Pg01 -Joint Commission Annual Report Shows Big Improvements for Hospital Care FYI: JCSC, PI, Accountability measures are defined as "quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes". Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2010 focuses for the first time on these measures and shows that TJC-accredited hospitals are providing higher-quality, evidence-based care for heart attack, pneumonia, surgical care, and children’s asthma care. [PEARL] SPHCC facilities should pay attention because in 2009 six new performance measures, were introduced for inpatient psychiatric services. They include:
? Use of physical restraint
? Use of seclusion
? Multiple antipsychotic medications at discharge
? Multiple antipsychotic medications at discharge with justification
? Post-discharge continuing care plan created
? Post-discharge continuing care plan transmitted
Although these measures have not yet been evaluated against the accountability criteria it is likely that they will be. Again, 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". For more background on Accountability Measure see also: Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified.
Pg04 -Joint Commission Center for Transforming Healthcare Announces Second Set of Solutions [REF: RN, PI] The first set of solutions from TJC’s Targeted Solutions ToolTM (TST) focused on Hand Hygiene. The Hand-off Communications Project is the second set of solutions for the Center for Transforming Healthcare. Why? Because, "Miscommunication between caregivers during the transfer—that is, handoff—of responsibility for a patient plays a role in an estimated 80% of serious preventable adverse events". This time the Center teamed with 10 hospitals that applied Robust Process ImprovementTM (RPI) methods to this issue. The result is a series of targeted handoff solutions whose acronym is SHARE. A sidebar on page 4 elucidates the acronym but here is a brief summary:
• Standardize critical content (e.g., Pt history, other key info)
• Hardwire within your system, (e.g., standardized forms, checklists)
• Allow opportunities to ask questions, (e.g., share contact info)
• Reinforce quality and measurement (e.g., Monitoring compliance with use of standardized forms)
• Educate and coach (e.g., Standardizing handoff training)
Pg06 -Clarification: CMS Will Accept Alternatives to Manufacturer's Maintenance Recommendations FYI: EOC, E&M, TJC has successfully convince CMS to accept its three criteria for scheduling maintenance activities:
1. Manufacturer’s recommendations (Previously the only criteria accepted by CMS)
2. Risk levels associated with the equipment
3. Hospital experience (EC.02.04.01, EP 4; EC.02.05.01, EP 4)
The article provides the a brief outline of three steps in the equipment management process:
1. Create and manage an accurate inventory
2. Evaluate what maintenance strategy is most beneficial (EC.02.04.01, EP 3, and EC.02.05.01, EP 3)
3. Establish maintenance activities based on the manufacturer’s recommendations, risk levels of the equipment, and hospital experience
Pg07 -Updated Sentinel Event Statistics for Midyear 2010 FYI: JCSC, LDR The 10 most frequently reviewed sentinel events for the first three quarters of 2010 continue to include Suicide (#5), Patient Fall (#6), Medication Error (#7), Assault, Rape, Homicide (#9) and Patient Death or Injury in Restraints (#10). The article provides the full chart of 10 and a comparison chart for the period of Jan 1995 through Sept 2010.
Pg11 -Approved: Policy Regarding Accreditation Status of Organizations That Cease Provision of Services for a Period of Time FYI: LDR, GB Effective January 1, 2011, a cessation of patient services may affect your accreditation status as follows
• No patients up to 60 days: Current accreditation status is continued
• No patients from 60 days to less than six months: an extension survey required in order to continue status
• No patients for six months or longer: Accreditation status is lost
Pg01 -Patient-Centered Communication: Tips for the New Standards[REF: JCSC, LDR, GB, PtAd, StEd, HR, RN] Patient-centered communication has been defined as "communication that effectively identifies and respectfully responds to the patient’s preferences, needs, and values," by Paul M. Schyve, M.D., senior vice president at TJC. Although non-compliance with the new Patient-Centered Care standards will not impact an accreditation decision before January 1, 2012, surveyors have already begun to evaluate it during survey. To help facilities prepare for 2012, TJC has published Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The Roadmap provides useful explanations and examples. Appendix A (Pages 47-48) of the Roadmap also provides a full, 10-category checklist of efforts to improve compliance with the new standards that addresses six functional areas (i.e., 1. Admission, 2. Assessment, 3. Treatment, 4. End-of-Life Care, 5. Discharge and Transfer, 6. Organization Readiness). This article contains a 5-category checklist to help determine readiness for implementation of the new standards. It also provides tips for implementation that include the following:
1. Understand the needs of your patient population
2. Assess the appropriateness of current services and communication strategies for those needs
3. Design effective services for the needs of frequently seen pt groups
4. Also ensure the ability to provide for needs of less frequently and/or rarely seen pt groups
5. Educate and train staff to instill cultural competence and increase their sensitivity to the needs of patients and families
6. Monitor performance and compliance with the new PCC standards
You are strongly advised to read this full article, utilize its checklist, then download and study the full Roadmap described above. See also:Standards in Support of Language and Culture for Hospital Accreditation Program (HAP), Facts about patient-centered communications, Update: Implementation Plan for Patient-Centered Communication Standards {Review/Full Article}, New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) {Review/Full Article} Perspectives, January 2010 Vol 30 #1, pg 5
Pg02 -5 Sure-Fire Methods: Ensuring that Medication Orders are Clear and Accurate[REF: MD, P&T, Phrm]MM.04.01.01 requires that medication orders be clear and accurate. The article provides an extract from the standard that defines different types of orders and provides the following 5 tips for compliance:
1. Develop a written policy that defines required elements for complete orders, their indications and required precautions
2. Educate staff about what to do when they encounter an order that is not complete
3. Implement computerized provider order entry (CPOE) if possible
4. If you use range orders, consider developing a policy that guides how such orders should be interpreted
5. Periodically monitor and evaluate medication orders to uncover compliance issues.
Pg03 -The 2011 E-dition: New Features Help Organizations with their Compliance Efforts FYI: JCSC, BHC The 2011 version of E-dition to be released this month contains several new enhancements including:
1. The ability to print out an entire standards chapter (vs. 1 standard at a time)
2. The ability to Further Customizing the BHC Service Profile concerning the extent of medication management so that only relevant medication standards/EP are displayed
3. The ability to remember the last program you logged into, so you do not have to reselect the program each time you access the E-dition. [Note that this feature is not applicable to individuals accessing the Edition from their organization’s Joint Commission ConnectTM extranet site.]
Pg01 -MDRO Risk Assessment: Strategies for Complying with NPSG.07.03.01[REF: IC, RN] There has been a steady increase in MDROs that are associated with increased lengths of stay, costs, and mortality. This is partly because it is not known when an antibiotic will stop being effective for a particular strain of bacteria. The article lists the following MDROs as current risks to patients in U.S. hospitals: • MRSA • VRE • Clostridium difficile (CDI) • Multiple drug–resistant gram negative bacteria, including Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Stenotrophomonas maltophilia, Burkholderia cepacia, and Ralstonia pickettii • Multidrug-resistant S. pneumoniae • Vancomycin-intermediate S. aureus and vancomycinresistant S. aureus. The article also reminds us that NPSG.07.03.01 requires hospitals to implement an evidence-based approach to MDRO prevention and recommends the following MDRO prevention strategies.
1. Conduct a Risk Assessment for MDRO Acquisition and transmission The article suggests a team approach and consulting Standard IC.01.03.01 that provides some guidance for structuring the assessment. There is also a table on page 5 with an example of how to use a SWOT (strengths, weaknesses, opportunities, and threats) analysis to conduct such an assessment.
2. [The CDC recommends that organizations assess their rate of MDRO infections and If the rate does not decrease, the organization should implement additional measures (CDC Tier 2). Active detection and isolation (ADI) or active surveillance cultures (ASC) (i.e., that newly admitted or certain high-risk patients are screened for MRSA) is a one of several Tier 2 measures. It should be noted that Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) have determined that there isn’t enough evidence to support ADI for routinely preventing MRSA.2. It may still be worth considering if your MRSA rates are increasing.]
3. Educate health care workers on MDROs. NPSG.07.03.01 requires the education of staff and LIPs about MDRO prevention strategies at hire and annually thereafter. If MDRO infection rates are increasing you should consider increasing the frequency of education, especially on the most effected units. The article also suggests providing nurses with a grid that identifies each MDRO and the type of precautions it requires (i.e., contact, droplet, or airborne)
4. Implement a Surveillance Program for MDROs. The surveillance program can be targeted to higher priority units and/or on the highest risk organisms for your facility.
5. Create Effective Alert Systems for MDROs. Once MDRO is isolated, notification should be timely and reliable. Consider building this into your process for critical test results.
6. Involve Patients and Family Members in Preventing the transmission of MDROs. At minimum they need to understand how to comply with isolation precautions and how/when to wash their hands. See also: Strategies to prevent transmission of methicillin-resistant Staphylococcus aureus in acute care hospitals.
Pg06 -NPSG.03.04.01: Medication Labeling in the Perioperative Setting[REF: RN, Phrm, P&T] Psychiatric hospitals should be aware that NPSG.03.04.01applies to any surgical or other procedural settingÖ to include prep areas, radiology and other imaging services, dental services, and patient care units where bedside procedures are done. In 2009, 27% of organizations were found to be out of compliance with this goal. There are many factors contributing to labeling errors. These include the inconsistency of non-standardized approaches, communication failures during handoffs, insufficient light and a failure to appreciate the need for a more meticulous approach. The article details 7 more factors that are worth reviewing. To minimize such errors, the author suggests the following:
• Be sure to label all medications and all liquids used in the perioperative
• Be sure the label includes name of the medication or solution its strength, quantity, concentration, and expiration date or time.
• Be sure labeling is done immediately prior to pouring the medication or solution into the container or immediately after.
• Be sure containers are not labeled in advance.
The article also provides 11 additional strategies
[Index] [Blog] Environment of Care News(December Vol 13 #12)
Pg04 -Joint Commission Adopts 2010 Guidelines for Design and Construction of Health Care Facilities State Rules and Regulations Still Viable Option[ALERT: EOC, E&M, JCSC] Effective January 1, 2011 EP#1 EC.02.06.05 (designing and constructing a health care Facility) will be updated from 2001 to reference the 2010 Guidelines for Design and Construction of Health Care Facilities (read-only copy). As before, organizations will also have the option of using state rules/regulations and projects in the design phase prior to January 1, 2011, can continue to use the 2001 Guidelines. These guidelines, updated every 4 by a years by a 116-member multidisciplinary Health Guidelines Revision Committee (HGRC) They are used by more than 42 states and several federal agencies and are considered the preeminent reference for health care facility design. For the first time, the Facility Guidelines Institute has made available a read-only copy of the current edition of the 2010 Guidelines. What’s New in the 2010 Guidelines?
This latest release has new and revised sections relating to Telecommunications areas and Patient safety assessments. It includes the merger and incorporation of Standard 170 (by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) and ASHE), Ventilation of Health Care Facilities, to eliminate any confusion caused by having two national ventilation standards for health care. Guidelines suggest single-patient rooms as a minimum requirement for medical/ surgical and obstetrical units for most new hospital construction.
Pg06 -Critical Clarifications, Part 2 Authoritative Answers to Common Questions About the Standards[REF: EOC, E&M, SFT]This is the second in a two-part series of articles that appears to have derived a number of issues from past EOC articles and worked them into a Q&A interview format 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 some key points (KP) from the last installment of issues. Plans for Improvement (PFI)
• KP: There is no limit to the number of open PFIs an organization can have, but they should be written in a specific (vs. blanket) manner Contingency Plans
• KP: Your organization should have plans to address possible risks such as security incidents and potential failures of medical equipment and utilities. Fire Watch
• KP: if there are unscheduled problems with some components of the fire suppression system and those problems compromise the system for at least 4 hours out of a 24-hour period, even if those 4 hours are not sequential—then you must conduct a fire watch. Door Locks
• Re: Life Safety Code Chapters 18 and 19
• KP: It is permissible to have more than one operation to open a door based on the clinical needs of a patient. • See Also: June 2008 Healthcare Interpretation Task Force Interpretation
Pg07 -Life Safety Code® Specialists Given Extra Time On Site for Hospitals and Critical Access Hospitals in 2011[ALERT: JCSC, EOC, E&M] This article was first published in Perspectives November 2011. Here is a repeat of our review from the November Reading Tips: 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.
Pg08 -Osha & Worker Safety Underserved Health Care Workers Lack of Coverage for Frontline Workers Can Compromise Patient Safety FYI: HR, StEd, LDR, GB Underserved workers are defined as those who have little or no access to health care, especially preventive care. While most of our hospitals provide health care benefits, you may have part-time or contract staff that are not eligible for these benefits. The article suggests that allowing such persons to lose their health will reduce the effective workforce and ultimately jeopardize patient safety. The situation calls for advocacy that is probably at the national level. However, encouragement was also given to reach out to such persons with education, training and free vaccines to help prevent injury and illness as much as possible.
2011 on-site survey and annual fee increasesFYI: LDR, GB,JCSC, F&B. Described as the first across the board fee increase since 2008, effective January 1, 2011 there is to be a 1% average increase for on-site surveys and annual fees for most facilities. You may estimate your 2011 fee based on your last survey (and adding 1%) by going to the TJC Connect intranet.
Revised NPSG on medication reconciliation is approvedFYI: MDx, RNx, SW, PI. A revised version of NPSG.08.01.01 now replaced by NPSG.03.06.01 will become effective July 1, 2011. Please note that NPSG.03.06.01 replaces Goal 8 (08.01.01, 08.02.01, 08.03.01 and 08.04.01) and its related elements of performance.,
Update: Targeted Solutions Tool™ hand hygiene projectsFYI: IC, RNx, SW, PI. Over 27,800 hand hygiene observations from over 990 hand hygiene projects have been entered into the TJC’s Center for Transforming Healthcare’s Targeted Solutions Tool (TST), The tools and videos provided to support improved hand hygiene are available in the TST.,
Bringing Immunity to Every Community webcast available for continuing education creditsFYI: RNx, RN, StEd. This free webcast was developed to increase the knowledge and competency of the nation’s 3.1 million registered nurses about immunizations, to encourage nurses to be vaccinated, and to position nurses as leading advocates for immunization among colleagues, patients and the public.î Registrants completing the activity can submit their certificate along with a copy of the course content to their professional organizations or state licensing agencies for recognition of 2.5 hours of continuing education credits. The webcast is available until 11/29/2012 and can be found at http://www.yourcesource.com/ecbt.
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