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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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Publications

Joint Commission this Month  June/July 2007)

Accreditation:
• The Joint Commission announces 2008 NPSGs - The 2008 National Patient Safety Goals are out.  See the TJC News Release and full text of 2008 NPSG. 

• Update on Standard MM 4.10 in the Emergency Department Effective immediately: MM 4.10 EP 1 interim action suspended -  The interim action (retrospective Pharm reviews) that was announced in Perspectives this past January (SL4 - RT07Jan) has been suspended as of 4/6/07.  This issue is aimed primarily at Emergency Depts but bears watching by MD Phrm and your P&T.  See TJC 'Urgent Bulletin' that will appear in the July Perspectives (see also below).

• New Leadership chapter effective January 1, 2009 - This change may seem soft but it is especially  significant in its address of leadership accountability and facility culture.  Smart LDR will understand the importance of using the long phase-in period to your strategic advantage.  Start reading the 2009 standards [PDF], understanding, planning and implementing sooner vs. later.

 
Patient Safety:
• New Speak Up™ program urges patients to ‘Know Your Rights’ - PtAd and PtEd would be well advised to add this to the info you provide your patients. [Brochures]

• New NPSGs compliance data for first quarter 2007 - The new compliance data has been updated through the 1st quarter of 2007.  PI and JCSC should check out the latest hospital data [ PDF]  and trends [PDF].

 
Communications:
• Connect redesign launches in third quarter - The article references a preview that we did not find, but JCSC can find a summary of the new features in an FAQ on your TJC extranet website.  [FAQ/Summary]  

• WikiHealthCare - "WikiHealthCare is a Joint Commission-sponsored wiki application. Unlike Wikipedia (which is an encyclopedia), the purpose of WikiHealthCare is to foster collaboration among tens of thousands of health care professionals." - TJC.  Like SHCC, this is brand new, so there is not much content yet.  The only category we saw was "Quality Improvement Discussions and Solutions" with two subheadings both related to smoking cessation and smoke-free hospitals (including a review article abstract on psych hospitals). 

• Free audio conferences*:

Relevant topics/dates follow and are on the SHCC Calendar:
--7/18: Standard MM 4.10: Review of Med Orders in the ED [Note call starts 90 minutes earlier than usual]
--8/16: Strategic Surveillance System—Understanding Reports
--9/13: National Patient Safety Goals
--11/8: Hospital Leadership: Administration, Governance and Medical Staff Working Together .

 Perspectives (July, Vol 27 #7) 

Pg01- The Joint Commission Announces the 2008 National Patient Safety Goals and Requirements - There are two new goals (3E and 16)  and 7C has new language.  3E is about anticoagulant therapy.  16A calls for special attention to patients whose condition might deteriorate into a cardiopulmonary/respiratory arrest.  MD take note.  This will apply to psychiatric facilities/patients.  IC should note that 7C now allows use of WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft - final is pending) instead of CDC, but must choose to stick with one or the other.  We understand the more liberal WHO option (e.g., glove re-use) was added primarily for the benefit of the international community and so we would encourage sticking with CDC.  3E and 16 both come with an interesting new approach, a formal 1-year phase-in with defined 'milestones'.  JCSC should review the changes and consider using the phase-in approach with milestones each September for all new, relevant NPSG.  [Abstract]

Pg03- UPDATE: Standard MM 4.10, EP 1 in the Emergency Department—Interim Action Suspended Effective Immediately - The action in question was focused on Emergency Depts/rooms, but the principle of medication review should be of interest to Pharm, P&T and MD.  Read about the 2 exceptions that are back in place and broadened a bit.   This is becoming a hot topic.  Consider dialing in to the audio conference on 7/18 (see above) or reviewing the discussion brief afterward.  [Abstract]

Pg04- APPROVED: Revisions to Contracted Services Standard LD.3.50 - [*REF*]  Must read for JCSC, MEC. MDx, HR, C&P and LDR.  Good clarification and reference piece on contract services.    [Abstract]   See also:

• Human Resource Standards Applicability to Contracted and Volunteer Personnel   

• Credentialing And Privileging For Providers From Joint Commission Accredited Organizations .

The Source (July, Vol 5 #7)

Pg01- Health Information Technology’s Role in Patient Care - Light article, but IT may find it useful ammo if you still have LDR or GB  that need  encouragement to move toward electronic health records (EHR).  [Abstract]

Pg03- Cultural and Linguistic Issues in the Informed Consent Process - [*REF*]  Fair article but with outstanding resource links to include: 1 - TJC-sponsored list of links,  Hospitals, Language & culture [Link] , 2 - Downloadable, short patient-sensitizing video clips and 3 - National Standards for Culturally and Linguistically Appropriate Services in Health Care.  One of the few times specific links are included in the article.  At a minimum, PtAd, PtEd, HR and CHP should familiarize themselves with these resources!  [Abstract]

Pg05- Discharge Planning: Instructions and Follow-up Care - That TJC is starting to focus more on preventable cardio/respiratory events (e.g., NPSG 16) is in evidence here.  However, the basic principles and suggestions for written discharge instructions are relevant to PC.15.20 for us, too.  MD, SW and discharge planners should take note.  [Abstract]

Pg07- Complaint Management of Joint Commission–Accredited Organizations - Good review and clarification of TJC complaint management process and role of its Office of Quality Management (OQM).  Includes summary of their review criteria.  Useful reading for JCSC and LDR.  

Pg01-  Kayenta Health Center’s Leadership Evaluation Tool - Describes use of an online 360-degree feedback process for leadership.  Includes nice sample of questions.  HR and C&P could consider adapting this for use with hospital LDR and even MD (e.g., part of ongoing competence evals).  [Abstract]

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Patient Safety (July, Vol 7 #7)

Pg01- Part I. Creating Expert Teams: Giving caregivers the tools to work together - Article provides impressive resource and specific strategies for building better TxTms.  "TeamSTEPPS™ is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals."  LDRs should read.  Part II next month.   [Info]  [Toolkit]  [Abstract]

Pg02- IHI offers adverse event measurement tool - Only a few of the identified triggers are relevant, but if you want/need a more effective way of identifying events that can cause harm, you may want to consider this retrospective approach and adapt their form. JCSC, PI  [Info/PDF]  [Abstract]

Pg05- Strategies for Reducing Restraint Use: Assessing organizational, equipment, communication, and environmental factors - Not much new here, but the focus on reducing restraints for older adults and persons with dementia may be a useful refresher for RN and those who work with Ger pop.  [Abstract]

Pg07- Maximizing the Benefits of CPOE Technology: Addressing potential errors proactively - A computerized physician order entry system (CPOE) may seem far-fetched for our minimally resourced hospitals.  But, it is probably coming.  Worth a brief review by IT. P&T.  [Abstract]

Pg09- Reducing Community-Associated MRSA Skin Infections: Initiating a community education program on hand hygiene - If you are having more than your share of MRSA, you may want to consider expanding your preventive efforts into the community as was done in this case study.  Needless to say the principles can be applied internally as well.  Ideas for IC and PtEd.  [Abstract]

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Environment of Care News (July, Vol 10 #7)

Pg01- e-SOC Interface for Easy PFI Import: Automated Tool and Other Enhancements Available July 2007 - Remember, your migration of info to the new e-SOC  must be fully achieved by 9/1/07.  The e-SOC will have (this  month)  automated features that can help (e.g., upload PFI data directly to the e-SOC).  This article provides good info on the mechanics of making the change and those responsible for your SOC, BBI and PFI should read it.  [Abstract]

Pg04- Q&A: Authoritative New Answers to Questions About Corridor Door Gaps, Combining Generator Tests, and New Testing Frequency for Dampers - The review of the 1/8th inch corridor door gap is worth knowing (and probably keeping a copy of) by  E&M, SFTofco and those who perform environmental rounds.  The issues of combining generator tests and accessing dampers is a verbatim repeat of  the  FAQ in June Perspectives, Pg 18.  

Pg06- Pandemic Flu Preparedness: OSHA Guidelines Provide Direction on Protecting Patients,Workers - Although state hospitals rarely deal with N95 respirators and negative pressure rooms, ICofco, SFTofco will want to be familiar with the upcoming OSHA guidelines (to be posted @ www.pandemicflu.gov ) and relevant preparations for pandemic flu (ala EC.1.10).  [Abstract]

Pg08- Conducting a Mass Vaccination Drill: Ambulatory Care Facility Kayenta Health Center Prepares for Possible Disaster - You may not believe that an influenza pandemic is just a matter of time, but if you are the ICofco, it is still worth a brief FYI  review of this drill.  [Abstract]

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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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. Quarterly Provider Updates

Most Recent:  April 2007

April Provider Update

What's New Summary Pages  [HTML]  April [PDF]

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NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD)

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• Presentations from the Fifth National Summit of State Psychiatric Hospital Superintendents - Sunday, May 6 through Tuesday, May 8, 2007 in Bethesda, Maryland.  Topics include:
  1.    Welcome and Opening Remarks  PDF
  2.    Increasing Mental Illness from 1750 to the Present: The Rise, Fall, and Resurrection of State Hospitals  PDF
  3.    Morbidity and Mortality in People with Serious Mental Illness PDF
  4.    Smoking Policies and Practices in State Hospital Settings: Helping People Make Healthy  Decisions Toward Recovery  PDF
  5.    Psychiatric Advance Directives: The Challenges of Implementation  PDF
  6.    State Hospitals and the Future of Forensic Services  PDF 
  7.    Promising Practices: Southern Region - Kentucky’s Direct Intervention: Vital Early Responsive Treatment System (DIVERTS): A Program to Reduce State Psychiatric Hospital Admissions for People with Mental Illness   PDF  
  8.    Promising Practices: Northeastern Region  - The Anti-Stigma Project in Maryland: A Collaboration Between “On Our Own of Maryland” and the Maryland Mental Hygiene Administration  PDF   
  9.    Preventing Seclusion and Restraint in Public Mental Health Settings: Successes, Challenges and Lessons Learned  PDF1  PDF2
  10.    Lost in Transition: Addressing Continuity of Care   PDF
  11.    Overweight and Obesity in People with Mental Illness: Medication Utilization and Managing Cardiometabolic Risk  PDF
  12.    Workforce Issues: Recruiting, Retaining, and Training Providers of Mental Health Services in Rural Settings   PDF  
  13.    Promising Practices:  Mid-Western Region  - Peer Specialists: Roles and Challenges   PDF?
  14.    Promising Practices: Western Region - Inpatient Dialectical Behavior Therapy (DBT) and the Reduction of Self-Harming Behaviors   PDF    

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SURVEYS .

Recent Hospital Surveys

• 2006/08/29-31 Central Louisiana State Hospital (CLSH)   [PSQ]
• 2007/05/15-17 Chicago Read Mental Health Center (CRMHC)  [PSQ]

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F&A