Pg01 -Joint Commission Launches New Core Measure Solution Exchange Accelerating Change by Expanding Access to Data [REF: JCSC, PI, LDR] The Core Measure Solution Exchange (CMSE) is a free online tool/forum for hospitals to share information, experiences and examples on how to improve performance on core measures. Currently, the CMSE’s 73 entries contain no solutions for the psychiatric core measures, but this is expected to change soon. Mr. Scott Williams, Associate Director, Division of Healthcare Quality Evaluation indicates that at the end of this month, selected psychiatric hospitals will be invited to submit solutions. These invitations are based on criteria of significantly improving and sustaining that improvement at a level that meets or exceeds a core measure’s national target. However, it should be noted that TJC makes no guarantee (see disclaimer) about any of the solutions meeting its requirements or survey expectations. Instead, the hope is that over time, exchange participants will log rating feedback on solutions that help identify those that are most helpful. In addition to the invited solutions, there is an option for any organization to make a submission. The exchange can be accessed via a link under the ‘Quality Improvement Tools’ section of the TJC Connect extranet site website or directly at http://solutionexchange.jointcommission.org. The developing pool of solutions can be searched according to hospital type, specialty, bed size, and ownership type and one can subscribe for e-mail notification of solutions related to particular core measures (e.g., HBIPS 1-7).
Pg03 -CMS Recognizes Joint Commission Accreditation of Psychiatric Hospitals for the Special Psychiatric Conditions of Participation FYI: JCSC, LDR, GB In the past, TJC accreditation allowed psychiatric hospitals to be deemed as having met CMS conditions of participation under the State Operations Manual, Appendix A for general hospitals (or the A tags). Now that TJC has received its latest deemed status for Psychiatric Hospitals, their surveys will also meet the two special conditions for psychiatric hospitals in Appendix AA (B Tags). This means TJC hospitals will no longer require a separate survey by state of CMS contract surveyors. This latter group will be relegated to performing surveys on the 160 psychiatric hospitals that are not accredited. It will be interesting to see if this new status and recent revisions of TJC to align with those CMS requirements, will also add more of a CMS-like focus on issues like treatment plans and active treatment.
Pg03 -Accreditation Manual Updates to Mail in April FYI: JCSC The 2011 Update 1 to the following comprehensive accreditation manuals is scheduled to mail in mid-April for hospitals.
Pg08 -New Standards BoosterPak Available for Medical Staff Evaluations [REF: MDx, MD] TJC is now providing guidance on how to conduct focused professional practice evaluations (FPPEs - MS.08.01.01) and ongoing professional practice evaluations (OPPEs - MS.08.01.03) via its second BoosterPak. Its contents include the following:
? A description of both standards with implementation suggestions
? A description of what surveyors are likely to discuss and documents needed during an on-site survey credentialing and privileging session
? Key definitions and frequently asked questions related to FPPEs and OPPEs
? Definitions of key terms and supporting documentation, evidence, value, and historical information
? Links to relevant CMS Conditions of Participation and additional references
Pg01 -PPReparation Developing Effective Plans of Action FYI: JCSC, PI This article proposes tips and strategies for developing more effective Plans of Action (POA) using appropriate Measures of Success (MOS). Being specific was a particular point of emphasis. Other recommendations included:
• Use a multidisciplinary team approach to POA development, but designate one person to have overall responsibility to prevent confusion and things dropping between the cracks
• Make sure there is medical staff participation (as required by APR.03.01.01, EP# 2)
• Make sure the POA completely and thoroughly describes what your organization will do to
bring the process into compliance. Vague or generic statements about addressing the issue are not likely be accepted
• Ensure that data collected for an MOS will truly indicate whether or not a POA has been successfully implemented and obtain advanced input from those likely to be involved with the process in question, to determine if the data collection plan for that MOS is feasible and realistic
• Note, a sidebar on page10 provides a brief overview of the PPR and its different variations
Pg02 -5 Sure-Fire Methods Complying with Standard MM.03.01.03 in Ambulatory Care FYI: P&T, Phrm, RN, Although the focus is on emergency medications in a non-hospital setting, MM.03.01.03 is also relevant to psychiatric hospitals. In particular, one of the chief concerns prompting this article (and apparently underlying compliance concerns for Ambulatory Care facilities) is the frequent survey finding of expired emergency medications. This concern also challenges our facilities. The article makes 5 basic recommendations for improving compliance that largely reiterate the requirements of EPs 1-3 and 6. However, the strategy of assigning a specific person (vs. a committee) to periodically check for expired emergency medications should be noted. TJC has found better rates of compliance with this approach (evidence basis). In addition, the process of timely restocking of emergency medications should also be evaluated. Another suggestion requires staff to take broken breakaway locks to a nurse manager who must inquire about the re-stocking before providing a replacement lock.
Pg04 -Tracer Methodology 101 The Patient Flow Tracer in a Hospital [REF: JCSC, LDR, PI] First, be aware that this concept and related requirements are applicable to psychiatric hospitals. If you reframe Patient Flow Tracer as Treatment Delay Tracer (e.g., admission, testing, consultation, etc), the relevance to our hospitals may be more readily apparent. Leaders should consider what sources of data (e.g., incident reports) might help identify improvement opportunities in this area. With just a little tweaking, the scenario and sample questions can be profitably modified for our facilities to help identify or assess delays in patient care. Although this is not the first time the Patient Flow Tracer has been presented in this publication (see also Tracer Methodology 101: The Patient Flow Tracer in Source Jan '09 Vol 7 #1 Pg06), this time there is also a sample tracer worksheet that can be downloaded.
Pg02 -Joint Commission Releases Tdap Vaccination Monograph FYI: IC "Adults may not realize that some of the vaccines they received in childhood will not protect them throughout their lives or that newer vaccines have been developed since they were first immunized. In addition, some adults simply were never vaccinated". As a result, Many American adults are not getting vaccines they need. "Pertussis is the most common vaccine-preventable childhood disease and the least well controlled bacterial vaccine-preventable disease". In fact, there is an increasing number of adolescents and adults with Pertussis infections that can have a significant impact on vulnerable infants. Action needs to be taken and the evidence strongly suggests that the strategy most likely to control the spread of Pertussis is pre-exposure vaccination. To that end, TJC has participated with other leading infection control leaders (e.g., APIC, CDC) in authoring a free monograph entitled Tdap Vaccination Strategies for Adolescents and Adults, Including Health Care Personnel: Strategies from Research and Practice (142 pages). "The monograph incorporates strategies founded on evidence-based guidelines and published literature, as well as examples of vaccination initiatives that organizations have used to establish or enhance vaccination programs".
Pg09 -CDC Targets Safe Injection Practices: One Needle, One Syringe, Only One Time FYI: IC, RN, SFT In July 14 2010 issue of Joint Commission Online, TJC announced that its surveyors would be observing for safe injection practices relevant to standards IC.01.05.01, EP#1 and IC.02.01.01 EP#2. Just as in this article, they also highlighted the CDC’s ‘One & Only Campaign’ that provided information about “optimal injection practices” as outlined in their guideline entitled, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. This article expands a bit on the previous piece. It indicates that 3 of the most problematic practices are:
1. Reinserting used needles into a multiple-dose vial or solution container (such as a saline bag)
2. Using a single needle or syringe to administer intravenous medication to multiple patients
3. Preparing medications in the same workspace where used needles and syringes are dismantled
It also summarizes 8 of the guidelines recommendations that include:
• Do not administer medications from one syringe to multiple patients
• Use single-dose vials for parenteral medications whenever possible.
• Do not administer medications from single-dose vials or ampules to multiple patients.
• Do not keep multidose vials in the immediate patient treatment area.
[Index] [Blog] Environment of Care News(April Vol 15 #4)
Pg01 -When a Hospital Becomes a Crime Scene: How Johns Hopkins Hospital Responded to a Murder, an Attempted Murder, and a Suicide FYI: SFT, LDR, EM This article describes the response of Johns Hopkins Hospital (JHH) when a patient’s upset family member fatally shot a physician, barricaded his family member’s room and ultimately killed her and himself. Two key points stood out. First of all, the hospital had and properly implemented standard operating procedures (SOP) associated with its Emergency Operations Plan (EOP) and standard EM.02.01.01. JHH advises, "If you don’t have a command-and-control system and an EOP in place, you won’t do well in such an event, because you won’t know how to direct your response." Secondly, JHH benefited significantly from the fact that after the 2007 Virginia Tech shooting/suicide, they developed and added a shooter component to their EOP. They rehearsed the planned response at least once a year. A key take home here is the importance of emergency and/or disaster drills that are conducted in a serious and rigorous manner. Perhaps psychiatric hospitals should also consider adding and rehearsing a shooter scenario to their EOP.
Pg06 -Case Study Identifying Security Risks: Provena St. Joseph Uses a Structured and Proactive Approach FYI: SFT, LDR In this case study, a 480-bed tertiary care center shares how it conducted a facility-wide security risk assessment. The approach began with security interviews of all the facility departments to identify security concerns/risks. Concerns were then rated on a 4-point scale for impact (up to life threatening) and multiplied by their cost factor to yield a risk ranking score. In addition to this risk identification and ranking process, there is also a strong recommendation to involve your local police department. They can help to better understand demographics and crime statistics for your community, provide an outside review of relevant protocols and clarify the most effective ways to interface with them during an emergency. A sample Security Risk Analysis Form with brief definition of the risk and cost factors is provided on page 11.
Pg08 -Joint Commission Updates EC, EM, and LS Standards Elements of Performance Refined to Better Reflect CMS Requirements FYI: JCSC, To maintain its deeming authority, TJC’s standards must be equivalent to CMS Conditions of Participation (COP). To that end, TJC has updated the following EPs (effective 2/1/11):
• EC.02.03.01, EPs 9, 10
• EC.02.05.03, EPs 1-6
• EM.03.01.03, EP 1
• LS.02.01.30, EPs 6, 25
A good part of the additions are simply the addition of a reference to see NFPA 99, 1999 edition (Section 12-3.3) for additional guidance on the requirement. Full text of the updates is provided in the article with additions and deletions marked. See also JC Online 4/13/11 (below) for additional EC revisions.
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
Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for Psychiatric Hospitals (2/15/11) This notice announces decision to approve the Joint Commission for recognition as a national accreditation program for psychiatric hospitals seeking to participate in the Medicare or Medicaid programs. This initial 4-year approval is effective February 25, 2011, through February 25, 2015.
Revised EC requirement for fire protection systems in hospitals FYI: EOC,
TJC has also revised EC.02.03.05, (EP) 2 regarding fire protection systems to ensure that it is equivalent to CMS Conditions of Participation (CoPs). The revision changes the time frame for water-flow devices (only) in automatic sprinkler systems from every six months to quarterly. Effective 7/1/11, the revised requirement corrects the January notification that also included tamper switches in the change. Full text of the updates is provided in the article with additions and deletions marked.
Field Review: Proposed primary physical health care standard for BHC FYI: BHC
Comment is invited on a proposed new standard that would be applicable only to organizations that already provide primary physical health care to individuals served (directly or by contractual agreement). Comments will be gathered through May 4. Contact Joyce Marshall – Division of Healthcare Quality Evaluation – at (630) 792-5934 or jmarshall@jointcommission.org
New Speak Up video now available on infection control FYI: PtEd, StEd
This is the second in its series of 60-second, animated Speak Up™ videos, intended as public service announcements now airing on The Joint Commission’s YouTube channel. This one encourages others to wash their hands before preparing food, asking co-workers to stay home when they’re sick, and encouraging others to get a flu shot to prevent the spread of illness. A free downloadable copy is available. It's cute. Check it out if you have a spare 60 seconds. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
Health Affairs article written by Drs. Chassin and Loeb publishes tomorrow, focuses on high reliability and health care [ALERT: PI, LDR, GB] The concept of safety and performance improvement within TJC continues to evolve as indicated by the comments of TJC leadership in this recent article. Here the focus is on consistent performance by healthcare organizations at high levels of safety over long periods of time… or “high reliability”. The article lists the three requirements for achieving high reliability as Leadership Commitment, having a Safety Culture and utilizing Robust Process Improvement. All three have been points of emphasis by TJC in recent years. The full article, The Ongoing Quality Improvement Journey: Next Stop, High Reliability (PDF)1108 , is available for download. This is another indicator of TJC philosophical direction that LDR, GB and PI would be wise to be more aware of.
Clarification: Information put into the Targeted Solutions Tool is CONFIDENTIAL FYI:JCSC, PI, LDR
"There may be some misunderstanding about data input by health care organizations to the Targeted Solutions Tool (TST); some people may assume that information put into the Center for Transforming Healthcare’s TST is shared with The Joint Commission’s accreditation operations – this is NOT the case. Any information input by health care organizations to the Center for Transforming Healthcare’s TST is strictly confidential; health care organization specific information is contractually protected by a 'firewall' that prohibits sharing with The Joint Commission, and cannot affect an organization’s accreditation".
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