RT0701Jan
8 Jan 2007
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ALL: Everybody, CHP: Chaplain, C&P: Credentialing & Privileging, E&M: Engineering & Maint, EOC: Environment of Care, FB: Finance/Business, FdDt: Food services/Dietary, GB: Gov Body, HR: Human Resources/Personnel, HST: Human Service Tech/Aid, IC: Infection Control, IM: Info Mgt/Med Records, IT: Info Technology, JCSC: Jt Com Survey Coordinator, LDR: Leadership/Mgt, MEC: Med Exec Committee, MD: Medical Staff, ofco: Officer and/or Committee, PI: Performance/Quality Improvement com/dept, PPR: PPR team mbrs/ldrs, P&T: Phrm & Therapeutics Com, Phrm: Pharmacy, PSY: Psychology, PtAd: Patient Advocate, PtEd: Patient Education, RHB: Rehab/Activity Therapy, RN: Nursing, SFT: Safety, StEd: staff ed & training dept, SW: Social Work, TxTm: Treatment Team, x: Exec, Dir or Chief (e.g., MDx = Medical Director)
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THE JOINT COMMISSION (TJC and JCR)
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Goto SHCC Alerts
Publications
Joint Commission this Month - January 2007
• Fixed RUS Performance Areas: The Joint has prioritized these areas for random unannounced surveys that help it keep tabs on the quality of its survey process. If you expect a survey this year maybe you should give them a little extra attention too. For 2007, they are Patient Safety, Medication Management, Assessment and Care/Services, and National Patient Safety Goals
• Free JC Audio Conference: Date is Thursday, 1/11/07. Topic is credentialing and privileging standards; should be worth a listen if you have an hour (begin at 11 a.m. PT, noon MT, 1 p.m. CT, 2 p.m. ET).
• 2008 NPSG: If you are curious or want some input, check out the proposed goals. They are available for comment until Thursday, 1/26/07. See full text of goals.
• 2008 Core Measure Sets: It's a little early for this too, but JC has a nice summary of its expectations for hospital core measure sets in 2008. Four (4) is the new magic number (depending on applicability) with a cap of 9 through 2009.
• Name Change: Just in case you had not heard: JCAHO will shorten its name to "The Joint Commission" and update its logo accordingly in early January 2007. Rumors abound, but JC says it's about strengthening their brand. See also hcPRO.com.
Perspectives
• Interim Action for Standard MM.4.10, Element of Performance 1, for Critical Access Hospitals; Modifications for the Emergency Department and Radiology Practitioners - Although the article focuses on emergency departments and radiology services, it provides a hard to find clarification of Standard MM. 4.10, EP 2 that in order for an LIP to be controlling ordering, preparation, and administration of a medication, he/she is required to remain with the patient during administration of the medication. [Jan 07, v27#1: pg 9, col B, para 2]
• REVISION: Standard NR.1.10, Element of Performance 6, for Critical Access Hospitals and Hospitals - The language of NR1.10 was revised and reported in the November 2006 issue of Joint Commission Perspectives (pgs 10-11). Apparently this confused some folks about the role of nursing leadership at the executive level. This issue of Perspectives re-clarifies by revising the language again to more specifically indicate that the the nurse executive does not just have a role in executive level decision making but is to " actively participate with" those who make such decisions (e.g., governing body, medical staff, management, etc.) . [Jan 07, v27#1: pg 11] [Abstract]
The Source
• Accreditation Essentials: How Does Your Organization Respond to Adverse Drug Events? Re: IM.6.20 - Some useful strategies for managing and evaluating ADE. Recommended reading for Med Staff in general and the P&T committee in particular. [Jan 07, v5#1: pg 3-4]
Patient Safety
• Top 5 In the News: Screening All Patients for HIV - This section references the recent (Sept 06) CDC revised guidelines calling for HIV screening of all pts age 13 - 64 in a health care setting regardless of risk. You can see the CDC report at (http://www.cdc.gov/hiv/topics/testing/resources/slidesets/pdf/testing_healthcare.pdf). [Jan 07, v7 #1: pg 2]
• FOCUS ON FIVE: Medication Sample Disbursal Needs Oversight, Procedures - If your hospital uses samples you will find a brief but useful discussion of disbursal and oversight strategies. [Jan 07, v7 #1: pg 11]
Environment of Care News
General
07 NPSG are now in full effect. Beyond the 2 new goals, there are some subtle but significant changes in the 06 goals that you should know about. See - "What's Really New" below
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- Seclusion & Restraint: the finalized Pts’ Rights CoP becomes effective 1/8/07. There are revisions to the standards for S&R that update key definitions, give more flexibility for the face-to-face within 1 hour. Two new standards specify requirements for training and reporting of S&A-related deaths. - See - CMS-3018-F below
- Verbal Orders: final rule revises and updates CoP requirements in a number of areas, but pay particular attention to those for verbal orders. Unless you state, "indicates otherwise", there is now a 48 hour limit for countersignature and authentication by another practitioner responsible for the care of the patient. This is a temporary permission that will expire in 5 years. See - CMS-3122-F below
Quarterly Provider Updates
October 2006
- CMS-3018-F, entitled "Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients' Rights," was released 12/8/06. Summary of CMS-3018-F Final Provisions. This ruling "revised the standards regarding restraint and seclusion and set forth standards regarding staff training and death reporting."
- CMS-3122-F, entitled "Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Orders; Securing Medications; and Postanesthesia Evaluations," was released 11/27/06. Summary/Synopsis of Changes (rf).
- CMS-4105-F, entitled "Notification of Hospital Discharge Appeal Rights," was released 11/27/06. This ruling specifies "how hospitals must notify Medicare beneficiaries who are hospital inpatients about their hospital discharge rights."
.NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD).
SURVEYS
Recent Hospital Surveys
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