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THE JOINT COMMISSION (TJC and JCR)
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[Index] [Blog] Perspectives (July, Vol 30 #7)
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Pg01- Implementation of New Telemedicine Requirements Delayed Until March 2011 [ALERT: MDx, MD] Last month's announcement of this delay promised more details in an upcoming Perspectives. This is the promised article. While there are not a great many new details, here is what we have been able to understand:
1 - Prior to its deemed status application, TJC allowed telemedicine credentialing by proxy (i.e., the orginating site where care is provided could use/accept info from the distant site to credential and privilege tele-providers)
2 - In Sep 2009 TJC announced that as part of its deemed status application it would modify its standards to align with CMS and disallow credentialing by proxy. This change was to go into effect the middle of this month, 7/15/10.
3 - As a result of advocacy by TJC and others for credentialing by proxy, CMS has reconsidered the issue, coming to the conclusion that its "present requirement is a duplicative and burdensome process". It has consequently allowed TJC to delay implementation of the 7/15/10 change of requirements (until 3/2011) while it revisits this issue with a new proposed ruling on the matter.
4 - On 5/26/10, CMS issued a proposed new ruling that would allow credentialing by proxy. This proposed ruling is currently in a 60-day comment period (i.e., until 5 p.m. on July 26, 2010). You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the "More Search Options''
5 - It is expected that the proposed ruling would be finalized and credentialing by proxy for telemedicine would be allowed by permitting a hospital's medical staff to rely upon the credentialing and privileging decisions of the distant-site hospital in lieu of the current requirements at Sec. 482.22(a)(1) and (a)(2)
6 - However, if the proposed ruling is not finalized, then the change of TJC requirement that disallows credentialing by proxy would go into effect on March 2011
7 - In the interim (until 3/15/11), credentialing by proxy will be permitted by TJC although it could result in a citation by CMS. If an organization is cited on this matter by CMS during the iterim it should contact Patricia Kurtz in TJC's Washington office at pkurtz@jointcommission.org or at 202/783-6655. In a brief interview, Ms Kurtz confirmed that if contacted by a hospital with a CMS citation because of this conflict, she would go to CMS as an advocate for the organization. While she could not guarantee the outcome, she did give assurance that TJC had officially requested further clarification from CMS and would be making formal comment on the proposed ruling, CMS-3227-P.
Pg06- Change in Leadership at JCR and JCI FYI: JCSC, LDR. Paula Wilson has been appointed president and chief executive officer of Joint Commission Resources (JCR) and Joint Commission International (JCI). Ms. Wilson is an expert in management and strategic planning who has consulted to public, nonprofit, and private organizations. She was previously the vice- president for policy at the United Hospital Fund. She is also a member of the Board of the New York City Health and Hospitals Corporation and was previously the vice-president for policy at the United Hospital Fund.
Pg07- Sentinel Event Alert: Preventing Violence in the Health Care Setting [REF: SFT, SEC, HR, LDR, GB, JCSC] This alert was issued on 6/3/10 and reviewed in our June Newsletter. The article is essentially a reprint of the Alert 45. However, it informs us that TJC's sentinel event database has been receiving increasing reports of assault, rape and homicide since 2004. In that context it is worth noting that leadership, human resources and the quality of assessments (e.g.,psychiatric assessments ) and communication failures are identified as causal factors in over half of such reports. As part of the approach to prevention, hospitals are encouraged to identify the high risk areas for such violence (especially areas of relatively high stress and high traffic) and to screen more rigorously e.g., take background checks more seriously) for the identification of staff who might be potential perpetrators. [PEARL: SFT, RM, PI] The alert also identifies a non-profit research organization called the ECRI Institute and a reference article published by them, entitled, "Violence in Healthcare Facilities". This 2005 ECRI Risk Analysis provides valuable guidance for violence prevention. Some of the strategies include conducting a violence walk-thru and performing a violence audit. There are also recommendations for violence management training and how to respond after a violent incident. See also: OSHA's Guidelines for Preventing Workplace Violence for,Health Care & Social Service Workers [PDF]
Pg11- Modifications to S3 Report FYI: JCSC, PI, LD - Since core measures are coming (see *NQF Below) to psychiatry it may be worthwhile to refresh a bit on S3. S3 is the Joint Commission's Strategic Surveillance System launched in 2007. It includes no-cost, non-required "comparative-measures reports to help hospitals improve their care and prioritize improvement efforts and actions." Based in part on undesirable performance on core measures, a hospital receives S3 points. (It should also be noted that these points are assigned to relevant PFAs and CSGs to help determine areas of survey focus) and a resulting S3 score. In a brief interview with TJC's Frank Ziebrat, we learned that there is currently no comparative data for psychiatric hospitals in S3. However, he confirms that TJC is anticipating the requirement for collection and reporting of data on the 7 Hospital Based Inpatient Psychiatric Services core measures in the near future. The point of the article is that Medicare Provider Analysis and Review (MedPAR) data is being eliminated from the S3 report. TJC says more details are to be reported in the August issue of Perspectives. See also: FAQs about Strategic Surveillance System (S3) , Facts about the Strategic Surveillance System for Hospitals and Perpectives, 2008, April Vol28, #4 Strategic Surveillance System (S3): Dispelling the Myths . *NQF Endorses Measure for Hospital Pscyhiatric Care (5/6/10)
[Index] [Blog] The Source (July Vol 8 #7)
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Pg01- Systemwide Strategies Help Hospitals Manage Patient Flow: How to Comply with Standard LD.04.03.11 FYI: RNx, MDx, LDR, JCSC. Although Pt flow is more often a consideration for busy emergency departments, LD.04.03.11 is also relevant to psychiatric hospitals. That standard requires LDR to assess patient flow. In the case of our hospitals, this should be thought of in terms of delays. Such delays may be internal (e.g., consultation response time) or external (e.g., how long your patients wait to be seen in the ED of your local general hospital). The article provided suggestions for approaching the assessment such as conducting a mock tracer of a patient who has experienced a significant delay. As with any improvement process, you are also advised to collect and evaluate data that might reveal delays (e.g., incident reports, consult completion times, lab report timeliness, wait lists, average LOS). Recommendations for improving Patient Flow compliance included:
1 - Look for ways to streamline the admission process (e.g., eliminate redundant intake forms/questions)
2 - Schedule nonclinical staff according to patient need just as you do for clinical staff (e.g., increase numbers around times for highest admissions or discharges)
3 - Look for ways to increase the timeliness of the discharge process (e.g., arrange physician rounds to see discharge-ready patients first and provide more advance notice to families)
And, of course, TJC recommends its recent publication, Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed.. Oak Brook, IL: Joint Commission Resources, 2010
Pg02- 5 Sure-Fire Methods: Assessing and Managing a Patient's Pain [REF: RNx, MDx, RN, MD, Phrm, P&T] Standard PC.01.02.07 requires hospitals to assess and manage patient pain. TJC reports that 23% of its hospitals surveyed during the first half of 2009 failed to fully comply with this standard. Results from our 2009 post survey questionnaires (PSQ) revealed a similar rate of non-compliance (19%). While the cause for citation varies, often it is a failure to reassess the patient's pain. The article provides a number of strategies to help improve compliance. One of the first is to clearly define what assessment method/scale (e.g., NIH Pain Intensity Scales) to be used for each of its populations. A second important strategy is to educate all staff (not just nursing) about clinical recognition of pain (including nonverbal signs) and the related policies. It also helps to provide reminder prompts for staff to reassess a patient's pain after an intervention. This could be a 'hard stop' in an electronic record or the real-time monitoring of a nurse supervisor. Hospitals are also encouraged to avoid fragmentation of pain/medication information and use documentation approaches that place data for assessment , medication administration and reassessment in one place.
Pg09- Measures of Success Requirements Deleted: FYI: JCSC The deletion of 32 MOS relevant to psychiatric hospitals was announced in the June Perspectives. This month, TJC has provided a summary table of those deletions for easy reference.
[Index] [Blog] Patient Safety (July Vol 10 #7)
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Pg01- Maintaining Optimal Blood Glucose Levels Preventing Episodes of Hypoglycemia and Hyperglycemia [REF: MDx. MD, Phrm, P&T] In response to NPSG.03.05.01, many of our hospitals have developed clinics for managing patients with diabetes in general and insulin in particular. Typically, there are one or two general practitioners who are relied upon for this management. Such persons and any others responsible for managing insulin patients should find this article a useful review. The primary message of this piece is an advocacy for the avoidance of both over and under control of blood glucose levels. More specifically, efforts to prevent hyperglycemia should not include iatrogenic hypoglycemic episodes since there is now some concern that the latter may increase mortality. Certain evidence of poor glycemic control (e.g., Diabetic ketoacidosis, Nonketotic hyperosmolar and hypoglycemic comas) is now considered a CMS Never Event. Such outcomes are considered unacceptable quality of care resulting in extra costs that CMS will no longer pay for. The article points out risk factors for both hyperglycemia (e.g., diabetes mellitus type 1 or 2, stress, inadequate monitoring) and hypoglycemia (e.g., diabetes mellitus, insulin, polypharmacy or drug interactions, NPO status). It encourages more education for physicians, not to use sliding scale insulin only, discontinuing oral hypoglycemic medications (while in the hospital) and ensuring that patients eat after insulin administration. The smoothness of transition from intravenous to subcutaneous insulin is also thought to be an important preventive measure.
Pg05- Critical Test Results: Mitigating the Barriers to Timely Reporting FYI: JCSC. Almost 60% of SPHCC members submitting post survey questionnaires (PSQ) for 2009 failed to achieve full compliance with NPSG.02.03.01. Most often, the cause was related to a failure to have the required policy and/or related definition of key terms. However, in addition to policy, this goal requires timely reporting of critical results of tests and diagnostic procedures. This article focuses on the issue of timeliness in the reporting. [PEARL: PI, LDR] Most of the suggestions it provides for identifying and overcoming obstacles to timeliness are drawn from a nine-page, May 2010 article in the Joint Commission Journal on Quality and Patient Safety entitled Eight recommendations for policies for communicating abnormal test results (PDF) by Singh and Vij.. Some recommendations such as the need to clearly define key terms (e.g., critical results vs. critical tests), timeframes, roles, responsibilities, and ensuring that staff responsible for contacting a 'responsible licensed caregiver' have accurate contact information are fairly obvious. A less obvious strategy is the encouragement to instill a "real word" value (vs. do it because a regulator requires it) into the process. They also recommend defining verbal and/or electronic reporting methods. These concepts are briefly summarized in Patient Safety, but more fully explored and explained in the Singh/Vij source article.
[Index] [Blog] Environment of Care News (July Vol 13 #7)
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Pg01- The Hospital Safety Index: A Tool for Determining How Your Hospital Will Perform in an Emergency FYI: GB, LDR, SFT. In 2003 the the Pan-American Health Organization (PAHO) assembled a group of expert engineers, architects, health services administrators, and disaster specialists to form the Disaster Mitigation Advisory Group
(DiMAG). The group developed a system for evaluating and rating the projected safety of hospitals during a natural or man-made disaster. The evaluation produces a Safety Index score and places a facility into one of 3 categories based upon its projected ability to resist disaster and protect the lives of its occupants. Although the article focuses upon the use of this tool with Carribbean and South American hospitals, GB, LDR and SFT may find some useful applicability of the Safe Hospitals Checklist (PDF) as a self assessment tool. The article suggests the self-assessment can be conducted in as little as 8-12 hours. If your hospital is at greater than average risk for impact by disaster (e.g., Louisiana state hospitals) you may find it useful to have your safety committee review this material. More details about the components of the Hospital Safety Index (PDF) are provided in a summary sidebar.
Pg04- Communicating in an Emergency: Temple University Health System Standardizes Emergency Color Codes FYI: EM, SFT, LDR, MDx, RNx. Planning for effective communication during emergencies is a requirement of EM.02.02.01. In this case study, the Temple University Health System (TUHS) addresses this standard in part by taking a 'best practice' approach to the use of color-coded emergency alerting. Their approach was largely derived from the work of the Healthcare Association of Southern California (HASC). The article references Emergency Codes: A Guide for Code Standardization, 2000, an 89-page guide. However, according to HASC, it and the "Safety and Security Committee and AllHealth Security Services have released an updated version of Health Care Emergency Codes: A Guide for Code Standardization. The copyrighted information is available at no charge for any hospital that seeks to implement uniform emergency code standards for their facility". Documents for Implementation of Standardized Emergency Codes includes a 59-page guide, implementation plan, competency checklist/test, posters, sample newsletter article and model letter for leadership.
Pg06- Ensuring Effective Fire Alarm and Automatic Sprinkler Systems: Examining the "Life Safety" (LS) Chapter, Part 7 [REF: EOC, SFT]. Calling heavily upon comments by TJC's Senior Engineer, George Mills M.B.A., F.A.S.H.E., C.E.M., C.H.F.M., C.H.S.P., this article explores and explains 7 key aspects of LS.02.01.34 and LS.02.01.35. Some of the useful information included:
Re: Methods to Transfer Fire Alarm Signals - The are 4 standard methods of transmission (Auxiliary alarm system, Central station connection, Proprietary system, Remote station connection), but TJC now permits manual transmission under 7 conditions that are specified in side panel on page 8.
Re: Location of the Master Fire Alarm Panel - The panel should be in an area that is protected/continuously occupied or with a smoke detector. Yes, you can put a smoke detector near the panel to satisfy this requirement.
Re: Ensuring That Sprinkler Systems Are Tied to Fire Alarm Systems - signals in the automatic
sprinkler system (e.g., water flow alarms) must communicate directly with the master fire alarm panel.
Re: Ensuring Safe Sprinkler Equipment - Key is to ensure that piping is securely attached to the ceiling and not used to support other items, such as cables.
Re: Maintaining Space Below a Sprinkler Head - Note that one exception to the requirement for an 18-inch plane of space below the sprinkler deflector is with 'perimeter shelving' that is located against an existing wall and not directly under a sprinkler head.
Re: Distance to Fire Extinguishers - Remember that fire extinguishers can be no more than 75 feet from ANY location; not just every 75 feet along a hallway.
Re: Fire Extinguishing Systems for Grease- Producing Areas - If you have a kitchen with grease producing equipment (e.g., deep fat fryers, griddles, broilers) you must have a fire suppression
system in the hood AND a portable K-type fire extinguisher within 30 feet of that equipment.
Pg11- Clarification: Corridor Clutter FYI: JCSC, EOC, SFT. TJC is concerned that its April 2010 EC News article on "Curing Corridor Clutter" may have allowed some to think that the PFI process could be used to stall resolution of a Life Safety Code deficiency. Be forewarned, that TJC "would not allow corridor clutter to be a PFI with a longterm corrective action or repeated entries in lieu of resolution".
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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 7/26/10. FYI MDx, MD.
4/23/0: CMS-2300-N, Preliminary FY 2010 Disproportionate Share Hospital Institutions for Mental Disease Limits. FYI: F&B
INTERNET HIGHLIGHTS
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Institute for Healthcare Improvement Audio & Web Programs
Inside the Joint Commission (DecisionHealth) - June 21, 2010 , Vol 15 Issue 12
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How patient safety reading groups work: FYI: PI, RM. Patient Safety Reading Groups are "organized, multidisciplinary teams of clinical staff and operational managers who meet regularly to read aloud the descriptions of near misses and adverse events related to a specific topic or clinical area". Such groups are in operation at the Memorial Sloan-Kettering Cancer Center and the Children’s Hospitals and Clinics of Minnesota. They have found that reading aloud in a group (vs. reviewing in isolation) and looking at a number of similar or related incidents (vs. individual incidents) provides greater ability to identify trends and opportunities for improvement.
Joint Commission Online (JCO) & Website
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JCO 7/14/10
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On-site survey: Focus on safe injection practices FYI: RNx. RN, IC, StEd, PtEd. "One needle, One syringe, Only One time" is the slogan and heart of the Safe Injection Practices Coalition (SPIC)/CDC's One & Only Campaign. See also CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
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Comment on the standards FYI: JCSC, LDR, GB. Same as Comment on Any Standard Any Time Online, from June Perspectives
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Join JCR’s free Virtual Learning Community: first topic on MDROs and antibiotic resistance FYI: IC, RNx. The title of the first presentation is actually, "What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance", but, this is probably a topic only the IC Nurse could love. Yes, the information is free, but it will cost you 3-5 minutes to register and sign in. Once you do there is an MDRO Toolkit that may well be worth it.
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JCO 7/7/10
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The Joint Commission looks at refining, improving its tracer methodology FYI: JCSC, IC, EC, MDx, MD, IM. The goal is to more thoroughly evaluate high risk or problem-prone processes by integrating patient care and patient system tracers. The first seven areas of focus for refinement will include cleaning of medical equipment, patient flow, contracted clinical services, diagnostic/therapeutic radiation services, clinical information systems and Ongoing/Focused Professional Practice Evaluation (OPPE/FPPE).
SPHCC Library Additions
2010 Member Surveys (SL1a)
If you anticipate a survey soon, please click here
Our database of surveys now includes twenty-two psychiatric hospital members that underwent full, unannounced Joint Commission surveys in 2009. Reported surveys for the last six months are listed below. The full listing of all past surveys and the PSQ Analysis: 2009 (Full Year) is available in the Survey Feedback Library.
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)
