Pg01 -Joint Commission Top Standards Compliance Issues for 2010: Challenging Requirements Identified[REF: JCSC] The most frequently cited standards are reported by program. Although there has been some small change in the percentages, the top ten issues and their relative rankings are the same as previously reported for Jan-June 2010. The one exception is that RC.02.03.07 moved up one ranking to #7 replacing PC.01.02.03 which moved down to #8. See also Most challenging requirements for 2010 in JCO 4/27/11 below for a listing of the Top Five.
Pg03 -The Joint Commission Urges Health Care Organizations to Focus on Achieving High Reliability FYI: JCSC, LDRC, The urging is done in an article by Drs Chassin and Loeb, entitled, The Ongoing Quality Improvement Journey: Next Stop, High Reliability (PDF)1108. The authors call for something they admit has never been achieved; consistent performance by healthcare organizations at high levels of safety over long periods of time or "high reliability". The key to achieving this ambitious goal is in leadership making high reliability a priority; creating a culture of safety and utilizing proven quality improvement methods such as Lean Six Sigma and change management (aka Robust Process Improvement). The authors also urge TJC hospitals to self assess these areas. As we indicated last month in our first review of this article, we believe this is an important evolving concept and direction for TJC. See also: Drs. Chassin/Loeb article focuses on high reliability and health care (JC Online 4/6/11)
Pg05 -Tracer Methodology Evolves to Include Detailed Exploration of Several High-Risk Areas: Second Generation Tracers Now in Use for Some Hospital, Critical Access Hospital On-site Surveys[REF: JCSC] Second Generation Tracers (SGT) are deeper and broader systems explorations (drilling down) that are triggered when concerns are raised about what TJC calls high-risk issues (HRI). These are defined as including “processes or procedures that, if not planned or implemented correctly, have significant potential for affecting/impacting patient safety." This article identifies the first 5 such issues as: 1) Cleaning, disinfection, and sterilization (CDS), 2) Patient flow across the care continuum, 3) Contracted services, 4) Diagnostic imaging, 5) OPPE and FPPE. HRIs 1, 2 and 4 may seem to have limited significance for psychiatric hospitals. While the CDS issue was generated largely in response to concerns about steam sterilization, its relevance to us includes the cleaning of small equipment and surfaces. Patient flow is relevant because of its applicability to any delay or lack of timeliness in patient services. Diagnostic imaging may affect few of our facilities. However, contracted services and OPPE/FPPE should be considered key HRI to pay attention to. The article also provides examples of possible triggers for SGT in Credentialing & Privileging session (OPPE/FPPE) and Cleaning, disinfection, and sterilization. It should be noted that once an SGT is triggered, a specific patient may or may not be involved. See also: TJC-LPL: FPPE OPPE Policy Contributed by Teche Regional Medical Center Morgan City, LA (5/17/11)
Pg08 -CLARIFICATION: Assessing Baseline Coagulation Status Under NPSG.03.05.01(PDF) FYI: JP&T, Phrm, A clarifying note has been added to NPSG.03.05.01, (EP) 3. Effective 5/1/11, the requirement to establish baseline coagulation status can be satisfied in “a number of ways’ that now includes identifying risk factors such (e.g., age, weight, bleeding tendency) and/or genetic factors.
Pg01 -In Focus: A Closer Look at Joint Commission Second Generation Tracers [REF: JCSC] Second Generation Tracers (SGT) were introduced in this month’s Perspectives (see above) as a significant evolutionary development in tracer methodology. As suggested in its title, this article provides more insight into SGTs. In particular it sheds more light on the triggers likely to invoke an SGT for one of the 5 high-risk issues (HRI). They include:
• Inconsistent practices (i.e., lack of standardization) especially in decentralized processes
• Lack of leadership/supervisory oversight and/or quality checks
• Involvement of large numbers of contracted staff in related processes
• Inconsistent staff orientation and training regarding the HRI
• HRI-related procedures that are not based on nationally recognized guidelines
An SGT may or may not occur during your next survey and there is no need to focus specifically on preparing for one. Still, it would be wise to examine HRI in your organization and include mock SGT as part of that process. Identifying HRI-related sentinel events or survey citations experienced by other hospitals in your system or SPHCC (go to the Survey Feedback Database) can also help you prioritize particular HRI to evaluate. Also consider using peers from sister hospitals to conduct an SGT for you.
Pg02 -5 Sure-Fire Methods: Complying with MS.08.01.03[REF: MDx, MD] Accredited hospitals continue to have difficulty with OPPE and FPPE. Frequent citations include:
• Failure to define the data to be collected
• Failure to clearly define the OPPE process
• Failure to use collected data in privileging decisions
This article provides the following five Strategy steps to improve compliance:
1 – First identify data already being collected by your organization that could be used to address OPPE/FPPE.
2 – Determine the type of data to be collected for psychiatrists vs. non-psychiatrists
3 – Make sure your OPPE process is clearly defined
4 – Make sure there is a mechanism established to ensure the use of collected OPPE data in your FPPE and other privilege-related decisions
5 – Determine how OPPE/FPPE data will be incorporated into credentialing files. It need not be stored there permanently, but must be easily accessible for reviews.
MDX and JCSC should also review the recently developed FPPE/OPPE BoosterPak for more detailed implementation suggestions and tips. See also TJC-LPL resources to include: : FPPE OPPE Policy, Physician Performance Toolkit ,
Pg06 -Tracer Methodology 101: Second Generation Tracer for Cleaning, Disinfection, and Sterilization of Equipment[REF: JCSC, IC, RNx, RN This is the second article in this publication and the third this month on the topic of Second Generation Tracers (SGT). Here you are provided more specific assistance for conducting a mock SGI related to cleaning, disinfection and sterilization (CDS) of equipment. As part of that assistance, a table (pg7) lists five standards (IC.02.02.01, HR.01.02.01, HR.01.04.01, HR.01.05.03 and LD.04.01.07) that are likely to be the focus of an SGT on CDS. As is typical for this series, there is also a sample scenario with sample questions for staff. It is significant to note that in this instance, there is a separate set of such questions for contracted staff. There is also a table (pg 8) that identifies key risk points in the CDS process where surveyors are likely to drill down. Tip: As part of your mock SGT, consider tracing a particular piece of equipment through its process of being scheduled for and ultimately cleaned.
Pg10 -Required Staff Education and Training FYI: StEd, HR This is a straightforward, but useful, listing of the 27 standards requiring staff education and training.
Pg09 -“RED” Hot Solutions Improve Posthospitalization Success FYI: SW, LDR. According to a JCR overview, 19% of 39.5 million discharged hospital patients have a post-discharge adverse event and 20% of Medicare patients are readmitted within 30 days. For this reason, the Agency for Healthcare Research and Quality (AHRQ) has funded development of the Project RED (Re-Engineered Discharge) intervention, a patient-centered, standardized approach to discharge planning and discharge education, designed to improve a patient's preparedness for self care and reduce the likelihood of readmission. The project is guided by 10 principles (Table 1, pg 9) that should be familiar to psychiatric hospitals. The approach also includes a discharge advocate that sounds like a case manager or social worker, but with more specific responsibility and authority for managing and ensuring completion of all the check-listed activities for discharge. Although the original design is for med-surg hospital patients, the idea of a standardized discharge process supported by a checklist and discharge advocate is well worth considering by any facility interested in improving the quality and reliability of their discharge process. AHRQ has now funded JCR to help hospitals implement the Project RED intervention. For additional information on Project RED, contact Deborah Nadzam at DNadzam@jcrinc.com and/or take advantage of the following links: Informational Webinar, Project RED Invitation, Project RED application,
[Index] [Blog] Environment of Care News(May Vol 15 #5)
Pg01 -Preventing Suicide in Non-Behavioral Health Care Units: Strategies for the Emergency Department and Medical/Surgical Units[REF: EOC, SFT] This article is related to SEA 46 (A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department) should be read for increasing awareness of the environmental factors that contribute to suicide in any room. The author reminds us that “patients have been known to “hang” themselves from objects as close to the floor as 18 inches, and one study found that 50% of hangings were from heights below the waist of the victim.” We did not find that statement in the referenced study, (Gunnell D., et al.: The epidemiology and prevention of suicide: A systematic review. Int J Epidemiol 34:433–442, 2005) but it did confirm that “Ligature points used by those in prisons and hospitals are often below head height”. [PEARL] On page 10, there is a useful Checklist for Assessing Environmental Risks for Suicide. It is also recommended that hospitals have a policy that addresses room searches for contraband, that specifies the scope of a reasonable search, when it should occur and who should perform it.
Pg04 -Security Sensitivity: Preventing Drug Diversion: OhioHealth's Auditing Process Increases Patient Safety, Security FYI: P&T, Phrm, PI. The OhioHealth hospital group has developed a rigorous approach to the prevention of drug diversion. The key to their approach is dedicating time and effort to identify and investigate unusual usage patterns (e.g., especially high by a particular caregiver or on a particular unit), and missing drugs. It also helps to be aware that diversion can occur in different forms to include: simple theft, theft by substitution, theft by documentation (e.g., manipulating charts, logs) and under medicating patients. Including sections on drug diversion in new staff orientation, and all-staff annual training programs further enhances prevention.
Pg06 -Construction Quality: Designing Facility Security: Proactively Addressing Risks Associated with New Spaces FYI: SFT, E&M, The primary purpose of this piece is to encourage readers to include security as part of the front end planning and designing of new facilities and construction. In support of this, The International Association for Healthcare Security and Safety (IAHSS) and the International Healthcare Security and Safety Foundation (IHSSF) have jointly formed a task force of experts who are to establish the first draft of a set of health care security design guidelines by this fall.
Pg08 -Pesticides as a Last Resort: Least-Toxic Pest Management Protects Most-Vulnerable Patients FYI: JCSC, Some pesticides still contain toxic chemicals that could be harmful to staff and patient. If your vendor uses such chemicals you are encouraged to consider changing to an integrated pest management (IPM) approach. In this evolving strategy, non-chemical approaches are to be exhausted before utilizing pesticides that are to be considered last resorts. This involves more emphasis on prevention, exclusion techniques (e.g., sealing cracks), mechanical techniques (e.g., traps) and sanitation techniques (e.g., washing bins, trash cans carts, etc). To get started, consider using the Model IPM Policy, Model IPM Plan, Model Landscape Policy, Sample IPM Contract, created by The Integrated Pest Management in Health Care Facilities Project (coordinated by Maryland Pesticide Network and Beyond Pesticides).
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
Memo 11-26-AO: Approval of Deeming Authority of the Joint Commission for Psychiatric (5/6/2011) FYI: JCSC, LDR SUMMARY: The Centers for Medicare & Medicaid Services has approved the Joint Commission as a national accreditation program for psychiatric hospitals seeking to participate in the Medicare or Medicaid programs. This approval provides psychiatric hospitals with an accreditation option that previously did not exist.
CMS-3227-F: Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital Conditions of Participation: Telemedicine Credentialing and Privileging (5/5/11) FYI: MDx, MEC SUMMARY: This final rule will revise the conditions of participation (CoPs) for both hospitals and critical access hospitals (CAHs). The final rule will implement a new credentialing and privileging process for physicians and practitioners providing telemedicine services.
Currently, a hospital or CAH receiving telemedicine services must go through a burdensome credentialing and privileging process for each physician and practitioner who will be providing telemedicine services to its patients. This final rule will remove this undue hardship and
financial burden. Effective Date: July 5, 2011.
New video: Dr. Chassin speaks about high reliability at Health Affairs briefing FYI: PI, LDR To view the 8-minute video of TJC President Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., speaking about high reliability at a Health Affairs briefing on April 7, 2011, click here and then scroll down to Overview: Where We Are On the Quality Journey.
New Speak Up video now available on taking medication safely FYI: PtEd
Today, The Joint Commission released the third in its series of 60-second animated Speak Up videos; this one on taking medication safely. Free, downloadable copies are available.
Invitation to participate in the 2011 ISMP Medication Safety Self-Assessment for hospitals FYI: Phrm, PI, JCSC
The Institute for Safe Medication Practices (ISMP) invites Joint Commission accredited hospitals to participate in its 2011 ISMP Medication Safety Self-Assessment, which assesses U.S. hospitals regarding their medication safety practices. This is ISMP’s third self-assessment and it is available on the ISMP website. Hospitals can participate anonymously via a secure, password protected website, and will have unlimited opportunity to view and download their scores during the data collection period. (Contact: selfassess@ismp.org or call (215) 947-7797)
Most challenging requirements for 2010
This issue provides a table of the top five TJC standards found not compliant for 2010. For hospitals they are as follows:
65% RC.01.01.01 The hospital maintains complete and accurate medical records for each individual patient.
51% LS.02.01.20 The hospital maintains the integrity of the means of egress.
49% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
42% EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.
40% LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
See also Perspectives above for the full Top Ten.
New Speak Up video now available on infection control
The Joint Commission has released the second in its series of 60-second animated Speak Up videos, this one on infection control. Free, downloadable copies are available.
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!
