Free 2011 Custom Resource Page for all SPHCC Members: Identify your top CMS and TJC issues and we will pull relevant materials from the SPHCC libraries onto a customized resource page for your facility. Click here to schedule your set up.
Pg03 -Accepted: New and Revised Hospital and Critical Access Hospital Requirements to Meet Relevant CoPs FYI: JCSC, These changes were effective 2/1/11 and were first announced in January 12 TJC Online. This article provides full text of the changes. Most of the changes are minor editorial revisions (IM.02.02.03, EP 2, TS.02.01.01, EP 2, EM.03.01.03, EP 1, EC.02.03.01, EPs 9 and 10, EC.02.05.03, EPs 1–6, LS.02.01.30, EPs 6 and 25). However, there were a few new and revised EPs that were specifically designed to bring TJC more squarely in line with CMS requirements for psychiatric hospitals. These include:
• PC.01.02.13, EPs 2 and 6: Director of SW function [ala: CMS B152 - §482.62(f)]
• PC.01.03.01, EPs 5 and 43: Documenting reason for admission [ala: CMS B107 - §482.61(a)(3)]
• LD.04.01.05, EP 10: Treatment plan responsible team members (ala: CMS B123 - §482.61(c)(1)(iv)]
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.
Pg02 -5 Sure-Fire Methods Assess and Reassess Patient According to Defined Time Frames FYI: JCSC, TJC reports that in the first half of 2010, 31% of surveyed hospitals were found out of compliance with PC.01.02.03. For psychiatric hospitals, the requirement to assess/reassess patients within defined time frames is probably most relevant to our H&P process (EPs 4 and 5). However JCSC should identify any assessment-related timeframes required by law or your facility that you currently have in place. Then do a spot check to see if meeting these timeframes is a concern. If you find a problem, consider redesigning/refining the relevant processes by using some of the 5 compliance strategies suggested in this article. They include: 1 – streamlining, 2- Utilizing physician input, 3 – refreshing staff education on relevant policies, 4 – real-time monitoring and 5 – feedback for those not in compliance.
Pg04 -Spotlight on Success Epworth Village's Philosophy Minimizes Physical Holding of Children and Youth[REF: BHC, StEd, RN] This article reports insights from a BHC agency providing children’s services that reduced the use of restraints by almost 40% between 2006 and 2009. To achieve this they followed the Cornell University’s Therapeutic Crises Intervention (TCI) System. This is a highly respected system that is worth exploring if you serve children. As you might expect, this agency’s success was based on fundamentals such as a philosophy of last resort/least restrictive use, staff training and education and rigorous monitoring and PI evaluation. But they also developed approaches such as ‘tapping out’ in which staff were trained and encouraged to identify when they need to remove themselves or others (who might be ineffective due to frustration or fatigue) from an escalating situation. They also focused more heavily in the initial assessment phase upon identifying patient triggers (for the need of restraint) and preventive coping strategies. It should also be noted that they continue to have in depth post-restraint debriefings. For more information on the TCI System download the TCI Bulletin.
Pg06 -Tracer Methodology 101 Individual Medication Management Tracer in a Hospital[REF: JCSC, Phrm, P&T, MD] Instead of the medication management system tracer, this installment of Tracer Methodology explores medication management issues in an individual patient tracer. The interviewee in this article encourages use of this tracer for evaluating high-risk medication issues. She also emphasizes the importance of medication reconciliation and reminds the reader that the revised goal addressing medication reconciliation (NPSG.03.06.01) becomes effective July 1, 2011. As in previous offerings in this series, the bulk of the article reviews a tracer scenario and provides a number of sample questions. In this instance, the scenario is of a 46-year-old female admitted to 320-bed hospital’s surgical intensive care unit following a ski accident with multiple fractures and a ruptured spleen. Still, the sample questions are worth adding to your mock tracer files.
Pg09 -Performance Improvement Project Evaluation Checklist FYI: JCSC, If you have sufficient PI expertise to understand random error, and bias related to selection, measurement and analysis, then this 1-page form could be a useful tool in your ongoing evaluation of facility PI (PI.03.01.01) in general and your PI projects in particular.
Pg01 -Medication Reconciliation: Complying with NPSG.03.06.01[REF: JCSC, MDx,Phrm, P&T, RN] MedicationReconciliation that was NPSG8 is now included with other medication safety issues under NPSG3 as NPSG.03.06.01. The 2-year suspension ends on July 1, 2011 when the revised standard becomes effective. Although streamlined, the basic requirements are still to make a good faith effort to get a complete list of current medications on admission, revise the list with any new medications provided during the patient stay and provide written information to the patient/family about their medication at discharge. However, the onus for communicating medication information to the next provider has now been shifted to the patient. The hospital’s role is to educate the patient/family adequately for that responsibility. Some tips (e.g., encourage patients to fill all prescriptions at the same pharmacy and ask questions) are provided about the content of that education. See also our January review of Approved: Modifications to National Patient Safety Goal on Reconciling Medication Information.
Pg09 -Long Shifts, Lack of Sleep Fatigue Health Care Workers: Changing Attitudes About Rest and Reasonable Work Schedules FYI: LDR, HR, MD, RN "Most Americans get 90 minutes less sleep each night than they need to be rested and productive the next day at work". For health care workers, studies have clearly shown that those who are fatigued/sleepy make more errors and mistakes. On the basis of such studies, medical residency programs began limiting first-year residents to 16-hour shifts with not more than 80 hours per week for any resident. This is a significant decrease from the 120-130 hour weeks that had been permissible in the past. The sources quoted in this article would like to further encourage such trends and to change attitudes about the need for rested workers. One even suggests that people should look at coming to work sleepy in the same way they would look at coming to work intoxicated. However, in addition to good sleep hygiene (briefly described in the article) they also cited some liberal support strategies such as allowing health care workers to nap on the job. For example, 12-hour shift nurses might combine their two 30-minute breaks to get a 45-minute nap. Ultimately, they indicate there is no substitute for proper rest and at least one of the sources cautions against longer shifts (e.g., up to 16 hours) and recommends 8-to-10 hour shifts as ideal.
[Index] [Blog] Environment of Care News(March Vol 15 #3)
Pg01 -Talking to the World Treating Patients with Limited English Proficiency—During Emergencies and Every Day FYI: PtAd, RN, Ldr The context for this article is the new standards related to patient-centered communication and cultural competence and the fact that almost 20% of persons in the US over the age of 5 use a language other than English. Surveyors have begun evaluating these standards, but findings will not impact accreditation until after January 2012. The article provides insights and suggestions from the experience of a 4-hospital system in Broward County, Florida that had to communicate with an influx of limited English proficiency (LEP) patients after the January 2010 earthquake in Haiti. Tips include periodically surveying staff (especially licensed staff) to determine other languages they are capable of speaking. In addition to telephone language lines that many state hospitals subscribe to, the article also mentioned one provided by the Red Cross. Upon exploring this, we discovered that there are language banks provided by entities like the Red Cross or local governments that sometimes provide translation services free of charge. Check your local Red Cross chapter. Also be aware that should a disaster or other influx of LEP patients overwhelm your translation capabilities, that there is the option to contact the National Incident Management System (NIMS) for assistance in finding the needed services. See also: New R3 Report details rationale/research behind Joint Commission requirements and Update: Implementation Plan for Patient-Centered Communication Standards {Review/Full Article}
Pg06 -Osha & Worker Safety: The Hazard Communication Standard in Health Care Labeling, MSDS, and Other Aspects of Dealing with Chemicals FYI: SFT, "Every employer with hazardous chemicals in the workplace is required to have a hazard communication program that includes the labeling of containers of hazardous substances, MSDS, and employee training". Unfortunately, the requirements of various countries and/or government agencies have impaired consistency in such communication. The "Globally Harmonized System of Classification and Labeling of Chemicals’ (GHSCLC) were designed to be a single coordinated system to address classification of chemicals, labels, and MSDS". Since its inception in 1992 it has undergone several revisions. OSHA is now considering an integration of GHSCLC into its own standards. This would shift OSHA’s approach from a largely performance orientation (i.e., organizations figure out how to meet the requirement) to a specification orientation that would provide more specific how-to’s for meeting the requirement. The article provides a brief overview of the structure of the proposed rule. For more details see: Guide to the United Nations Globally Harmonized System of Classification and Labeling of Chemicals (GHS)
Pg08 -Tracing the Environment of Care An Essential Approach to Identifying Safety Risks and Compliance Issues[REF: JCSC, EOC, SFT]This article encourages the use of mock tracers with an environment of care focus and points out some differences with clinical tracers. It suggests potential tracer ideas (e.g., security of pharmaceuticals,) and provides an example involving an eye wash station for the reader’s consideration. Sample questions are included (page 9).
R2111CP: Outlier Reconciliation and other Outlier Manual Updates for the Inpatient Prospective Payment System (IPPS) - FYI: F&B
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-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.
CMS recognizes The Joint Commission’s accreditation of psychiatric hospitalsFYI:JCSCOn 2/25/11 CMS granted TJC deemed status authority for psychiatric hospitals for a 4-year period. This essentially means that CMS considers TJC standards relevant to psychiatry to meet or exceed their own.
