RT0703Mar
4 Mar 2007
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: Suicide Prevent Tracer
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Joint Commission this Month .(March 2007)
In The News
• The Joint Commission issues white paper on risks of low health literacy: This past June, TCJ and JCR hosted a national symposium on health literacy and patient safety that has lead to development of a white paper on risks of low health literacy entitled “’What Did the Doctor Say?:’ Improving Health Literacy to Protect Patient Safety." The paper contains recommended approaches to improve the ability of patients to understand complex medical information. Click on these links for more info or fora full copy of the white paper.
Upcoming:
• Free audio conferences: Relevant topics and dates follow below and are on the SHCC Calendar: ** March 23 Annual Report: Performance Data and National Patient Safety Goals ** April 25 Credentialing and Privileging ** May 17 Standards Improvement Initiative (Hospitals) **
• The 16th Annual State Hospital Association Forum is scheduled for Friday, June 8, at the Joint Commission’s Central Office in Oakbrook Terrace, Illinois.
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Perspectives (March, Vol 27 #3)
• Pg03- Approved: The Joint Commission’s Hospital PM Implementation Plan Through 2008 (The HBIPS Measure Set): Hospitals participating in the Hospital Based Inpatient Psychiatric Services (HBIPS) test (a year-long pilot starting January 1, 2007) will be able to use the 5 new core measures to satisfy their ORYX® requirement instead of the 9 non-core measures. During the pilot, the new measures will not be posted to Quality Check and will not become ‘fully operationalized’ until October 2008. For profit psych hospitals and general hospitals with inpatient psych units will also be in the study. This may be an important opportunity for State Hospitals to influence their future requirements.
***** Get more details. It’s not too late to join the pilot! *****
• Pg08- UPDATE: PPR Process: This article provides 1 correction and 2 clarifications on the PPR process. Tip: Your plans of action (POA) for non-compliant standards found during your annual PPR must be implemented within 45 calendar days.
• Pg08- CORRECTION: Strategic Surveillance System Information • Pg 11 UPDATE: Strategic Surveillance System—Official User Roles: "Strategic Surveillance System (S3) is a series of hospital-specific risk assessment and performance measure comparison reports that will be available to accredited hospitals by mid-2007." It is being announced as a no cost, no additional submission, non-required "value-added element of the accreditation process intended to help accredited hospitals identify and prioritize areas for improvement". S3 was addressed twice in this issue and once last month suggesting its time to pay attention, even for state hospitals. This article provides an update worth reviewing, but the best details on S3 so far were published in the Nov 2006 Perspectives. That article describes 2 modules with associated data measurement tools, (i.e., The Performance Risk Assessment tool and The Performance Measure Compare tool) to be 'launched' in mid and late 2007 respectively. S3 is clearly coming but there is likely to be a question about the relevance of the comparison groups and potential benefits/value to state hospitals. For more information, check out the Joint's FAQ's on S3.
• Pg10- UPDATE: Expanded Scope of Service for Life Safety Code Specialists for Critical Access Hospitals and Hospitals: The expanded scope was announced last month and is further clarified in this article. Bottom line: " In some instances, an organization that has fewer than 200 beds may now have a Life Safety Code Specialist for two days, based on the organization’s size (more than 750,000 square feet) and ... (certain) criteria". The criteria are listed (without indication of weight) in the article but predicting who gets extra LSC specialist time may still be difficult since this will be determined by a 3-member Joint Commission Team on a 'case by case basis'.
• Pg10- CMS Defines Storage Quantities for Nonflammable Medical Gas: CMS and TJC are now using the same reference source for this matter (i.e., 2005 edition of NFPA 99 Health Care Facilities at 9.4.3.) and so there is now a consistent answer:
- Up to 300 cubic feet of nonflammable medical gas (12 E sized cylinders) may be accessible as operational supply rather than storage, when properly secured.
- An individual container of medical gas placed in a patient room for “as needed” (but regular) individual use is not required to be stored in an enclosure, when properly secured.
This is a tip worth knowing. Several of our hospitals were cited on this in the last couple of years. More details (e.g., 'properly secured') are available from the CMS source letter, {Ref: S&C-07-10}
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The Source (March, Vol 5 #3)
• Pg01- Surveyor Scenarios for Program-Specific Tracers (PST): Best details so far on a BH-related program-specific tracer (i.e., Suicide Prevention). 2 other PSTs (non-BH) are described. Tip: Incorporate this into your practice tracers now!
• Pg09- Using the Survey Activity Guide as a Management Tool: Nothing earth shattering in this spotlight on success piece from a community health center but the take home point applies to state hospitals, too: Prepare for surveyors and specific survey events (e.g., Program-Specific Tracers) by having key staff know and utilize the Survey Activity Guide (SAG). Remember, surveyors are also guided by the SAG.
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Patient Safety (March, Vol 7 #3)
• Pg01- Are Your Surveillance Methods Effective? Choosing appropriate surveillance activities and using data effectively: Good review of principles. Should be read by IC nurse and committee. Tip: Article describes concept of Using Syndrome-Based Surveillance Systems and the National Electronic Disease Surveillance System (http://www.cdc.gov/nedss)
• Pg03- Pushing the Envelope on Root Cause Analysis: Implementing challenging actions for long-term results: Decent review of RCA principles. Tip 1 - Article contains a nice RCA scenario with answers that could be used as a useful training tool (or refresher) for those who facilitate RCA's. Tip 2 - One of the references leads to an online interactive RCA facilitation tool provided (free of charge) by the VA National Center for Patient Safety (NCPS).
• Pg05- Part 2: Exposing Abuse: Identifying abuse in children and the elderly: Follow-up piece to last month's Part 1 with good summary tables on child and elder abuse assessment. Encourage reading by pt advocates, treatment teams and those who do the initial assessments or otherwise screen for abuse. [Abstract]
• Pg11- How to Be a Patient Advocate: Useful principles and reading for your facility ethics committee, patient advocate, chaplain and other interested parties.
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Environment of Care News (March, Vol 10 #3)
• Pg01- Questions on the Electronic Statement of Conditions™: This is a must-read for anyone responsible for the eSOC. Tip: Good clarification of eSOC deadlines.
• Pg04- Trouble in Paradise: A Hawaiian Hospital’s Response to an Earthquake: Useful reading for Safety Committee, but also leadership to help expand thinking about the scope of emergency contingencies to consider.
• Pg08- Using Universal Symbols: Improving Wayfinding Through Universal Signage Systems - Particularly useful for larger hospitals and/or when your population contains significant numbers of non-speaking persons. Symbols are available for free.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
. Quarterly Provider Updates
January 2007
Full Provider Update (http://www.cms.hhs.gov/QuarterlyProviderUpdates/JAN2007/list.asp)
1/07 What's New Summary
NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD)
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SURVEYS
Recent Hospital Surveys
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Goto SHCC Alerts
F&A
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