In the Nov 11, 2011 issue of Joint Commission Online, TJC announced a 4-month pilot of the new Intracycle Monitoring Process (IMP) that we encouraged psychiatric hospitals to sign up for. The pilot will begin as scheduled next month. Once it is fully implemented in January 2013, IMP will include ‘Touch Points’ at 12 and 24 months (post survey) and a Focused Standards Assessment (FSA) tool, which will replace the Periodic Performance Review (PPR) tool. During Touch Points, TJC may also engage organizations in more focused reviews of previously cited RFIs, program-specific risks, measurement data, and selected documents along with a discussion of TJC compliance tools that might be useful for your particular organization. See also TJC Intracycle Monitoring (IM) Process Pilot. TIP: 2013 is closer than you think, so keep an eye on this issue through our related review compilation, [RC(ap)_IntracycleMonitoring] that will also be posted on our first Topical Blog: Intracycle Monitoring.
The TJC Board has accepted final CMS revisions that uphold TJC’s position on the privileging of telemedicine practitioners (Transmittal # R78SOMA). The option (i.e., “may choose”) for an originating site to use a distant site’s credentialing and privileging information as the basis for making its privileging decision has been upheld as long as certain conditions are met. For example, the distant-site practitioner should already be privileged for the services to be provided at the originating site and MS.13.01.01, EP 1 now requires that such practitioners have a license recognized by the state in which the patient is receiving telemedicine services. Those using TJC for deemed status must also ensure compliance with CMS 42 CFR 482.12(a)(1) through (a)(9) and 482.22(a)(1) through (a)(4). Full text of the revisions is provided in the article. See also: CMS-3227-P (Telemedicine Credentialing and Privileging). TIP: Update medical staff bylaws if you plan to use the now confirmed option after reviewing the [PEARL] checklist and draft C&P agreement for telemedicine entities created by the Center for Telehealth and E-Health Law.
The primary focus of the IPCS tracer (and your facility’s infection control risk assessment and plan) should be on the issue of reducing the risk of infection in a manner appropriate to your setting and patient populations. This article gives particular emphasis to hand hygiene. As you might expect, it encourages the use of TJC’s Targeted Solutions Tool for Hand Hygiene. It also provides a brief scenario, 11 sample tracer questions and a [PEARL] downloadable Mock Tracer Tracking Worksheet. Tip: Make sure nursing staff are aware of the top10 barriers to effective hand hygiene as an easy way to further improve effectiveness. However, If hand hygiene concerns appear significant, consider utilizing the 6-step Hand Hygiene TST to improve. Please click here if you have ever used/attempted to use the TST?
While there is some inconsistency in the language of agency standards about the need to have a utilization review committee (URC), both LD.04.01.01 (TJC) and 42 CFR 482.30 (CMS) require hospitals to have a utilization review plan. Although there is considerable flexibility available for the approach, this article’s compliance strategies include:
Clearly define the goals and/or purpose of the URC
Determine an appropriate URC meeting frequency
Define roles (e.g., chair, recorder) and responsibilities of URC members
Define the types of records/minutes to be kept and where to distribute them
Specify the data to be included in routine reports and their distribution
Tip: Although LD.04.01.01 does not specify the need for a URC (as is the case in CMS's §482.30(b) Standard: Composition of Utilization Review Committee), we have confirmed with TJC that If you are CMS certified there must be a committee,…but, it does not have to be an internal committee as long as you follow the CoP requirements of §482.30(b).
Clinical Practice Guidelines (CPG) help to move care in the direction of evidence-based practice and greater quality. Although LD.04.04.07 only requires hospitals to ‘consider’ CPGs when designing or improving processes, a number of the resources and suggestions in this article may improve the quality of that consideration. One of the most useful resources may be the recent work of the Institute of Medicine (IOM) entitled, Clinical Practice Guidelines We Can Trust (March 2011). This work includes descriptions of the following 6 critical characteristics for trustworthy guidelines:
Be based on a systematic review of the existing evidence;
Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups;
Consider important patient subgroups and patient preferences, as appropriate;
Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest;
Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of recommendations; and
Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.
They have also developed 8 standards for guideline developers that can help end-users make their selection. These and other recommendations are provided in a 290- page report available for free download (after you register) from their website. However, there is also a 39-page summary (relax, 23 pgs are references) and 4-page brief (the basis for this article). See book display at end of this newsletter. Tip: Those exploring CPG should review the 39-page summary and take advantage of the more than 400 (out of 2,414) guidelines related to Psychiatry/Psychology in the National Guidelines Clearinghouse (NGC). The NGC provides for browsing of guideline summaries by topic and has the ability to perform side-by-side comparisons of multiple guideline summaries. [PEARL] Definition from the IOM report : Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.
Standard PI.02.01.03 was implemented on January 1, 2012. It requires hospitals to attain a minimum 85% composite rate of performance on ORYX accountability measures. Defining Accountability Measures
Accountability measures are measures that produce the greatest positive impact on patient outcomes of care when hospitals demonstrate improvement and are defined in accordance with the following four criteria: Research, Proximity, Accuracy and Adverse Effects. Based upon evaluations using these criteria begun in 2010, most TJC core measures (22 of 28) and many of its process measures are now part of the current group of 44 accountability measures. This includes 6 Hospital Inpatient Psychiatric Services (HBIPS – 2a, 3a, 4, 5, 6, 7), although they do not appear to be slated for use in 2012 rate calculation according to the TJC Table of Accountability Measures linked to this article. We are looking into this. Accountability Measures and Accreditation
The article briefly describes how the composite rate is calculated and where it can be found (first page of their ORYX Performance Measure Report). Although the rate is automatically generated each quarter, it is only assessed during on-site surveys. Surveyors will check the rate on the first and last day of survey to ensure they have the most current figures. The last day result is the one that will determine compliance or the need for an RFI (if less than 85%). Evaluating Accountability Measures
While hospitals are required to transmit data on a minimum of four applicable core measure sets, they can add or change the measure sets they select, which can affect the number of accountability measures they report and consequently, the basis for their composite rate. Tip: Consider carefully the minimum set of measures you want to submit, but track data internally and calculate your composite rate for all applicable measures. It may help you decide if and/or when to change your selection. Tip: For more background and a more detailed explanation of composite rate calculation see: RCpi: Accountability Measures
This article describes itself as the first in a series designed to provide ‘at-a-glance’ (i.e., NOT in-depth) reviews and tips of key compliance issues for the most challenging standards in EC, EM and LS. Thirteen issues are addressed in this month’s installment including the following: LS.02.01.10 Fire Protection (TJC Hospital non-compliance = 57%/SPHCC non-compliance = 40%)
Re: Automatic Sprinklers – Use LSC Table 19.1.6.2 to determine your need, but in general building plans dated after March 2003 require them
Re: Building Separations (Walls) – Must protect for 2 hrs, be solid, extend from floor to floor/roof slab and outside edge to outside edge with no unprotected holes and any doors fire rated for 90 minutes.
Re: Fire-stop Material – material should be fire rated by a testing agency (e.g., UL). Be ware of polyurethane expanding foams which often are not acceptable fire stop material
Re: Doors in egress path – must open in the direction of egress (few exceptions)
Re: Corridor – Installed items should be no more than 36” wide and project no more than 6” into a hallway that is at least 6 feet wide. Only three types of carts and 'in use' equipment (i.e., used at least q30 minutes) are allowed in egress corridors.
Re: Automatic Sprinklers – Ensure piping is securely attached with nothing hanging on it.
Re: Extinguishers – no more than 75 feet from any location
LS.02.01.35 Fire and Smoke (TJC Hospital non-compliance = 47%/SPHCC non-compliance = 30%)
Re: Vertical Openings/Shafts – enclosed with 1-2 hour fire-rated walls.
Re: Corridor Doors – Can positive latch with bottom undercut less than 1 inch, contain no ventilation grills/louvers except for bathrooms, toilets and sink closets.
Tip: Use the brief points and reminders in this article as basis for pop quiz testing of staff to assess knowledge needs and keep them on their toes.
Pg03 -Update: Implementation of Patient-Centered Communication Standards FYI: JCSC, MDx, RNx, HR, PtAd,The phased Implementation plan for Patient-Centered Communication Standards that began in January of last year comes to completion on 7/1/12 when findings related to HR.01.02.01, EP 1; PC.02.01.21, (EPs 1 and 2); and RC.02.01.01, EP 28 are no longer excluded from affecting accreditation decisions. Additional guidance for effectively communicating and serving the Lesbian, Gay, Bisexual and Transgender (LGBT) community is also now available (see page 11 article review below).
Pg08 -Revisions to 2012 Decision Rules for Contingent Accreditation [Ftxt] FYI: JCSC, A finding of possible fraud and/or abuse will now result in Contingent Accreditation under the new Contingent Accreditation decision rule CONT03 that replaces Accreditation with Follow-up Survey (AFS) decision rule , AFS02. Two more new rules call for Contingent Accreditation for organization undergoing first time survey if they receive and RFI related to a condition level finding (CONT04) or demonstrates systemic patterns or trends of noncompliance with TJC standards. (CONT05).
NPSG – A new goal related to overuse (i.e., patients receiving “medication, tests, surgeries, or other treatments that are not medically necessary”. ) is being considered for 2013.
Pt-Centered Communication (PCC)– Full implementation (and survey impact) of the PCC-related standards in HR, PC, RC and RI goes into effect on 7/1/12.
Pt Fall Reduction – TJC’s Center for Transforming Healthcare is applying Robust Process Improvement™ (a data-driven problem-solving methodology that incorporates tools and methods from Lean, Six Sigma, and Change Management) as part of a new project to develop targeted solutions for preventing patient falls by the end of this year.
Second Generation Tracers (2GT) – Additional 2GT focus issues (e.g., handoff communication, record documentation) are being considered for this year.
Pg08 -OSHA & Worker Safety: OSHA Issues Directive on Workplace Violence: Health Care Organizations May Be Inspected After Incidents or Complaints Occur FYI: JCSC, Although it seems rare for state psychiatric facilities to be directly involved with OSHA, this article provided two resources that could be useful to any facility experiencing a significant rate of violent Pt:Staff incidents. The first is OSHA’s Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. (BHC) This document provides suggestions for an overall violence prevention plan to include a workplace analysis. It also provides useful (although somewhat dated, in the mid-late 90s) references. The second resource is OSHA’s Hospital eTool. The 'eTool' focuses on some of the hazards and controls found in the hospital setting, and describes standard requirements as well as recommended safe work practices for employee safety and health. Each eTool is a 'stand-alone', interactive, Web-based training tool on occupational safety and health topics. They are highly illustrated and utilize graphical menus as well as expert system modules. These modules enable the user to answer questions, and receive reliable advice on how OSHA regulations apply to their work site. That advice can be used apart from OSHA as general ideas for improvement. There are specific sets of tools for • Administration • Central Supply • Dietary • Engineering • Housekeeping • Laundry • Pharmacy.
Transmittal # R78SOMA: (PDF): Revised Appendix A, Interpretive Guidelines for Hospitals, and Revised Appendix W, Interpretive Guidelines for Critical Access Hospitals (CAHs). New guidance is provided to reflect regulatory changes concerning the provision of telemedicine services in Hospitals and CAHs. Issue date 12/22/2011
