Customized Resource Pages: Customized resource pages have been temporarily added to the website for MASMHO, WPSHA, CLSH and SFETC. Each page provides references and tools relevant to compliance topics presented during a recent conference or workshop held by these organizations. Passwords were provided during the presentations and are available in their handouts. The pages are a trial run for SPHCC consideration of similar pages for all members in 2011 that would be tailored to their particular compliance interests/concerns.
Pg01 -Center for Transforming Healthcare Releases First Targeted Solutions Tool Tackles Hand Hygiene Challenges [REF: JCSC, PI, LDR, IC, RN]As announced in the March Perspectives article *Update: Progress at The Center for Transforming Healthcare Perspectives about TJC's Center for Transforming Healthcare (CTH), a new, free PI application/tool is to be made available this month via the Joint Commission Connect™ extranet site. It is called Targeted Solutions Tool™ (TST). Once the TST is accessed, it guides you through a step-by-step process to "measure (your) organization’s actual performance, identify barriers to excellent performance, and identify proven, tested, and targeted solutions. The tool is self-paced and does not require specialized PI expertise or statistical data analysis. Nor is it necessary to use Lean and Six Sigma concepts to implement the solutions…but, as we have been suggesting, it would probably be advantageous to be more familiar with these concepts that are to be used in all CTH projects. The target of the first tool was hand hygiene. Its development has grown out of the work of 8 hospitals (leading healthcare organizations) that used a Robust Process Improvement-type approach (e.g., DMAIC) to the chronic recurring concerns of hand hygiene. The causes they uncovered and the related improvements they implemented doubled their levels of hand hygienic performance. Subsequently, "many more hospitals across the country" of varying sizes have tested, duplicated the gains, and refined those improvement/solutions into what is now part of the TST for Hand Hygiene. The project slogan, "Patient Safety Is in Our Hands" summarizes a number of those solutions into categories represented by the acronym HANDS. HANDS stands for Habit (Make washing hands a habit), Active Feedback—(Coach and intervene to remind staff to wash hands), No One Excused—(Hold everyone accountable and responsible: doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists), Data Driven—(Data provides a framework for a systematic approach for improvement), Systems—(Focus on the system, not just on people). TST content will be expanded to include contributing factors, root causes, and solutions to other Center projects such as hand-off communications. (For a fuller explication of HANDS and a listing of the projects 10 main causes of poor performance, see: Facts about the Hand Hygiene Project, Hand Hygiene Project Storyboard) and *Update: Progress at The Center for Transforming Healthcare Perspectives, April, 2010 Vol 30, #4 Pg08.
Pg03 -Top Standards Compliance Issues for the First Half of 2010 FYI: JCSC, PI, LDR, GBThis is the latest installment of TJC’s periodic listing of the ten most frequently cited requirements by program with the percentage of organizations receiving Requirements for Improvement (RFIs). Although our sample size is significantly smaller, you are encouraged to compare this listing to our specific finding for state psychiatric hospitals over the last 18 months (i.e., PSQ Analysis). 62% of hospitals received RFIs for RC.01.01.01 (complete/accurate medical records) making it number one of ten for TJC. Only 30% of our post survey questionnaires contained that citation placing it in a tie for 9th in our ranking. The most frequent citing reported in our PSQ’s was HR.01.02.05 (verifying staff qualifications)
Pg09 -Flu Vaccination Challenge Enters Third Season with Room for More Participants and Better Rates 83% of Participating Facilities Improved Vaccination Rates in 2009FYI: IC, LDR, StEd, RNx. An average of 5% to 20% of the population gets the flu each year resulting in more than 200,000 hospitalizations per year between 1979 and 2001. In 2008, JCR launched its first annual Flu Vaccination Challenge with a goal of bettering the 42% national healthcare worker flu vaccination rate that was the average at the time. 94% of the participating hospitals met that goal. For the 2009/2010 flu season, the bar has been raised to achieve vaccination rates of at least 65%. So far almost 1,100 health care facilities have participated and achieved an average vaccination rate of 76%. If you are not experiencing vaccination rates like this it is not too late to join in the challenge since influenza activity often does not peak until January or later. The FLU Vaccination Challenge homepage includes links for signing up along with informational/campaign resources (e.g., Free Podcast on Improving Your Influenza Program)
Surveyors will begin evaluating compliance with the standards beginning January 1, 2011, but findings will not affect the accreditation decision until January 1, 2012.
They will “include qualifications for language interpreters and translators, identify and address patient communication needs, address provision of language services, require race and ethnicity information in the patient’s medical record, and prohibit discrimination in patient care”
For more details and implementation aids, see: Update: Implementation Plan for Patient-Centered Communication Standards,{Review/Full Article} Perspectives, August 2010 Vol 30 #8, pg 10 and New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) {Review/Full Article} Perspectives, January 2010 Vol 30 #1, pg 5
Re: Revised Medical Staff Standard
Revised MS.01.01.01 will not take effect until March 31, 2011,
The basic steps of any process required by EPs 12 through 36 must be included in an organization’s bylaws, including:
Privileging and reprivileging licensed independent practitioners
Selecting and/or electing and removing medical staff officers and medical executive committee members
Adopting and amending the medical bylaws, medical staff rules and regulations and policies
Appointing and re-appointing medical staff membership
Automatic and Summary suspensions of medical staff membership or clinical privileges
Recommending termination or suspension or reduction of clinical privileges or medical staff membership
These standards now incorporate recovery concepts and include new expectations for trauma assessment, eating disorder assessment and treatment, independent living needs and referral, outdoor/wilderness programs, psychiatric advance directives and animal-assisted treatment.
Note that “If there is no lead-in sentence, then that standard or EP applies to all BHC organizations”.
4 elements of performance have been revised. Only one, NPSG.03.05.01, EP6, is relevant to psychiatric hospitals.
For more details see: Approved: No New National Patient Safety Goals, Only Minor Revisions for 2011: SSP Still Considering Medication Reconciliation {Review/Full Article} Perspectives, August 2010 Vol 30 #8 pg 6
Pg02 -5 Sure-Fire Methods Complete and Accurate Medical Records [REF: MDx, MD, IM] Hospital rates of non-compliance with Standard RC.01.01.01, have increased from 49% in 2009 to 62% in the first half of this year. TJC reports that most of the difficulty was related to the requirements for dating (EP 11) and timing (EP 19) of all entries (including orders). The non-compliance rate for our state hospital members reported in post survey questionnaires (PSQ) over the same 18-month period was only 30%. However, EP19 was their most common concern as well. The article’s recommendations included:
Increasing staff and LIP awareness of the importance of this requirement via training, posted reminders, etc.
Conducting real-time monitoring and counseling
Use of date and time signature stamps
Increasing reinforcement and accountability for this requirement
Re: FPPE for initially requested privileges – EP1 does not require (and should not be confused with) a period of provisional appointment. This is a time-period approach that too often ends without a specific and evaluation of privilege competence that is the critical task. Dr. Herringer recommends a volume-approach in which a small, pre-defined number of charts (e.g., 5) are reviewed for each privilege (independent of how long that takes). If the results are acceptable FPPE ends, if not, pull another sample and re-assess on the aggregate or larger sample. This approach is also acceptable for low-frequency privileges in which it may take an extended time (e.g., a year) to review the pre-defined number of charts.
Re: FPPE triggers –Although triggers may be single incidents or clinical practice trends, most often, “Triggers are very obvious problems and should be predefined by the organization.” Triggers always require a period of performance monitoring. On the other hand, “Performance issues are normally uncovered during ongoing professional practice evaluation…may or may not require additional performance monitoring, depending on the circumstances. How performance issues will be addressed should be outlined in the organization’s FPPE policy.”
Re: Surveyor Expectations – Be prepared for surveyors to assess if the hospital has:
FPPE triggers and a process for monitoring and evaluating performance,
Criteria for conducting performance monitoring
A method for establishing a monitoring plan specific to the requested privilege
A method for determining the duration of performance monitoring
Circumstances under which monitoring by an external source is required
taken appropriate action around performance issues or triggered reviews that might have occurred
Key/Additional Details:
Hospital rates of non-compliance with Standard MS.08.01.01, have increased slightly from 25% in 2009 to 27% in the first half of this year.
MS.08.01.01 has not been a Top 10 compliance concern reported in state hospital PSQ, but it continues to be a source of some confusion/uncertainty
EPs 2 through 9 are nothing more than what was historically peer review,” “It was renamed Focused Professional Practice Evaluation in 2004”
MS.08.01.01 was revised in January 2008 to include the requirement for a period of FPPE on all initially requested privileges (EP 1). “There are no exemptions for board certification, documented experience, or reputation”.
Note that FPPE is one of 7 “high risk or problem-prone processes” selected by TJC for more thorough tracer evaluation. (see Tracers below)
Pg11 -It's All in the Details: How to Write Acceptable Corrective ESC [REF: JCSC]Some corrective Evidence of Standards Compliance (ESC) are unacceptable because they lack sufficient detail. An example of an acceptable corrective ESC is provided. The suggested approach divides the ESC into four sections addressing the Who, What, When and How of the correction. The article makes it clear that simply developing or revising a policy is not a sufficient response.
Pg01 -Special Report! 2011 National Patient Safety Goals: The Official, Approved Goals and Helpful Solutions for Meeting Them [REF:JCSC, PPR, LDR] This article constitutes the whole of this ‘Special Edition” of Patient Safety. It is a worthwhile reference not because it reveals new information but rather because it provides a useful, all-in-one-place summary of the changes along with a review of NPSG scoring guidelines, a tabular summary of the revised EP and the full text of 2011NPSG rationales and requirements. For more details see the related articles in Perspectives above.
[Index] [Blog] Environment of Care News(September Vol 13 #9)
Pg01 -Poison in the Air Preparing for an External Hazmat Spill or Release FYI: EM, EOC, SFT “Thousands of hazardous materials spills and releases involving tank trucks and railroad cars occur each year”. As such, these events may be more common than most of us think and your facility more at risk than you might think… especially if you are located near manufacturing sites, railways or interstate highways. The point of this article is to make sure your Emergency Operations Plan (EOP) address this potential hazard. Beyond this, there are recommendations to:
Establish a relationship with your local fire department and Emergency Planning Committee
Avail yourself of resources such as [PEARL] the Emergency Response Guidebook (ERG), a “comprehensive resource used by fire fighters, police, and other emergency services personnel to quickly identify the dangers involved in a hazardous materials incident and guide the initial response”.
Make sure you have a plan for providing or arranging for decontamination
Standard LS.02.01.50 , EP 1-3 applies to real fireplaces and/or heat-generating units utilizing propane, natural gas, real wood logs, or other flammable materials.
Such units must be equipped with an enclosure, must be made of heat-tempered glass (or other approved material) and guaranteed not to break at temperatures up to 650 degrees Fahrenheit.
The hearth on newly installed fireplaces must be at least 4 inches off the floor
Elevators
Elevators are addressed by EP 4 in Standard LS.02.01.50 addresses this topic.
If your organization is multi-storied and required to support fire fighter access, at least one elevator must be designated for fire fighter use; be tied to emergency backup power; fitted for fire service recall and allow for in-car key operation by the fire department. “This requirement applies to elevators in new facilities as well as those in existing facilities that have a travel distance of 25 feet or more from the main fire fighter access point,”
For more information about fire fighter service requirements, see Section 9.4.3 of the Life Safety Code®,* NFPA 101-2000.
Linen and Waste Chutes
The majority of the EPs in Standard LS.02.01.50 deal with the topic of linen and waste chutes.
The chute must vent through the roof and be sprinklered at the top and bottom as well as on alternating floors. (EPs 6 and 7) if more than two stories high,
The inlet or door to the chute must be self-closing and positive latching.
This chute door must be fire rated and locked, or located in a room that must be locked.
The discharge door from the laundry chute “must also be self-closing and positive latching (and) fire rated for 1 hour. The room where the chute discharges should not be used for any other purpose and should be separated from the corridor by 1-hour fire-rated walls."
The corridor door should be fire rated at 11/2 hours. (EPs 5, 9, 10, and 11)
Combustible Materials
Standard LS.02.01.70, EP 1, addresses decorations.
Combustible decorations that are not flame retardant are prohibited.
Permitted decorations cannot be suspended from sprinkler systems nor can doors be covered with combustible material.
Further information on these requirements can be found in Section 10.2.5 of the Life Safety Code.
Waste Receptacles
Standard LS.02.01.70, EP2, addresses waste receptacles such as recycling bins, wastebaskets and dirty linen carts
Waste containers (or section of a divided container) may not be larger than 32 gallons for every 64 square feet, “If your trash containers are larger than that, they must be stored in a hazardous materials storage area. If that area is sprinklered, then there is no limit to the volume of the waste containers.”
Space Heaters
LS.02.01.70, EP 3 addresses space heaters
Portable space heaters are prohibited in all patient sleeping and treatment areas to include nurses’ stations.
They are only allowed in non-sleeping and non-treatment areas such as an office that is separated by a door or wall
Where permitted, space heaters must be no hotter than 212 degrees Fahrenheit and cannot have an open flame.
Pg10 -Some Measure of Success Requirements Removed from the EC Chapter FYI: JCSC, EOC Effective 4/26/10 Measures of Success (MOS) were removed from 15 BHC/HAP (EC.02.01.01, 11 / EC.02.03.01,1, / EC.02.03.05, 3,4,7,9,12,16-20 / EC.02.05.01,3 / EC.02.05.05,1/ EC.02.05.07,2) and another 5 HAP-only (EC.02.01.01,7 / EC.02.02.01, 7-8 / EC.02.04.01, 3 / EC.02.04.03,1) elements of performance related to standards in the Environment of Care Chapter.
Inside the Joint Commission (DecisionHealth) - August 16, 2010 , Vol 15 Issue 12
Avoid surprise RFIs in credentialing: FYI: MDx, C&P. Glenn Krasker, former Joint Commission Director of Hospital Accreditation, warns that although it is not a specific requirement of standard, that hospitals can receive an RFI for failing to consider medication safety in the credentialing and privileging process for physicians. To that end he has devised a Medical staff credentialing and privileging benchmark survey checklist (page 7) that might be worth incorporating into your process.
Updated sentinel event statisticsFYI: JCSC, LDR. “Since the sentinel event database was implemented in January 1995, The Joint Commission has reviewed 6,923 reports of sentinel events as of June 30, 2010. A total of 7,064 patients were affected by these events, with 4,726 or 67 percent, resulting in patient death”. Of the top ten reported sentinel events, Suicide remains at #2, with Medication Error at #5, Patient Fall #6, Assault/Rape/Homicide #8 and Patient Death or Injury In Restraints #10.
The Joint Commission looks at refining, improving its tracer methodology FYI: JCSC, MDx, HR, IM, LDR TJC is planning to integrate patient care and patient system tracers to achieve a more thorough evaluation of high risk or problem-prone processes . The first processes selected will be:
• Cleaning, Disinfection And Sterilization Of Medical Equipment, Devices And Supplies
• Patient Flow
• Contracted Clinical Services
• Diagnostic Radiation Services
• Therapeutic Radiation Services
• Clinical Information Systems
• OPPE and FPPE
SAMHSA Recovery to Practice Initiative (A Resource for Mental Health Professionals): The Recovery to Practice Project Overview explains that this is part of the Federal Government’s efforts to promote recovery for all Americans affected by mental illness…by collecting and sharing recovery resources. The site also includes an E-newsletter, monthly highlights and free webinars. Submitted bySara Virginia Knight, RN, PhD
2010 Member Surveys (SL1a)If you anticipate a survey soon, pleaseclick here
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!
