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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Publications:
Refs - Program Specific Tracers,
Joint Commission this Month (Feb 2007)
Standards Changes:
• Standard NR.1.10, EP 6 - Apparently, this announcement is important enough to repeat. The revision of this standard about the role of executive nursing leadership was reported in the January Perspectives (REVISION: Standard NR.1.10, Element of Performance 6, for Critical Access Hospitals and Hospitals - [Jan 07, v27#1: pg 11] ) and summarized on our January Reading Tips Page.
In The News
• Study indicates that patients’ broad definition of medical errors, can undermine satisfaction with care - Patients in this study also considered falls, communication problems as well as clinical mistakes to be medical errors. The implication for your 'Speak Up' campaigns is to ensure clear definitions. You can see the full news release and a link to the actual study at: http://www.jointcommission.org/NewsRoom/NewsReleases/nr_jcr_121806.htm
Upcoming:
• Free audio conferences: Relevant topics and dates follow below and are on the SHCC Calendar: ** February 28 Medication Reconciliation ** March 23 Annual Report: Performance Data and National Patient Safety Goals ** April 25 Credentialing and Privileging ** May 17 Standards Improvement Initiative (Hospitals) **
• SHA Forum
The 16th Annual State Hospital Association Forum is scheduled for Friday, June 8, at the Joint Commission’s Central Office in Oakbrook Terrace, Illinois.
Perspectives (Feb, Vol 27 #2)
• Pg 4 Top Standards Compliance Issues for 2006: NPSG's (i.e., #2, #3, and #8) are now being included as compliance issues. The rest of the Top 10 [MM.2.20 (40%) EC.5.20 (28%) MM.3.20 (26%) PC.8.10 (19%) EC.1.10 (18%) IM.6.10 (17%) PC.13.20 (15%)] are standards that were also on last year's list. Given their high likelihood of being found non-compliant these should receive special attention during the PPR.
Pg 6 Frequently Asked Questions on the Electronic Statement of Conditions: The eSOC is required and currently in effect. The 7/1/07 cut-off date regarding completion of old PFI's is important. This should be reviewed by the person in your organization who is responsible for the SOC.
Pg 8 Process for Missing CLIA Certificates for Waived Testing: Last year several of our hospitals were surprised during survey to find their CLIA certificate did not cover everything the surveyors thought it should (PC16.10). JC has decided that coming up short will still activate the PDA process, but it can be easily reversed if you obtain the needed certificate before central office starts the formal process of PDA deliberation. Additional CLIA refs: FDA, CDC, CMS
Pg 13 2007 Fixed Components for Random Unannounced Surveys: Although you are unlikely to be in the 5% of hospitals selected for an RUS, JCSC and PPR should pay particular attention to the top PFA's (Patient Safety, Medication Management and Assessment and Care/Services) identified as fixed components for these surveys. Take it as a useful hint that the Joint thinks they are important and frequently finds compliance issues for hospitals here.
The Source (Feb, Vol 5 #2)
• Pg 1 Update on New Program-Specific Tracers: P-S tracers are currently in effect, and at least 5 of the 12 developed so far are applicable to state hospitals. This article provides 'Hints' about what surveyors will be looking for. If you expect to be surveyed this year, review these hints--paying particular attention to those labeled 'BHC' and 'HAP'. Others should build P-S tracers into their mock/practice tracer process. Refer also to Perspectives, Nov 06, pg 4-5, which has a better description and applicability table for these tracers.
• Pg 4. ACCREDITATION ESSENTIALS: New Quarterly Priority Focus Process Reports: Although JC has moved to quarterly PFP reports, you only get an update if there has been a change in your PFA'a or SCG's, and this is not expected often. Check your extranet around the 15th of March, June, September, and December. Should there be changes, consider them warning signs and dig in for deeper understanding and possible need for improvement.
• Pg 8. THE EXPERT CONNECTION:, Community- and Health Care–Associated Infections: An Update on MRSA: Your IC officer/group will find the seven (7) strategies identified by the IC Practices Advisory Committee helpful as a checklist for recommended prevention strategies. Read IC.3.10 closely and ensure your facility is implementing the relevant strategies. Surveyors give special attention to your IC Plan that is required to be based on A - risk assessment, B - identification of priorities and C-realistic goals (both required by standards and indicated as appropriate by your risk assessment).
Patient Safety (Feb, Vol 7 #2)
• Pg 5 - Part 1: Exposing Abuse: Identifying female patients who are victims of intimate partner violence: First of two-part article on the identification and assessment of patients who are high-risk for abuse. Useful for therapist, Social Work staff, Pt Advocates and especially those who do initial assessments (PC12.40#5). Consider discussing it briefly in treatment teams to meet educational and other requirements of PC.3.10, PC.3.120 and PC.3.130. [Abstract]
Environment of Care News (Feb, Vol 10 #2)
• Pg 1 - Battling “Superbugs” in the Environment of Care New CDC Guidelines Include Recommendations for Environmental Services: MDRO = MRSA + VRE + GNB. Your Infection Control Committee/Officer and EC/Safety Committee/Officer need to read this article. Then review IC.4.10 and determine what aspects of the new guidelines you may need to incorporate and implement. The article points out other relevant standards. Details of the guidelines and summary table of the two tiers is available from the CDC publication: Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. (http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf).
• Pg 7 - Q&A: Authoritative Answers to Common (and Not-So-Common) Questions About the Environment of Care: Two common questions about implementing the extended run requirement are addressed here.
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)
General
- 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 your 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
January 2007
Full Provider Update (http://www.cms.hhs.gov/QuarterlyProviderUpdates/JAN2007/list.asp)
1/07 What's New Summary
October 2006
Full Provider Update (http://www.cms.hhs.gov/QuarterlyProviderUpdates/OCT2006/list.asp)
10/06 What's New Summary
- 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."
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NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD)
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SURVEYS .
Recent Hospital Surveys
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