• New Review Format for RTN:In response to your suggestions, we are using larger print in this edition. We are also taking our reviews of reference [REF] articles more in-depth. We began more detailed reviews in July with one format and are trying out a slightly different one this month. Please compare the review approach used in a July reference article with an August reference article. Then let us know which you prefer. We want to help you make better use of your limited reading time. Thank you. R. Fields, MD
••ALERTS:
• Approved: No New National Patient Safety Goals, Only Minor Revisions for 2011: SSP Still Considering Medication Reconciliation {Review/Full Article}
• Update: Implementation Plan for Patient-Centered Communication Standards {Review/Full Article}
Pg01-Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified[REF:JCSC, PI, LDR, GB] The Joint Commission now has a new approach to performance measurement and it is based on something called accountability measures (AM). An accountability measure is described as an evidence-based quality measure for processes of care that are known to improve health outcomes for patients. TJC has defined 22 accountability measures (AM) and 6 non-accountability measures (NAM). The point of accountability measures is supposedly to help an organization focus its limited resources more effectively on those issues/measures that are most likely to actually improve health outcomes. Psychiatric hospitals should note that TJC is already applying the accountability criteria to current hospital core measures including hospital-based inpatient psychiatric services. We strongly suggest paying attention to this as TJC also intends to adopt these accountability measures for use in the ORYX program and is considering their integration into “accreditation requirements”. We would suggest this initiative is further confirmation of an unfolding PI direction and philosophy earlier evidenced in TJC’s evolution of the Center For Transforming Health Care, Robust Process ImprovementTM and revision of the Sentinel Event Policy described below. Take heed!
Key/Additional Details
The 22 accountability measures were based on their meeting a set of 4 criteria that were applied to a list of 28 Hospital Process of Care Measures (HPCM) utilized by CMS's Hospital Compare website.
The 28 HCPM are listed in a chart on page 9 of the article and consist of seven measures related to heart attack care, four measures related to heart failure care, six measures related to pneumonia care, eight measures related to surgical care improvement project and three measures related to asthma care (for children only).
Accountability measures (AM) are scored/weighed more heavily than non-accountability measures (NAM). Unsatisfactory performance on an AM would result in 1.0 point (vs. 0.33 points for NAM) being assigned to a hospital’s related priority focus area (PFA) and clinical service group (CSG). Remember, PFAs and CSGs are part of the data used by TJC to determine the particular points of focus or emphasis for a survey.
Pg03-Looking at Sentinel Events Along the Continuum of Patient Safety: A Future Direction for the Sentinel Event Policy[REF:JCSC, PI, LDR, GB, SFT] An internal TJC workgroup has completed the initial phase of implementing the first major revision of the Sentinel Event Policy (SEP) since it was created in 1995. The purpose of the revision is “to better define patient safety incidents and unsafe acts and recommend how a health care organization can prioritize and respond to them”. The first phase has defined the “Elements of an Ideal Response to Patient Safety Incidents”. These elements incorporate previously described values/recommendations of Sentinel Event Alert 43 (Leadership Committed to Safety), principles of a Just Culture and the concepts/tools of TJC’s Robust Process Improvement…all of which we have been strongly encouraging our readers to become more familiar with.
Key/Additional Details:
Analysis of reported Sentinel Events has led to Sentinel Event Alerts (to warn of life-threatening patient risks), a number of which have served as the basis for National Patient Safety Goals.
SEP revision is partly based on the study of high-reliability organizations (HROs) defined as those that “operate in complex systems with hazardous technologies in a nearly error-free manner” characterized by mutually reinforcing trust, commitment to improvement and accurate reporting of safety incidents.
The nine ‘Elements of an Ideal Response to Patient Safety Incidents’ that were defined during Phase 1 included:
Focusing more on unusual occurrences, close calls and weaknesses in the organization’s risk defenses (as per James Reason’s Swiss Cheese Analogy)
Using both prospective (e.g., FMECA) and retrospective (e.g., RCA) analysis techniques to better identify risk defense weaknesses and prioritization of mitigation/prevention
Utilizing the concept of individual accountability for unsafe acts when analyzing patient safety incidents
Improving the understanding and use of root cause analysis that is focused only on the most serious of patient safety incidents.
Supporting the use of Robust Process ImprovementTM tools design, implementing and sustaining effective improvement/corrective action
A patient safety incident is “an event or circumstance which could have resulted or did result in unnecessary harm to a patient”. In addition to actual patient harm, such incidents include close calls and hazardous circumstances that may or may not have reached the patient.
Root cause analysis is defined as “a retrospective incident investigation technique that emerged from the field of engineering that is used to uncover an incident’s causative factors and to identify system vulnerabilities”.
Robust Process Improvement is defined as “a systematic approach to performance improvement (involving process improvement methodologies such as Lean Six Sigma) that analyzes specific breakdowns in quality and safety, discovers their underlying causes, and develops solutions that specifically address these causes”.
Phase Two (of three) is to focus on various aspects of identifying and prioritizing “information rich” incidents, critical weaknesses and the risk reducing responses to them. This could include the development of an abbreviated or alternate RCA method for lower priority incidents.
[ALERT: JCSC] There are no new National Patient Safety Goals for 2011. Medication Reconciliation (NPSG 8) is still under review and any related survey findings will not generate RFI.
Key/Additional Details:
Revisions to 4 elements of performance involving no new requirements are effective immediately. Only one of these, NPSG.03.05.01, EP6 is relevant to psychiatric hospitals. The revision replaces the specification of ‘heparin and low molecular weight heparin therapies’ with ‘anticoagulants’.
The expected implementation date for a revised NPSG 8 has been pushed back to July 2011 (vs. January 2011).
The Patient-Centered Communication Standards are now available in pre-publication version. A free compliance guide is also available for download. Be sure to check out the implementation checklist in Appendix A on page 47.
Key/Additional Details:
The new and/or revised requirements are found in HR.01.02.01, PC.02.01.21, RC.02.01.01, RC.01.01.01 and RC.01.01.03
Although surveyors began evaluating compliance with the standards beginning January 1, 2011, findings will not affect the accreditation decision until January 1, 2012.
Pg10-Concurrent Survey Option Now Available for Health SystemsFYI: JCSC, LDR, GBAny accreditation program with more than one hospital or other accredited entity included in a single system can now have the option for a concurrent approach that would survey all of the system’s organizations/hospitals during the same days in the same week. Applicability to state hospital systems was confirmed by interview with Jeff Conway, Associate Director at TJC.
Key/Additional Details:
As compared to the older Corporate Survey approach, all surveys are done in the same week and there would not be a consistent team leader although the cost would be the same as for a regular survey. Pre and post conferences with central office/governing body can be arranged (I would guess with added cost).
The approach is thought to work best when conducted in systems with 12 or fewer hospitals.
Each organization with a distinct CMS Certification Number (CCN) would receive a separate survey report and accreditation decision.
Seek information from the CDC, other hospitals of similar size and scope and register for e-mail alerts sent by your health department
Give heavy weight to your own surveillance data from last year
Directly observe staff in their cleaning activities, use of contact precautions and performance of hand hygiene
Prioritize risks by severity and probability of occurrence
Review/prioritize infection control related risks annually and whenever there are changes in your organization that may change or increase risk
Pg04-Revised BHC Standards Clarify Physical Holding of Children or Youth: How to Comply with CTS.05.05.01 through CTS.05.05.21[REF: BHC, RNx, PI] The revised Care, Treatment and Services chapter will go into effect January 1, 2011. It will include 11 customized standards addressing all aspects of situations involving the physical holding of children or youth. These standards will apply to any child or youth who is physically held. For holds lasting less than 30 minutes, only two current PC standards (i.e., staff competency and the physical well-being of the child or youth) apply. However, physical holds that last more than 30 minutes, must meet all the current PC mechanical restraint and seclusion standards. Recommendations for compliance included:
Cultivate the philosophy that physical holds are a last resort
Use role play and demonstration when training staff
Be careful not to overwhelm children/youth with adults in a debriefing
Collect and evaluate data on physical holds to include related staffing patterns
Ensure documentation of less restrictive alternatives
Pg09- Clarifying the ESCFYI: JCSC. If you believe a cited standard was actually in compliance at the time of survey, you have 10 days to submit a clarification. The ‘charticle’ provided suggestions for doing so that included:
For Category “A” EPs: Directly address the surveyor’s observation(s) and/or finding(s) with pre-survey ‘factual evidence’ of your own that clearly demonstrates compliance. Simply challenging the surveyor’s observation is not sufficient.
For Category “C” EPs: Submit an audit utilizing a sample that is random and in accordance with TJC sample sizes from the 30-day period prior to the start of the survey. Explain how the sample was randomized, size determined, who conducted it and its date range.
Pg08-Driven to Distraction: Reducing Interruptions Among Nursing Staff[REF: RNx, Rn] According to some recent studies, nurses are “interrupted 3 to 6 times an hour (31% of the time by other members of the health care team and 25% of the time by other nurses) and at least once per every three medications administered. Although nurses are considered the most trusted of healthcare professionals, the potential impact of such interruptions on the quality and/or safety of their work is concerning. Much of this article focused on protecting nurses during medication-related activity. [PEARL] It is largely based on the reference, Distractions and Interruptions: Impact on Nursing (PDF) that also provided a number of recommendations to include:
Prioritizing the vital activities (e.g., med admin) and Saying “No” to or delaying less critical interruptions
Establishing “No interruption” zones And/or “Medication Pass Time-Out.”
Having the medication nurse wear a “Do Not Disturb” vest during administration
Pg04-Emergency Management Focus: Going Offline: Using a Controlled Power Outage to Improve Electrical System SafetyFYI: EOC, EM. Although not required by TJC, a planned power shutdown is worth considering if there is concern about the safety and/or reliability of your facility’s electrical system. “In some ways, a planned shutdown of power is like a planned emergency”. As such, it could provide a comprehensive test of your electrical system and be a useful exercise for exploring/evaluating your compliance with the six critical aspects of emergency management. Suggestions from this article included testing at off-peak times, activating your incident command center and having a contingency plan in place should the planned outage be unexpectedly extended.
Pg08-Snow Emergency: Temple University Hospital Transports and Houses Staff During BlizzardsFYI: EOC, EM. This case study shares the successful experience of a 740-bed Philadelphia hospital in managing a blizzard in February of this year. The article reveals how some of their efforts addressed requirements of Standards EM.02.02.07 and EM.02.02.03. A significant factor in their success was the attention paid to the needs of staff. For example, they offered transportation to staff who could not get to the hospital and provided overnight housing for them. You may want to take note of some of the issues they confronted in providing such support (e.g., beds/bedding, privacy, supplies) and consider developing an emergency housing plan for staff as part of your emergency management strategy.
Inside the Joint Commission (DecisionHealth) - August 16, 2010 , Vol 15 Issue 12
What data should you collect to monitor your performance improvement: FYI: PI, RM. TJC standard PI.01.01.01 requires the collection of data to monitor performance but is "somewhat vague" about the what and how of it all. Since it would be impossible to collect data on everything, two interviewees suggest some areas for prioritization to include Behavior Management (e.g., number , duration and outcomes of behavior modification plans), Seclusion/Restraint, Falls and Medication Occurrence Reports (e.g., rates, trends), Chart Audits, Master Treatment Plans, Medical Records (e.g., delinquency rates), Patient/Staff Grievances, Environmental Rounds/Risk Assessments, Policies & Procedures (e.g., timely reviews), Discharges/Length of Stay and Training.
Most challenging requirements for first half of 2010 FYI: JCSC. 62% - RC.01.01.01, 50% - LS.02.01.20, 44% - LS.02.01.10, 38% - EC.02.03.05 and 37% - LS.02.01.30
Updated sentinel event statistics FYI: JCSC, LDR, GB. The 10 most frequently reported events continues to include suicide, medication error, patient falls and assault/rape/homicide.
SPHCC Library Additions
SL7_Lean Six Sigma & Robust Process ImprovementTM:
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