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
Joint Commission this Month (May 2007)
Standards Changes:
Pg01- Revised standard addresses restraint and seclusion: Standard PC.12.90, aligns the requirement for in-person evaluation of a patient when restraint or seclusion is initiated with CMS’ Final Rule for Patient Rights. Issued in December 2006. Effective immediately.
Pg02- Revised standard regarding procurement and donation of organs and other tissues: Standard LD.3.110 ( organ procurement and donation) has been revised. Specifically, EP#12 has been clarified around the requirement that hospitals have a policy addressing opportunities for asystolic recovery or “donation after cardiac death”. Effective January 1, 2008.
Pg02- Revised standard addresses timeframes for histories and physicals: Standard PC.2.120, (timeframes for taking histories and physicals), has been revised to align with the CMS’ final rule regarding these timeframes. The medical history and physical examination is to be completed no more than 30 days prior to or within 24 hours after inpatient admission. If completed within 30 days prior to inpatient admission, an update documenting any changes must be performed within 24 hours after inpatient admission. Effective January 1, 2008.
Pg03- Standards Improvement Initiative update: Changes recommended to the standards in the Surveillance, Prevention and Control of Infection (IC) chapter will be posted and available for online comment/feedback April 30 - June 8, 2007. Implementation is expected in Jan 2009. TJC expert panels are also beginning discussion of improvements for the medication management standards. More on the later to come. See: summary, revisions, or give feedback.
Patient Safety/Public Info/In the News/Communication/Etc.
Pg05- Joint Commission report: National strategies needed to better serve increasingly diverse patient population in American
hospitals: “Hospitals, Language, and Culture: A Snapshot of the Nation, Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings” makes it hard to tell if any of the 60 hospitals in the 32 states represented were psychiatric. However, at least 15 of them were public hospitals and there is mention of social needs/services. If your patient population is particularly diverse in culture and/or language this could be a useful resource. You can download the 107-page report for free, but we would suggest you start with the 8-page Exec Summary :) Get more info or report.
Pg06- Connect redesign is in development: TJC's extranet site is being redesigned. Expected improvements will include enhanced security controls, a "What's Due" section and 'New Reports" section. Completion is expected in the third quarter of this year..
Fields Reviews & Draft Standards - {Info}
Upcoming:
• Free audio conferences: Relevant topics and dates follow below and are on the SHCC Calendar: ** 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 #5)
Pg04- UPDATE: Strategic Surveillance System—Preparing to Launch the Tool - Bottom line… JC Survey Coordinators should make sure your ownership and contact info are current and accurate because S3 will default to some of that information. What is S3? Check out our March Reading Tips for Perspectives.
Pg11- APPROVED: The Joint Commission’s Gift Policy - JC Survey Coordinators will appreciate having a clean definition of this issue. Bottom line … 1 - You should not offer and surveyors should not accept cash, its equivalent or entertainment. 2 - You may provide "a modest on-site meal" to help keep the survey process on schedule. More detailed definitions of gifts and vendors are provided in the article.
Pg13- The Joint Commission Releases White Paper on Health Literacy - The latest TJC white paper is free and entitled "What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety. Pt Advocates may want to consider including it with your Pt handbook. Share the executive summary with medical staff as part of communication competency.
Pg14- UPDATE: Quality Check®, Speak Up and Web Site Enhancements - Speak Up brochures are being redesigned for easier reading. There will also be Spanish translations. Pt Advocates may want to take a look.
The Source (May, Vol 5 #5)
Pg03- Assessment and Care/Services Part of 2007 Random Unannounced Surveys - This article provides useful basics about Random Unannounced Surveys (RUS) for survey coordinators and sheds some light on likely points of emphasis within one of this year's fixed components: Assessment/Care. It also underscores the issue of risk assessment and its growing importance with TJC. While suicide prevention/assessment is currently the focus (via NPSG 15A), wise clinical leaders will give similar attention to falls, elopement and violence.
Pg04- Communicating Care Planning with Staff - Because of its huge association with sentinel events, communication is important to TJC and one of the PFA's surveyed in all programs. Although this is not one of their best how-to articles, it is worth a review by managers, clinical leaders, and education directors. The categorization of communication barriers is particularly useful for conceptualizing improvement opportunities.
Pg04- Blount Memorial Hospital Conducts Weekly Mock Tracers - Although the featured hospital is Med/Surg, the sections on " How Blount Memorial’s Mock Tracer Works" and " Addressing Staff Concerns" should be read by all PI/Srvy Coordinators and Nurse Leaders. It is a good guide for conducting practice patient tracers on general care and safety issues for all nurses.
Patient Safety (May, Vol 7 #5)
Pg01- The Rules of Rest and Relaxation - That worker fatigue increases error is no surprise. This article provides some strategies and suggest a tool (the Fatigue Avoidance Scheduling Tool - FAST) that Nursing and other Leaders should be aware of. Did you know that rotating shifts are not recommended? Read to find out why. Useful references at the end. FAST PDF
Pg02b- Top 5 in the News - A Kit For Reporting Infections APIC is providing a toolkit, Essentials of Public Reporting of Healthcare-Associated Infections that should be reviewed by all IC Coordinators/Committees. Get the kit.
Pg05- Errors Associated with New Technology - If you are considering new technology as a solution to various charting or medication management issues, this is an article worth reading. Some important basics for effective implementation are reviewed. Best to "weave new technologies into existing systems". [IT, Ldrshp]
Pg07- Using Double-Checks Effectively - Types of double-checks and when to use them are discussed. Good review for Nurse Leaders.
Pg11- Using the Five “R”s to Apologize Effectively - In April they made the case for apologies and here they give a how-to outline. Useful reading for Med Staff.
Environment of Care News (May, Vol 10 #5)
Pg01- Preparing for a Change in Preparedness Improving Emergency Management - TJC is proposing updates for 6 areas of emergency management: 1. Communication 2. Managing resources and assets 3. Managing safety and security during emergency conditions 4. Defining and managing staff roles and responsibilities 5. Managing utilities and 6. Managing clinical activities. Article provides a brief intro to the changes and reasons why. No specific EC standards changes yet but Safety Officers/Committees may find it useful to scan this piece.
Pg04- From “Cradle to Grave”Creating Safeguards for Hazardous Materials and Waste - Good review of basics for your HazMat Mgt Plan. Whoever writes your plan and/or has PPR responsibility for EC.3.10 should read this article.
Pg06- Managing an Emergency Using NIMS and HICS to Navigate the Emergency Management Process - Safety Officers/Committees interested in taking their emergency management planning to the next level would do well to read this article. Although it only summarizes key points about NIMS, ICS and HICS, the real value is in the links, references and free HICS resources it provides. A little heavy, but worth the read.
Pg08- The Joint Commission Extends Date for Completing the e-PFI - Just in case you missed the earlier announcement in the April Perspectives or our April Reading Tips, the new date is Sept 1, 2007.
Pg01- Q&A - Roller Latches - One of two Q&A provides useful guidance related to roller latches and positive latching. [EC, Safety Officer]
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
