Pg01 -Approved: Modifications to National Patient Safety Goal on Reconciling Medication Information[REF: JCSC, MDx, P&T, Phrm, RNAfter 2 years of suspension (since 1/1/2009) and rigorous field review, a newly modified version of the safety goal for medication reconciliation will go into effect as NPSG.03.06.01.on July 1, 2011. The revisions are designed to correct the excessive detail and prescriptiveness of the previous version. For example, the requirement now allows a ‘good faith effort’ to obtain complete information on a patient’s current medications to be accepted as meeting the EP intent. In addition, the organization is given more choice about how to document the information. Reconciliation upon transfer is no longer specifically mentioned, but information (and some education) is still expected to be imparted to the patient (and family as needed) upon discharge. The full text of the new requirement (which may vary slightly by program) is included in this article and will be published in 2011 CAM update 1.
Pg08 -Approved: Revised Public Information Policy FYI: JCSC, LDR, GB. The revisions primarily address 1 – updating for consistency with the changes to the accreditation decision categories announced in the November Perspectives, 2 – largely removing quality report references for non-accredited or non-certified programs, and 3 – allowing patient-identifiable information in the quality report only if authorized by the patient. The full text of the modified requirement is included in this article and will be published in 2011 CAM update 1.
Pg12 -New Distribution Method for Perspectives to Accredited Organizations FYI: JCSC, LDR Just a reminder, that as previously announced hard copies of Perspectives will no longer be mailed to organizations unless a subscription has been purchased. Instead, effective January 2011, the publication will be provided electronically (as a PDF document) via your TJC extranet site.
Pg14 -Enhanced Joint Commission Web Site Improves Accessibility and Increases Interaction FYI: JCSC, IT. TJC’s new Web site is now up and running with highlights that include “Daily Update” section, sign up for various updates, enhanced search capability and an events calendar. Because of the enhanced multi-media functionality, Internet Explorer 7, Firefox 2, Safari 3 and Chrome 4 are suggested. Be aware that your bookmarks to the old site will need to be re-done.
Pg15 -Sentinel Event Alert A Follow-up Report on Preventing Suicide[REF: RN, MD, StEd, PtEdAlmost 25% of the cases of suicide reported to TJC occurred in non-psychiatric settings. It is clear that "non-psychiatric patients are committing suicide in emergency departments and medical/surgical inpatient units". Ergot, SEA 46: A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Despite the non-psychiatric bent, SEA 46 contains a helpful review of suicide risk factors, ties in NPSG 15 and provides some useful references. For example:
• American Society of Health-System Pharmacists (ASHP) list of medications associated with an increased risk of suicidal thoughts and behavior, including antidepressants, antiepileptic or anticonvulsant medicines, and antipsychotic agents.
• Mental Health First Aid (www.MentalHealthFirstAid.org), a new international public health intervention that is intended to provide those who are not mental health professionals with the skills to deal with mental health crises. (Could be useful training for tech-level staff)
Pg16 -Joint Commission Releases Innovative Leading Practice Library[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]
Pg01 -Reducing Infections Associated with Equipment, Devices, and Supplies Complying with IC.02.02.01 FYI: JCSC. “As reported during the Joint Commission Resources 2011 Hospital Executive Briefings in September by Pat Adamski, R.N., M.S., M.B.A., director, Standards Interpretation Group, The Joint Commission, Standard IC.02.02.01, EPs 2 and 4 pose the greatest compliance challenges for health care organizations. Although this is unlikely to be the case for psychiatric hospitals, if you have an onsite dental department or suite, this article is worth reviewing. TJC says almost one third of all hospitals surveyed last year had difficulty complying with IC.02.02.01. The complete Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 is available for download in PDF format (948 KB / 158 pages). This might suggest that surveyors will be particularly alert for findings related to any equipment you might have requiring intermediate and/or high-level disinfection or sterilization. For more information on both low level (e.g., stethoscopes, BP cuffs) cleaning and high/intermediate level disinfecting, see also:
• Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
Pg09 -The Flu Vaccination Challenge FYI: IC, HR, RN, LDR. If your facility is not currently achieving at least 75% flu vaccination rates for staff, you should consider taking on the Flu Vaccination Challenge to improve your required (IC.02.04.01) annual influenza vaccination program. For more details go to www.jcrinc.com/fluchallenge.
Pg01 -Patient Identification in the Laboratory: Complying with NPSG.01.01.01 FYI: RNx, RN. Few state hospitals continue to have onsite laboratories, but many still employ phlebotomists. In addition to phlebotomy staff, this article might also be useful as a brief review/reminder about the use of two patient identifiers. A number of the suggested compliance improving strategies recommended involved use of technology and automated systems such as bar-coding specimen labels and electronic order entry in the lab . However, there was also the simple recommendation involving the patient (when appropriate) by labeling specimens in their presence and asking them to inspect the label as added insurance of accuracy.
Pg10 -Center for Transforming Healthcare Finds Solutions: Tool Raised Hand Hygiene Compliance to Nearly 80% Among Users FYI: JCSC, LDR, IC, RN, StEd. TJC announced Hand Hygiene as its first Targeted Solutions Tool (TST) this past September (see Center for Transforming Healthcare Releases First Targeted Solutions Tool Tackles Hand Hygiene Challenges). This article tells us that in less than 10 months of implementing TST Hand hygiene solutions , 8 pilot hospitals went from an average hand hygiene compliance rate of 48% to "about 80%". Given the importance of hand washing to infection control and these reported results, leadership is encouraged to look into the use of the Hand Hygiene TST (HH-TST). Utilizing the HH-TST involves working through 6 steps over a 12-week period. The balance of this article provides a useful description of those six steps and suggestion for implementing them:
1. Getting started: start with just one or two units
2. Training data collectors: The recommended process involves two types of collectors :
hand hygiene observers and just in time coaches. Observers are like ‘secret shoppers’ who watch for hand washing activities (or lack thereof) and record their findings without comment. Coaches interact with staff that fail to wash their hands at crucial times to both encourage washing and obtain feedback about why washing did not occur.
3. Entering data: enter data is entered into a downloaded application and the user is guided to choose from an array of causes for not participating in hand hygiene or enter causes unique to your facility.
4. Analyzing data: The entered data is used to provide "three types of graphical analysis that reveal the top contributing factors to poor hand hygiene, track unit compliance over time, and identify the biggest offenders in the unit’s noncompliance, by role type".
5. Targeting solutions: The tool then offers multiple guides and improvement strategies for each factor.
6. Sustaining your gains: The tool also allows for and encourages ongoing data collection after the initial 12 weeks on a smaller sample size to support continued feedback and reinforcement of staff and the hand washing gains that have been made.
Pg06 -Requesting Life Safety Extensions and Equivalencies A Brief Outline of the Submission Process[REF:EOC, E&M, SFT]Re: Extensions – TJC automatically permits an organization to extend the projected completion date of a Plan for Improvement (PFI) up to six months. After that an extension must be formally requested. The article describes the steps for doing this, how to complete the necessary request form (i.e., the Joint Commission Online Standards Submission form) and other key information that will be required (e.g., Original and proposed projected completion dates, ? Brief description of the deficiency ? Reason(s) for the extension request ? Confirmation that the extended PFI will be given a high priority for completion). There are also directions for accessing the request form via your TJC Connect. To request an extension go to http://jcwebnoc.jcaho.org/newsigsub/ Re: Equivalencies – Equivalencies are approved, alternate methods of ensuring life safety when Life Safety Code requirements are not being met. There are two types of equivalencies that can be approved by a TJC engineer in the Standards Interpretation Group (SIG). The Traditional Equivalency: This equivalency can be requested via electronic submission or by mail (address is provided in the article). Four steps are described to include 1 – identifying the specific Life Safety Code deficiency(cies) involved, 2 - a written proposed alternate safety approach for each, with 3 – project time line (with key milestones) and 4 – certification that the proposed alternative meets LSC intent by a fire protection engineer, a registered architect, or a local authority having jurisdiction (AHJ). The Fire Safety Evaluation System (FSES) Equivalency: This process is designed to identify alternate methods of ensuring life safety "based on the level of safety provided throughout the building". This process is significantly more involved, but is summarized by the article into 7 steps that include references to the several FSES Worksheets (e.g., 4.7.6, 4.7.9 and 4.7.10) that are required. It should be noted that an FSES request should not be submitted if the survey or evaluation data is more than a year old and that all such submission must be in writing (with appropriate support documentation). "The typical turnaround for the FSES request is six weeks". See also: The PFI Change Request & Equivalency Request Information (full text) 11/10/10
CMS-2321-N, entitled “Medicaid Program; Final FY 2009 and Preliminary FY 2011 Disproportionate Share Hospital Allotments, and Final FY 2009 and Preliminary FY 2011 Institutions for Mental Diseases Disproportionate Share Hospital Limits” was published. This regulation affects Medicaid.
Field review: proposed performance expectations for ORYX accountability measures[ALERT: JCSC, PI, MDx, RNx] In August of last year, we encouraged psychiatric hospitals to pay attention to Accountability Measures because TJC was already applying the accountability criteria to then current hospital core measures including hospital-based inpatient psychiatric services and was considering their integration into "accreditation requirements". TJC is now proposing a requirement "that would establish specific performance expectations (e.g., 85%) for the ORYX accountability measures for hospitals". Field review comments are being sought and will be accepted through February 22. You are strongly encouraged to participate. For quick additional background on Accountability Measures see our August review of Helping Hospitals Improve with Accountability Measures: Joint Commission Changes How Core Measures Are Classified.
Deleted EP 10 at standard MM.05.01.01 FYI: P&T, Phrm, MD. EP 10 (All medication orders are reviewed for the following: Variance from the hospital’s indications for use) was deemed redundant with other EP and so was deleted.
Today is the last list-serve distribution of Joint Commission Online; sign up to receive E-Alerts FYI: JCSC. "After today’s publication, the list-serve distribution of Joint Commission Online will be discontinued. To continue to receive Joint Commission Online, readers need to sign up to receive the newsletter via E-Alerts – e-mail alerts. The E-Alerts are the new method of delivering Joint Commission news. You can sign-up to receive E-Alerts daily or weekly. To sign up, go to http://www.jointcommission.org/ealerts/."
New and revised EPs for hospitals and CAHs regarding CMS hospital CoPs and psychiatric hospital CoPs FYI: JCSC, MDx, RNx, SWx. New and/or revised EPs (PC.01.02.13 EPs 2 and 6, PC.01.03.01 EPs 5 and 43, and LD.04.01.05 EP 10) were developed in order to comply with the psychiatric hospital special CoPs. They go into effect on February 1, 2011. A pre-publication version of the new and revised EP will be available until 4/4/11 after which they will be incorporated into manuals
CoP changes regarding patient visitation for hospitals and critical access hospitals FYI: JCSC, LDR
• Effective February 18, 2011, deemed hospitals will be surveyed for the CoPs regarding visitation rights under standards RI.01.01.01 EP 1, 2, 5, 6 and LD.04.01.01 EP 2.
• Effective July 1, 2011, all hospitals (deemed and non-deemed) will be surveyed under the EPs above and new EPs 28 and 29 under RI.01.01.01 (new EPs are available in the newsletter).
New and revised fire alarm and fire protection systems requirements for hospitals FYI: SFT, E&M. Effective July 1, 2011, under EC.02.03.05, EP 2 has been revised (i.e., testing of valve tamper switches and water-flow devices becomes ‘at least quarterly’ vs. ‘every six months’) and a new EP 25 (i.e., requirements for documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems) has been added. The changes and additions are provided in the newsletter
New BoosterPak on MS.08.01.01 and MS.08.01.03[REF: JCSC, MDx] TJC developed BoosterPaks to provide (facilities and surveyors) greater understanding and tools/suggestions for improved compliance on complicated standards. The second Standards BoosterPak™ focusing on MS.08.01.01 (Focused Professional Practice Evaluation) and MS.08.01.03 (Ongoing Professional Practice Evaluation) has been released, but is only available on The Joint Commission Connect extranet.
Field review: Proposed physical examination standards for BHC
The Joint Commission is proposing revisions to an existing standard for non-24 hour programs (CTS.02.01.05, EP 1) and the development of a new standard and elements of performance to replace CTS.02.01.07, EP 2 for 24-hour residential and group home programs. TJC is seeking input through February 2, 2011. The survey consists of 28 questions and should take you about 15 minutes to complete View the proposed requirements and comment.
