RT0704Apr
31 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)
.
.
THE JOINT COMMISSION (TJC and JCR)
.
Publications
Joint Commission this Month (April 2007)
Accreditation:
• Due date for e-SOC™ is extended: to September 1, 2007
Misc:
• Standards Improvement Initiative update: Between April 25 and June 6, 2007, you can comment on the recommended changes to the standards related to the Surveillance, Prevention and Control of Infection (IC).
• Updated sentinel event statistics: {Info}
• New Google search engine on jointcommission.org: Try it out
• Third quarter 2006 CEO opinion survey results: Needless to say, JC continues to be wonderful
Upcoming:
• Free audio conferences: Relevant topics and dates follow below and are on the SHCC Calendar: ** April 30 Credentialing and Privileging (Note: Date changed from 4/25) ** 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 (April, Vol 27 #4)
Pg01- UPDATE: Standards Improvement Initiative - Article provides an update on the Joint Commission's current efforts to edit the IC, PI, IM and HR chapters of standards. Drafts of the revised chapters to be available this spring on the Joint’s Web site. The expected effective date for the changes is January 2009 for hospitals.
Pg03- The Joint Commission Extends Date for Completing the Electronic Plans for Improvement - The Joint Commission has extended the compliance date for converting existing Life Safety Code (LSC) deficiencies into electronic Plans for Improvement (e-PFI) to September 1, 2007. This applies to LSC deficiencies with a “projected completion date” after September 1, 2007. TJC is developing a way for organizations to import and use their data to populate the e-PFI database. They hope to have an import tool available in the third quarter of 2007.
Pg04- The Joint Commission Revises Event Notification Posting Time on Extranet -- Effective immediately, if your facility is within the US or its territories, TJC's official time for updating events on its website is 7:30 AM in your organization’s local time zone. This, of course, includes the information provided on the first morning of unannounced surveys. So you now get only 30 minutes notice.
Pg05- REVISION: Accreditation Decision Rule PDA04 - A word to the wise. As per the latest revision of PDA04, receiving conditional accreditation during two consecutive full surveys for issues within the same PFA will now result in Preliminary Denial of Accreditation.
Pg06- The Joint Commission Awarded Grant to Test Nursing-Focused Quality of Care Measures - The Joint Commission has begun an evaluation of nursing- focused performance measures (e.g., quality of care and patient safety) endorsed by the National Quality Forum (NQF) to determine if they are reliable and feasible for use in hospitals. The testing will occur over the next two years at hospitals that have already volunteered for the project. The 15 consensus measures have limited applicability to psych (e.g., falls, restraints, pain assmt.) but may be worth taking note of. This year, physician competencies. Can Nursing be far behind?
The Source (April, Vol 5 #4)
Pg01- The Joint Commission commitment to Reliable Data Management and Performance Measure Tools: This article provides further heralding and elaboration of the Joint's roll-out of its Strategic Surveillance System (S3) due this year. The first two tools from S3, Performance Risk Assessment and Performance Measure Compare are again described. This version may be a bit more understandable than that provided in the March Perspectives. Planning leaders and PI should keep track of this development. (See our earlier comment in SHCC Reading Tips - March).
Pg04- Medication Management Standard Compliance Results in 2006: Despite the broad title, the focus of this article is Standard MM.2.20. This standard requires medications to be properly stored and 40% of hospitals failed to fully comply making it on the hospital's top 10 for non-compliance. Article contains good review of useful strategies for compliance. Worthwhile reading for pharmacy and the P&T committee.
Pg06- Compliance with the Provision of Care, Treatment and Services Standards Vary in 2006: Again a broad title, and again the Joint pulls from its Top 10 non-compliant standards (Jan-July 2006). The focus is on PC.6.10 (Patient education and training) and PC.8.10 (Pain assessment). Excellent table of strategies for patient education and a pithy summary of basics (read compliance essentials) for pain assessment. You are encouraged to read 'basics' as 'compliance essentials', compare your pain assessment process to it and then refine as needed.
Patient Safety (April, Vol 7 #4)
Pg02- Making the Case for Apologies - The quality of care and risk management benefits of constructively owning up to undesirable patient care outcomes are discussed. Particularly useful reading for hospital leaders and medical staff.
Pg05- Transforming Care at the Bedside: Using innovative changes to allow nurses to focus on patient care - The goals of the TCAB initiative (sponsored by the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation) are to 1) Enhance the quality of patient care and service, 2) create more effective care teams, 3) Improve patient and staff satisfaction and 4) Improve staff retention. Although the focus was on med-surg units in primary care hospitals, there are some useful principles and ideas in the article for Nursing in general. Good article for reading and discussion of implications in a nurse leaders' meeting.
Pg07- What Was I Doing?: Reducing the occurrence of this question by limiting interruptions - Noise and interruptions are classic distracters on psychiatric units. Too often, we accept them as immutable. This article provides some practical strategies for the reduction of interruptions that might also improve quality and safety. This would be a great article for treatment teams to read and discuss. Implementation of just one relevant strategy could make a big difference in a team’s work experience and effectiveness.
Pg09- CASE STUDY: Creating a Spiritually Rewarding Environment - How a focus on spirituality can improve patient safety - One might think it a stretch to connect patient safety and spirituality … and stretching the mind would be the reason for both clinical and administrative leaders to consider the potential suggested by this article. If you’re one of the fortunate facilities that still have a chaplaincy, be sure they get a copy.
Environment of Care News (April, Vol 10 #4)
Pg01- A Suite Deal Taking Advantage of Suite Classification Can Ease Burden of Compliance: The Life Safety Code (LSC) permits the classification of certain areas as Suites that “somewhat eases the life safety requirements for doors, walls, and corridors within the suite”. State Hospitals might find some advantageous application of this option in areas such as sleeping dorms. If you are having compliance trouble with issues such as positive latching doors, this article would be worth a read by your engineer (or whoever prepares your SOC). Article provides a good overview and summary of the Suite Classification
Pg08- Meeting the Challenges of“Building Green”How to Plan and Design to Help Protect the Environment: Although few state hospitals are enjoying major capital improvement, there are still small construction projects that may allow opportunity to take advantage of Green principles. This is an important and evolving issue for our world that is worth keeping abreast of. The resources identified (e.g., Green Guide for Health Care http://www.gghc.org/, USGBC’s LEED Program. http://www.usgbc.org/) in the article are worth being aware of. Optional reading for your Facility Engineer and your Safety and Infection Control Officers.
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)
SURVEYS .
Recent Hospital Surveys
.
Goto SHCC Alerts
F&A
| 
