Clarifications and Expectations is a new series authored by George Mills. It will focus on compliance issues related to Life Safety and EOC. This first offering focuses on the maintenance of doors in general and the failure to latch by doors that are required to do so. TIP: Whether as a stand-alone or part of an existing safety rounding process or fire drill critique (as required by EC.02.03.03, EP 5), consider the use of a door inspection checklist. [PEARL] A sample door inspection checklist is included on page 7. Given the large number of doors in any facility, the inspection process might seem daunting. To keep it from being overwhelming, the article suggests categorizing the inventory of your doors (e.g., fire doors, smoke doors, corridor doors, etc.), then inspecting them at different rates based upon factors such as the frequency of traffic through the door or its relative importance to fire safety risk reduction.
MM.03.01.01 continues to be a top 10 problematic standard for TJC hospitals and BHC programs. Although it has not achieved top 10 ranking for SPHCC hospitals, approximately 15 -30% (general psych, forensic respectively) of our facilities still receive citations on this standard. The article describes three common reasons for citations. The first involves appropriate refrigeration of medications (to include weekends even for BHC programs) and staff knowing what to do when temperatures fall out of range. A second concern is keeping medications (especially controlled substances) properly secured. A third, less well known issue, is the need to withdraw access to automatic dispensing units when staff leave employment or for other reasons, they no longer need that access. As with all articles in this series, five compliance strategies are also suggested. The first of these should probably be to review the MM.3.01.01 BoosterPak if you have not previously done so. TIP: In addition, make sure there is written policy to specify who can have access to medications/medication storage rooms and a clear description of the process for monitoring and ensuring (i.e., responding to temperatures out of range) temperatures of refrigerated meds. Finally, do not forget to consider your floor stock and the proper handling of expired medications.
TJC has provided a 1-page flow chart illustrating requirements of the medication reconciliation process as per NPSG.03.06.01, EP 1-5 and other related standards. It is a useful summary.
Awareness of and sensitivity to EOC safety issues may be higher in hospitals, but BHC organizations also need to attend to such matters. Failure to do so is reflected in the fact that during 2011 TJC surveyors found 12% of BHC organizations non-compliant on EC.02.06.01. The article emphasizes the need to perform risk assessment of indoor AND outdoor space that might be utilized by patients. The use of a checklist is specifically recommended to help ensure completeness. EPs 24 and 26 remind us to make sure that the furniture within those spaces is "safe, clean and free of hazards". TIP: Consider incorporating the use of a safety checklist of your spaces (indoor and outdoor) and furniture into the environmental touring process required by EC.01.01.01.
[Index] [Blog] Perspectives [PR] - May, Vol 32, # 5
Pg04 -The Joint Commission Continues to Study Overuse Issues FYI: JCSC,Since late 2011, TJC has conducted a field review on a proposed NPSG for Overuse (of treatments, procedures and tests) and conducted two subsequent focus groups. While there seems to be agreement that overuse is an important issue, there remains a number of questions and obstacles to developing this issue into a formal requirement. Consequently, TJC is now planning a national summit to resolve those issues. Bottom line: "no accreditation requirement related to overuse in 2012".
Pg05 -Sentinel Events Statistics for 2011 FYI: EOC, LDR, MDx, P&T, RNx, SFTIn this article reporting updated sentinel event statistics, TJC has identified the top 10 most frequently reported SE and the top 10 most frequently identified root causes related to those events. Medical equipment, medication error, criminal events, falls and suicides are in that top 10. The list of root causes is presented in broad categories but include medication use, care planning, information management, assessment, communication and leadership.
Pg11 -Perspectives on Patient Safety™ CDC: C diff Infections Also a Risk in Long Term Care and Ambulatory Care FYI: JCSCNPSG.07.03.01 requires organizations to utilize evidenced-based practices to prevent HAIs including those caused by multidrug-resistant organisms (MDRO) like Clostridium difficult (C diff). This includes conducting periodic risk assessments, educating staff (and LIP) and patients along with implementing reduction strategies. Although the focus of this article is on long- term care facilities, many of our psychiatric hospitals provide care for patients who are 65 years or older. That age group experiences over 90% of the deaths caused by C diff. IC should review the CDC Vital Signs Report Preventing Clostridium difficile Infections. BHC programs should be aware that in 2010, most C diff infections were identified as being associated with receiving health care, but 75% were thought to have their onset in persons not currently hospitalized including discharged and outpatients.
Pg14 -From Science Fiction to Medical Fact: mHealth Brings Patient Care into the Future FYI: GB, IT, LDR, MDX, RNx Mobile health (mHealth) refers to the use of mobile devices such as smartphones, tablets, personal digital assistants, and their vast array of applications (apps) being used by health care personnel (HCP) to assist with and improve patient care. Some surveys report over 80% of physicians using smartphones for professional purposes and more than half of nurses having downloaded a nursing or medical app to their smartphone or tablet. The uses are ever expanding and include communicating (e.r., reminders) with patients, diagnosis (e.g., EKG apps), collecting data, integrating with electronic health records and remote patient monitoring. Over the next four years, mHealth app downloads are expected to increase from 22 million to 142 million. LD and IT should review this article just for the heads-up it provides on a not too distant (post-recession to be sure) future.
[Index] [Blog] Environment of Care News[EC](May Vol 15 #5)
Pg01 -What If the Environment of Care Is the Community? Behavioral health care workers need to stress safety, security in external environments FYI: BHC, LDR, SW Mental health workers provide direct patient care services in a number of settings outside of offices and other controlled environments. This may include client's homes, neighborhoods or other community locations, other agencies and even vehicles (e.g., during transportation). In such situations, BHC staff need to be alert to and prepared for safety risks. The organization needs to ensure that these staff have appropriate training (e.g., aggression management/de-escalation) and equipment (e.g., mobile phone, safe and reliable vehicles). The worker needs to know how to set appropriate limits/boundaries with patients seen outside of the office. They should also pay careful attention to their new surroundings to include identifying potential escape routes.
CMS-1346-F and CMS-1346-CN (Published: May 6, 2011) - Inpatient Psychiatric Facilities Prospective Payment System - Update for Rate Year Beginning July 1, 2011 (RY 2012) FYI: F&B
CMS-S&C-12-18: Hospital Patient Privacy and Medical Record Confidentiality (3/22/12) FYI: IM, PtAd
Update on TJC's "Integrated Survey Process" for Psychiatric Hospitals. FYI: JCSC, MDx, RNx Now that TJC has deemed status for the two special conditions of participation for psychiatric hospitals, it's survey process is changing. Surveys are reportedly a day or two longer. As you might expect, the survey forms previously required by CMS will now be required by the TJC survey process if you are using it for deemed status. TIP: A number of those forms can be completed in advance (e.g., Form 724 - Hospital Survey Data, Form 727 - Nursing Complement Data and Form 729 - Medical Staff Coverage) and only require minor changes at the time of survey. Surveyors will be impressed with your timely response. Be prepared also for a closed record review of 5-10 charts focusing on discharge planning.
Behavioral Health Organizations/Programs: Does your Health Screening Process Meet the New 2012 Requirements? FYI: BHC, JCSC, MDx, RNxCTS.02.01.05 applies to non-24 hour programs surveyed under BHC standards and it now has some new requirements for 2012 in EP #3. Unless your organization routinely provides physical exams on all patients, you will now need to screen all patients for the need of a physical exam. If the most recent one exceeds one year a new H&P is required. Make sure your policies, procedures and practices have been updated to comply.
