Pg01 -Approved: Accreditation and Certification Decision Rules for 2011 FYI: JCSC, Most of the changes reported are clarifications of existing rules or their re-alignment with revised TJC decision categories (see Refined Decision Categories below). Other changes are more significant and include:
Deletion of
Rule DA05 (Denial of Accreditation for failure to submit PPR)
Rule ESC02 (ESC required when first ESC unacceptable or failure to show progress)
Rule MOS02 (MOS required when first MOS fails)
Rules for Provisional Accreditation (PROV), Conditional Accreditation (CON), and Conditional Accreditation Follow-up (CONF)
Addition of
New Accreditation with Follow-Up Survey (AFS)
New Contingent Accreditation (CONT) rules
The full text of all changes is included in the article.
Pg03 -Life Safety Code® Specialists Given Extra Time on Site for Hospitals and Critical Access Hospitals in 2011[ALERT: JCSC, EOC, E&M] Effective January 1, 2011, Life Safety Code Specialists (LSCS) will be given one to three extra days on site. A base number of survey days are first established using 1.5 million sq ft as a reference point (RP). Less square footage than the RP = 2 base days while more = 3 base days. If you also have 0-2 healthcare buildings your calculation is complete, but if you have 3-5 or 6-8 you would add an additional 2 or 3 days respectively to your base. TJC cautions that each hospital should check with their account representative to be sure of the number of days they would be assigned. The extra time will largely be devoted to more thorough surveying of problematic standards (i.e., EC.02.03.05 and EC.02.05.07) and allowing LSCS to provide more education and training.
Pg04 -Enhanced E-App Coming in December[ALERT: JCSC] The E-App will be unavailable December 6 – 19 so updates will need to be saved and submitted before that time. Any E-Apps due between November 6, 2011 and January 31, 2011 will be given an extended due date of February 1, 2011. The refined E-App is expected to be more specific, have greater printing functionality and include a new 'read-only' option (for others in the organization) that should help surveyors be better prepared for your survey.
Pg05 -New Distribution Method for Perspectives to Accredited Organizations[ALERT: JCSC] Starting in January 2011, accredited organizations will receive Perspectives as a PDF document via the TJC Connect extranet where all 2010 issues will be archived. January will also be the last month in which hard copies of Perspectives are mailed without a paid subscription.
Pg07 -Approved: Refined Decision Categories for Accreditation and Certification[REF: JCSC, LDR] The decision category of Provisional Accreditation has been retired and Conditional Accreditation is being replaced with two new categories: Accreditation with Follow-up Survey (AFS) and Contingent Accreditation (CONT). There are now six categories of accreditation (Preliminary Accreditation, Accredited, Accreditation with Follow-up Survey, Contingent Accreditation, Preliminary Denial of Accreditation and Denial of Accreditation ) and five categories of certification (for staffing firms) that are described on pages 7 and 18 of this article respectively.
Pg09 -Deleted: Respiratory Service Orders Requirement for Hospitals FYI: MDx, P&T Effective 10/1/10, TJC deleted EP14 of PC.02.01.03 removing the limitation for ordering respiratory services to a physician or osteopath. Now, “a qualified, licensed practitioner who is responsible for the patient and acting within the scope of their practice" to order respiratory services may also do so.
Make sure there is a defined mechanism for communicating with the receiving organization and staff having the specific responsibility for doing so.
Begin the discharge planning process early, but ensure it continues throughout the stay
Consider having discharge planners participate with the multidisciplinary team to stay abreast of the patient’s changing needs
Involve the patient and his/her family in the discharge planning process
Provide the patient and his/her family with education about their follow-up care and the other organizations/providers that might be involved in clear language.
Consider making post-discharge follow-up calls to check on and reinforce the patient’s progress.
Pg04 -Resolving Patient Complaints Effectively: How to Comply with RI.01.07.01 FYI: PtAd, CHP, PI, The article encourages a constructive approach to patient complaint resolution that focuses on the opportunities to learn about and improve the organization. To that end it suggests several core components for a RI.01.07.01-compliant complaint resolution process that includes:
Clearly defining a complaint resolution process
Keeping open communication with and inform/educate patients and family about the complaint resolution process
Supporting the process with telephone numbers and/or addresses for filing complaints
Reliably reviewing and (when possible) resolving patient/family complaints and notifying them of the follow-up
Ensuring a climate and culture that make it safe and acceptable to file complaints when needed
The author also recommends comparing policy to practice and evaluating compliance by tracing a sample complaint from the perspective of how it (the complaint) was processed or what the involved patient experienced.
Pg09 -Complying with Safe Injection Practices FYI: IC, Safe injection practices are part of the standard precautions required by Standard IC.02.01.01,EP#2. 7 recommendations for compliance are provided including:
Do not administer medications from one syringe to multiple patients
Consider a syringe or needle/cannula to be contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible
If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile with each dose extracted.
Pg01 -Effective Handoff Communication Part 2: Standardizing Processes throughout Your Organization[REF:RNx, RN, TxTM], This is the second article in a two-part series addressing handoff communications. Last month, the first article discussed handoff-related risks and the SBAR technique. This article focuses on strategies for organization-wide standardization of handoff processes.
TJC requires a standardized handoff process, but the real importance of standardization is in its ability to prevent the significant number of undesirable patient outcomes that are related to ineffective communication. One key to effective standardization is to effect the cultural change that overcomes the reluctance of junior/subordinate staff to ask questions, speak up or raise concerns. Although the process is likely to be gradual, the author suggests it is critical for such change to start with top-down leadership endorsement. The use of inclusive team approaches for the needs assessment and design (or refinement) of the hand-off approach is recommended. The article includes 7 key questions that need to be answered as part of the assessment and provides a number of other tips for motivating and sustaining a standardized approach. Staff should understand why standardization is important, what are the benefits to them, what should standardization look like and what specific kinds of situations in your organization call for such communication. Leadership should provide the necessary education, create positive organization-wide awareness, develop accountability and implement routine follow-up on the standardization-related changes.
See also: Handoff Communications: Toolkit for Implementing the National Patient Safety Goal, The Association of periOperative Registered Nurses (AORN) Hand-Off Toolkit (PDF)
[Index] [Blog] Environment of Care News(November Vol 13 #11)
Pg01 -Critical Clarifications, Part 1: Authoritative Answers to Common Questions About EC, EM, and LS Standards [REF: EOC, E&M, SFT] This article appears to have derived a number of issues from past EOC articles and worked them into a Q&A format in an interview with TJC’s George Mills, M.B.A., F.A.S.H.E., C.E.M., C.H.F.M., C.H.S.P., senior engineer, Standards Interpretation Group (SIG). Here is a brief summary of some of the key points (KP). Generator Testing
Re: EC.02.05.07, EP 5
KP: Q&A clarify what workload percentages are required for diesel and non-diesel-powered generators. Remember, propane/natural gas generators do not have to meet the 30% name plate requirement. However, if you are diesel and running less than 30% of nameplate, a supplemental load will need to be added.
KP: Fire Alarm location must either be in an area that is ‘continuously occupied’ or has a smoke detector. You are not required to build a protected area.
KP: Defibrillators are classified as life support equipment and as such, require appropriate testing and maintenance.
See Also:
Corridor Clutter
Re: LS.02.01.20
KP: Only certain kinds of ‘in use’ carts (e.g., isolation, chemotherapy, housekeeping) are allowed in corridors but only while they are actually being used. As such, a housekeeping cart should not be left in the hallway for 45 minutes while staff go to lunch. The rule of thumb for allowable non-use storage time in a corridor is 30 minutes.
KP: Standards do not allow a waste container to be larger than 32 gallons for every 64-square-foot area. However, a larger container, can be acceptable if it includes a “clearly” verifiable insert or divider that restricts the capacity of the receptacle to no more than 32 gallons.
KP: Immediate Threat to Health or Safety is triggered by unaddressed facility system issues related to 1 – Fire Alarm system, 2 – Sprinkler System, 3 – Emergency Power Supply system and 4 – Medical Gas Master Panel. Compromised exits or a lack of appropriate interim life safety measures could also be a trigger.
See Also: Approved: Time Limits for Organizations to Eliminate an Immediate Threat to Life Situation, Perspectives May '08 Vol 28 #5 Pg09 - The time limit is 72 hours. Article provides additional details on the process and its relationship to PDA. FYI: LDR, MDx, JCSC.
Re: Daily, Weekly, Monthly, and Quarterly
A maintenance event due in a particular day, week, month or quarter is considered on time for TJC purposes if it was performed any time within that particular time frame, so it is useful to understand the following definitions:
Daily: Performed at least once (any time) per day
Weekly – Performed at least once (any time) during a calendar week of Sunday – Saturday
Monthly: Performed at least once (any time) within a calendar month.
Quarterly: Performed at least once (any time) within a calendar quarter
Re: Preventive Maintenance Scheduled Events
This article describes scheduled maintenance events as being due a designated number of months “from the actual month in which the scheduled work was completed”. However, the examples of compliance described are based on a plus or minus number of days. If you complete the task within the allotted ‘plus or minus’ timeframe you are credited with having met the scheduled target date. Even if you fail to do so, the scheduled (target) date does not change. It continues as the reference point for the next round. We have attempted to translate the definitions provided into more succinct, operational terms, but the reader is advised to study the examples provided in the article for a more complete understanding.
Semi-Annual: Performed 6 months from the last scheduled (target) date of the work plus or minus 20 days.
Annual - Performed 12 months from the last scheduled (target) date of the work plus or minus 30 days.
Triennial - Performed 36 months from the last scheduled (target) date of the work plus or minus 45 days.
Re: Other Time Frames Considerations
TJC permits an organization to establish written policies that vary from their definitions, “within reason”. For example, Semi-annual could be defined as plus or minus 45 days.
When specific timeframes and or frequencies are stated in an EP (e.g., EC.02.05.07, EP4), compliance requires adherence to those explicit requirements in lieu of the definitions provided above.
These definitions are also useful because TJC utilizes the 2000 NFPA which but does not provide working definitions of the time parameters presented in this article.
R2089CP: Implementation of edits for the Emergency Department (ED) adjustment policy under the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) - FYI: F&B
CMS-3228-F entitled “Medicare and Medicaid Programs; Changes to the Hospital and Critical Access Hospital Conditions of Participation To Ensure Visitation Rights for All Patients”. Includes requirement for written policies and procedures regarding the
visitation rights of patients. Effective January 18, 2011. - FYI: PtAd, LDR
Joint Commission Alert: Suicides a risk in the ER, hospitalFYI: MDx, RNx, SW, PI. SEA #46, entitled, A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department was issued on 11/17/10. It is actually a more in-depth follow up to the first TJC suicide-related alert, SEA #7 issued in 1998. Although its focus is not on psychiatric facilities, the information provided on risk factors, reduction strategies (including screens and interventions) and suggested actions would be worthwhile for any hospital. See also the SPHCC Suicide Resource Page
Full survey time frame to change from 39 to 36 months for accreditation programs.FYI: JCSC, LDR The change will become effective January 1, 2011. The change is a part of TJC ongoing efforts to better align itself with CMS requirements. This time the catalyst was CMS survey requirements for home health care agencies.
New! Leading Practice Library is now available[PEARL: JCSC, LDR, GB] The Leading Practice Library (LPL) is a free tool for TJC accredited or certified organizations that is accessed via your TJC Connect extranet. TJC says, “The library contains real-life solutions that have been successfully implemented by accredited organizations and reviewed by standards experts at The Joint Commission”. There is also a tutorial with guided steps on how to use the tool or submit suggestions. There is no requirement for its use. Be forewarned that the quality of the scanned documents is uneven ranging from excellent to barely legible and, of course, most of the HAP documents are for Med/Surg Hospitals. Still, the LPL documents, P&P are better than starting from scratch and they all have the advantage of being TJC approved. One of the current, relevant LPL topics is suicide risk screens. Search for them by using the subject 'Suicide' [Note: Please let us know about any particularly good documents you might find in the LPL that are relevant for Psych Hospitals]
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!
