed scoring category from C to A. The specifics are provided in an included table.
Pg07- Approved: Reinstatement of Antidiscrimination Requirement to Hospital "Medical Staff" Chapter FYI: MD, MDx. This was previously announced in the 4/14/10 issue of TJC Online. The specific wording is included in this article.
Pg08- Joint Commission Webmaster Encourages Organizations to Upgrade Browser FYI: JCSC. TJC is encouraging you to upgrade your browser if you are using Internet Explorer 6 that will not be fully compatible with web site upgrades slated for this fall. Suggested free replacements include: ? Internet Explorer 7 and above (http://www.microsoft.com) ? Firefox 2 and above (http://www.getfirefox.com) ? Safari 3 and above (http://www.apple.com/safari) ? Google Chrome 4 and above (http://www.google.com/chrome). Also note that in 2010, The Joint Commission Web site will be redesigned. Usability testing will be part of the process for the redesign. JCSC are encouraged to take TJC's 3-minute pre-survey and sign up to participate in the testing to provide perspective on behalf of psychiatric hospitals.
Pg09- Approved: Revised "Care, Treatment, and Services" Chapter for Behavioral Health Care [REF: JCSC, BHC, MDx Psych, SW] The PCS chapter has been reorganized and renamed “Care, Treatment and Services” (CTS ). It "now includes specific expectations for eating disorder treatment, outdoor/wilderness programs, and animal-assisted treatment (and) incorporates …recovery concepts…" In addition, there are also some new requirements focusing on the independent living needs of young adults, psychiatric advance directives, physical holding of children/youth and management of waiting lists. When CMS uses the term behavior management, it is only in the context of seclusion and restraint use. To avoid confusion, TJC is replacing that term in the CTS chapter with 'individualized behavior contingencies'. Opioid treatment program requirements have not been revised. An outline of the new CTS chapter is included in the article and a pre-publication version is expected this summer.
Pg10- Accepted: New Psychiatric Hospital Elements of Performance [REF: JCSC, HR, MDx, RNx, SWx] - 7 new EP (HR x 2, LD x2, MS x 1, PC x 2 and RC x 1) have been added to the requirements for psychiatric hospitals using accreditation for deemed status purposes. These EP align TJC with CMS requirements relating to record keeping (e.g., timeframes/frequency of psych evals and progress notes) and the qualifications of clinical leaders (e.g., Directors of Medical Staff, Nursing and Social Work). The new requirements are effective immediately but do not apply to psych units in general acute care hospitals.
Pg11- Comment on Any Standard Any Time Online [PEARL] JCSC and LDR are strongly encouraged to provide input on the value of standards from the perspective of psychiatric hospitals at any time there is a concern by using a new, online TJC standards feedback form.
Pg12- Clarification: Expiration of Multi-dose Vials [REF: Phrm, P&T, RN] The bottom line here is that under MM.03.01.01, EP#7 "the Joint Commission will require a 28-day expiration date for multi-dose vials from the date of opening or puncture, unless the manufacturer specifies otherwise". The article also explains why and provides references.
Pg12- Correction: Approved Abbreviations List Not Required Under IM.02.02.01 FYI: JCSC, P&T, PHRM. The title of this article says it all and the new language used in this standard will be rolled back to the less confusing wording of 2009 effective July 1, 2010.
[Index] [Blog] The Source (June Vol 8 #6)
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Pg01- Strategies for Complying with the Revised Medical Staff Standard: Understanding MS.01.01.01 [REF: MD, MDx, LDR, GB] Although not in effect until 3/31/10, the medical staff is encouraged to begin ensuring compliance with this revised standard now. The revisions require medical staff bylaws to address the requirements of EPs 2-36. This includes 11 processes that are conveniently identified in the article. The bylaws must include at least the basic steps for each of those processes and there is flexibility for the organization to define those basic steps for itself. The article includes an example of this for the credentialing and privileging process. As a matter of convenience, the details of minor processes (that might change more frequently) can be located outside of the bylaws (e.g., medical staff rules, regulations or policies). The revised standard also includes new requirements to 1- ensure more effective communication and collaboration (between the medical staff, the Medical Executive Committee (MEC) and governing body), 2-resolve conflicts should they occur and 3-allow for provisional adoption and approval of changes to the bylaws in an emergency. Five recommended steps for compliance are provided along with a reminder reference to the MS.01.01.01 FAQ.
Pg02- 5 Sure-Fire Methods: Are Your Staff Competent to Perform Their Responsibilities? FYI: HR, BHC. According to TJC statistics, 12% of BHC organizations are not complying with HR.01.06.01 and the requirement to ensure staff competencies that are consistent with their job descriptions. If your organization includes components surveyed under BHC standards, your HR should review this article and the five compliance strategies it describes.
Pg08- Spotlight on Success: Brigham & Women's Hospital Implements Alternatives to Restraint Use FYI: RN, RNx. B&WH is an urban academic medical center with over 700 adult inpatient beds and an array of services that include psychiatry. Their restraint reduction approach is particularly notable for its implementation of 'patient safety carts'. These carts are available on individual units and are designed to provide staff with alternatives to restraint. Items in the cart are described in the article and are set up with the least restrictive on top and the most restrictive on the bottom. For example, the top drawers contain sleep masks, earplugs, puzzles, cards, and board games to encourage diversion. Although the contents might need to be adjusted for psychiatric populations, the idea of making less restrictive alternatives more readily available to nursing staff is worth considering and adopting in some form. The article also includes a restraint brochure for family education.
[Index] [Blog] Patient Safety (June Vol 10 #6)
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Pg08- The smoker-free workplace How does it affect patients? FYI: LDR, GB, StEd. Since a number of our member hospitals have gone to or are considering a smoke-free campus, this article might be of interest. However the sub-title is misleading as the focus is more on staff. Some pros and cons along with a few intriguing ideas (e.g., not hiring candidates who test positive for nicotine) are discussed.
Pg10- Column: Error Prevention in a Just Culture System Design or Human Behavior? [REF: LDR, GB] This is the latest installment in the series on Just Culture. LDR and GB are encouraged to become familiar with this concept. This article is both thought provoking and pragmatic in its exploration of concepts such as human error, at risk behavior and reckless behavior along with our organizational responses to them. How we manage such concepts can influence not only the justness of our hospital cultures but also safety. Take five minutes to read this.
[Index] [Blog] Environment of Care News (June Vol 13 #6)
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Pg01- Improving Surge Capacity Through Emergency Management Collaboration: MESH Coalition Unites Central Indiana Health Care Organizations in Emergency Planning FYI: EM, EOC, LDR, GB - The point of this article is to endorse and showcase collaborative planning for the management of emergencies. In this example, hospitals, community health centers and other medical , public health and emergency response organizations in the Indianapolis metropolitan/central Indiana area have formed a coalition for this purpose called the Managed Emergency Surge for Healthcare (MESH). The Indiana State Department of Health is a partner. MESH has reportedly increased surge capacity and decreased financial risk for the individual organizations involved. The coalition's formation was largely funded by a $5 million Department of Health and Human Services grant. Hospitals in similarly metropolitan areas may also want to consider such a grant.
Pg04- Emergency Management Focus: When the Lights Go Out: Preparing for a Power Outage, Part 1 FYI: EM, EOC, LDR. In addition to the usual generator testing/maintenance, this article recommends strategic advance negotiations with your power provider/company and evaluating your internal electrical system in depth (e.g., infrared investigation). An illustration of approaches for both of these are provided in the recent experience of St. John's Hospital in Maplewood, Minnesota.
Pg08- Gathering Data to Improve Conditions for Health Care Workers and Their Patients: National Healthcare Safety Network Database to Provide Information FYI: JCSC. [ALERT: IC, EOC, HR, PI, LDR, GB] In 2008 an estimated 4.3 million hospital workers had approximately 258,200 recordable injuries and illnesses; the second-highest number among all industries. The National Institute for Occupational Safety and Health (NIOSH) is working with the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion (DHQP) to develop new modules for the Healthcare Personnel Safety (HPS) component of the National Healthcare Safety Network (NHSN). Fortunately, this amazing amount of alphabet soup you just read is translated later in the article as, "NIOSH is now working with the CDC’s DHQP to enhance the health care personnel surveillance feature of the NHSN". This article is both an information update on HPS and a request for participants. Although there are "more than 2,500 health care organizations already enrolled in HPS, they want more hospitals to provide input related to the next four issues of staff injury prevention that they wish to explore and develop best practice modules/guidelines for. Despite the focus upon general medical/surgical hospitals, at least one of these issues, Traumatic Injury (which would include patient lifting/handling, slips/trips/falls and workplace violence), seems particularly relevant to staff of psychiatric hospitals. To further induce participation, the article suggests that existing modules related to HAIs have assisted in compliance with TJC standards IC.02.03.01 and IC.02.01.01. In addition, their collected data provides benchmark rates of sharps injury and flu vaccine against regional or national rates that are otherwise difficult to come by. They also believe that the newly proposed modules will facilitate compliance with standards such as EC.04.01.01 and EC.04.01.03 (EP#2). Needless to say, for such endeavors to have relevance to psychiatric hospitals, they need our input. If your facility is enjoying a relatively stable phase of operation, we would encourage you to consider this opportunity. To get involved in the development of new modules, the article suggests contacting Dr. Luckhaupt at pks8@cdc.gov. There is also information about HPS enrollment and participation available from HSN. Our sense is that involvement might be similar to participation in the HPIPS project. At the very least, this would appear to be a resource worth being aware of.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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5/26/10: CMS-3227-P, entitled “Medicare and Medicaid Programs: Proposed Changes Affecting Hospital and Critical Access Hospital (CAH) Conditions of Participation (CoPs): Credentialing and Privileging of Telemedicine Physicians and Practitioners,” was published. You may review the proposed rule, submit a comment online or by mail (one original and two copies to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-3227-P, P.O. Box 8010, Baltimore, MD 21244-1850) until 7/16/10. FYI MDx, MD.
INTERNET HIGHLIGHTS
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Institute for Healthcare Improvement Audio & Web Programs
Inside the Joint Commission (DecisionHealth) - June 7, 2010 , Vol 15 Issue 12
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TJC raises expectations for 15 EPs,expects 100% compliance: FYI: JCSC. This article reminds us that the change of category for 15 EPs means your CAMH needs to be updated and your expectations for compliance need to be upgraded… from 90% to 100%. Don't miss this latter implication. The IJC article provides a useful table of the 15 EP in question.
Joint Commission Online (JCO) & Website
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JCO 6/9/10
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Telemedicine requirements for hospitals and CAHs are delayed until March 2011. FYI: MDx, MD, HR. This past September, TJC issued changes disallowing telemedicing credentialing by proxy as part of the new alignment with CMS requirements. At the time, TJC indicated it would continue to pursue greater flexibility on this matter. Their efforts appear to be in evidence. Hospitals will not need to make changes in their telemedicine process by 7/15/10 as previously announced. More information is expected in an upcoming Perspectives.
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JCO 5/12/10
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Update: Medication reconciliation NPSG field review results. FYI: MD, Phrm, P&T. The recently completed field review for this NPSG suggests that a significant portion of the field does not believe that revisions to date have resolved their concerns. Accordingly, TJC reports the likelihood of pushing back implementation from January 2011 to July 2011. In the interim, survey findings will not be part of an organization's accreditation decision and will not generate RFIs.
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Reminder: Interim staffing effectiveness requirements go into effect July 1, 2010 [ALERT: RNx, PI, LD] As the title of this article indicates, the interim requirements for staffing effectiveness (the last bullet under LD.04.04.05 EP 13 and PI.02.01.01 EPs 12,13,14) go into effect next month while TJC continues to research this issue. Survey of PI.04.01.01 remains suspended.
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Issue 45: Preventing violence in the health care setting [ALERT: JCSC] [REF: LD, MDx, RNx, HR] The latest sentinel event alert (SEA) was just issued on June 3, 2010. Although violence can come in many forms, this alert focuses specifically on "assault, rape or homicide of patients and visitors perpetrated by staff, visitors, other patients or intruders…" Unfortunately, these issues are consistently among the top 10 reported sentinel events. The write up provides some useful data as background and briefly discusses high risk areas and the perpetrators of violence to patients. As with all SEA, there is also a presentation of prevention strategies. For this issue there are 14 such strategies ranging from throughness upon screening/hiring to providing counseling for victims.
SPHCC Library Additions
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Midwest Association of Mental Health Organizations (MASMHO) - Spring Conference, May 11-12, 2010. [available on the 2010 MASMHO Resources page. The page password was provided to all conference attendees and is availble to any of the MASMHO member states upon request.]
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CMS & TJC Top 5: A Compliance Challenge Update for 2010 (Richard Fields, MD, Exec Dir, SPHCC) - with Audio
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Hope Redeemded: The Life, Death and Resurection of a Man with Mental Illness (Eric Arauz, MLER)
Developing Trauma Informed Systems of Care (Joan Gillece, NASMHPD/OTA Proj Dir)
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Active Treatment Programming (Greg Valentine, LSCSW, Superintendent, Osawatomie State Hospital & Troy Mire, LSCSW, Clinical Director, Osawatomie State Hospital and Rainbow Mental Health, Kansas) - with Audio
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Managing the Sex Offender Population to Discharge (Bill Gibson, Cindy Dykeman, TyLynne Bauer, Stacey Werth-Sweeney, Nebraska) -with Audio
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)
