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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  August 2007)

Accreditation
•  Accreditation policy clarifies that physicians should report quality, safety concerns – APR 17 now clarified to include physicians
•  Notice about removal of draft standards from The Joint Commission website – Draft standards will be pulled when the field test ends.
•  Revisions to standard MS 1.20 approved – Revisions related to Medical staff bylaws address self governance and accountability to the governing body, are summarized
Public Information
•  Updated sentinel event statistics

In The News
•  Journal of Healthcare Management study: Joint Commission accreditation ‘key predictor’ of hospital patient safety system implementation – {Details}

•  Mark R. Chassin, M.D., M.P.P., M.P.H, Named President of The Joint Commission:   Chassin is an internist,  the Guggenheim Professor of Health Policy and Chairman of the Department of Health Policy at New York's Mount Sinai School of Medicine. His appointment will begin January 1, 2008.    {TJC News Release}

• Joint Commission’s Deeming Authority Under Fire (CA): FYI JCSC, GB. This House version of The Children’s Health and Medicare Protection Act of 2007 currently under consideration contains a provision (Section 507) that would “Repeals JCAHO's unique statutory protection, effective eighteen months after enactment. “.  House and Senate version have yet to be reconciled and a presidential veto looms, but it makes for some interesting reading and following.  [Note: This preceding is from a non-TJC source - The MSSP Nexus Blog]

Communications
•   The Joint Commission pilot tests Internet-based forum, WikiHealthCare™  – We informed you last month (June This Month) when it debuted, but here is an official TJC announcement.  {Info}

Free audio conferences

• August 16    Strategic Surveillance System—Understanding Reports
• September 13    National Patient Safety Goals
• October 24     Standard MS 1.20 (Note new call topic)
• November 8    Hospital Leadership:  Administration, Governance and Medical Staff Working Together

[Index]                                                            Perspectives (August, Vol 27 #8) 

Pg01-  Joint Commission Accreditation “Key Predictor” of Hospital Patient Safety System Implementation - FYI GB.  Does accreditation make you a better hospital?  TJC cites a recent study (of hospitals in Utah and Missouri) that says  it makes you a safer one.  [Abstract]  Hospital Patient Safety: Characteristics of Best-Performing Hospitals, Daniel R. Longo, John E. Hewett, Bin Ge, and Shari Schubert  Exec  Summary

Pg03- APPROVED: 2008 Accreditation Decision Rules for All Programs - JCSC FYI. Two new decision rules were added.  One for failure to resolve Conditional status and the other for failure to pay TJC.  Article contains the entire set of rules and changes if you need them.  [Abstract] 

Pg010- Top Standards Compliance Issues for Full-Year 2006 - The Top 10 for hospitals has not changed much since the first half of 2006.  Except for the absence of PC.13.20 it includes the same issues although in slightly different ranking.  Top 10 = Goal 2 (58%) Goal 8 (46%) MM.2.20 (44%) UP 1 (30%) EC.5.20 (26%) MM.3.20 (26%) PC.8.10 (19%) IM.6.10 (18%) EC.1.10 (17%) Goal 3 (17%) .  JCSC and PPR teams may want the tear-out cards included in the article.  [Abstract] 

Pg011- APPROVED: Revisions to the Applicability of Accreditation Participation Requirement 17 for Hospitals - MD FYI. APR 17 leaves no doubt that physicians are part of the 'staff' that are educated and supported (no retaliation) in reporting safety/quality concerns to TJC  [Abstract]

Pg012- The Joint Commission’s New Speak Up™ Program Urges Patients to‘Know Your Rights’ -  'Know Your Rights' was announced last month. PtAd, PtEd, CHP and others may want to check out the free brochure   [Abstract] 

Pg013-  Expanded Scope of Service for Life Safety Code Specialists for Critical Access Hospitals and Hospitals Begins in 2008 - This 1-pager again (Jan/March Perspectives and June EC News) announces that  ALL HOSPITALS will have an LSC specialist starting in 2008 for at least 1 day  and possibly 2 days even if you do not have 750,000 sq ft.   For better detail, JCSC and EOC should read the 3-page June EC News article starting on page 1.   [Abstract]  Life Safety Code ®Specialists’ Scope Expanding (All Hospitals and Critical Access Hospitals to Be Included as of January 1, 2008. June EC News.  [Abstract] 

Pg014- APPROVED: Revisions to Leadership Chapter - As we explained last month, this change may seem soft but it is especially  significant in its address of leadership accountability and facility culture.  Smart LDR and JCSC will understand the importance of using the advance notice to your strategic advantage.  Start reading the 2009 pre-publication standards [PDF], understanding, planning and implementing sooner vs. later.  Those of you expecting survey soon should pay particular attention to the diagram on page 8 of the pre-pub standards. At least 1 surveyor has already incorporated it into his leadership session interview.  [Abstract]  

[Index]                                                            The Source (August, Vol 5 #8)

Pg01- A Look at the Changing View of Organ Donations - State hospitals might eschew issues requiring discussion of death with our patients.  However, CMS and TJC standards now require us to face the matter of organ donation.  Just read the first paragraph of this article and you will know why.  There are more than 3 times as many persons waiting for organs as there are recovered organs.  LDR, CHP, PtAd, MEC and JCSC are encouraged to consider compliance with LD.3.110 in that context.  [Abstract]

Pg03- Updating the History and Physical Examination - June Perspectives (pg 15) announced the CMS/TJC alignment, but here is more useful clarification of PC.2.120 for MD, MEC and JCSC.  Requirements for written documentation of certain definitions and granting of related privileges should be noted.  The CMS final rule referenced in the article is CMS-3122-F,(goto SL2)  [Abstract]

Pg05- Who Can Evaluate and Assess for Restraint and Seclusion? - Again, the CMS/TJC alignment was previously announced in June Perspectives (pg 16) , This article provides a bit more explanation of PC.2.120 and re-emphasizes the issue of preventing/reporting R&S-related deaths. Worthy of a brief review by JCSC, RN and MD.  See also SE Alert # 8.  [Abstract]

Pg07- Standards Interpretation Group: Classifying Privileges During the Privileging Process - Good discussion (for MDx and  C&P) of Core Privileges with useful tie-in of a few key CMS requirements.  [Abstract]  (see also State Operations Manual  Appendix A §482.22(c)(6))

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[index]                                                         Patient Safety (August, Vol 7 #8) 

Pg01- SPECIAL REPORT! Helpful Solutions for Meeting the 2008 National Patient Safety Goals - Despite the title nothing particularly helpful or new in this article unless you failed to read the original presentation in July Perspectives.  [Abstract]

Pg06-  Improving Anticoagulant Safety Strategies for meeting National Patient Safety Goal 3E - [*REF*] - If your facility uses Heparin or Warfarin NPSG 3E applies and this article provides the best explanations and examples for implementation we have seen so far.  Read carefully and you will see that all 11 EP are discussed under 5 categories in a way that can help with conceptualization as well as implementation.  Useful table on Food and Drug Interactions Related to Warfarin Therapy.  A must read for JCSC, Phrm, P&T and FdDt.  [Abstract]  Also refer to: Reducing anticoagulation-related adverse drug events: Closely monitoring and managing risks for patients on warfarin. in Joint Commission  Perspectives on Patient Safety 6:3–4, Jul. 2006.   [Abstract]

Pg08-  Improving Early Recognition and Response to Patient Changes Empowering staff to act quickly to prevent cardiac arrest - [*REF*] - This is the best article to date on how to address the requirements of the new NPSG 16.  It includes useful clarifications and identifies 3 key questions every plan should cover.  Be sure to review the IHI criteria for activating a rapid response team. Although NPSG 16 has a 2-year phase in with milestones, it is important to understand what things should look like when finally/fully implemented.  This article will help and should be read by JCSC, MDX, RNX, LDR and SFTofco.  [Abstract]

[Index]         Environment of Care News (August, Vol 10 #8)

Pg01- Revised Emergency Management Standards for 2008 Moving to an All-Hazards Approach - The coming revisions were previously announced in June Perspectives (pg 1), but this 1st installment of a 2-part article provides better details about the '6 Critical Areas'. {PDF}  The enhanced communication requirement also gives important context to the earlier article (May EC News, pg 6) on NIMHS which you are encouraged to revisit.   Highly recommended reading for EOC, SFTofco, JCSC and LDRs.  [Abstract]

Pg04- Preventing Occupational Exposure in the Laundry Reducing Worker Exposure to Hazardous Drugs in Linens - If your facility still operates a laundry this article is worth a read by EOC and SFTofco.  Determine if our hospital uses 'hazardous Drugs'  (see a sample list).  If so, consider using the yellow bag approach recommended in the National Association of Institutional Linen Management (NAILM) guidelines. {DOC}   [Abstract]

Pg011- New Questionnaire on Emergency Response Planning Resource Is a Combined Effort of AHRQ and HRSA - If you are interested in improving your emergency management and response plans, this free, download-able questionnaire could be helpful.  Worth checking out by EOC, SFTofco.    [Abstract] 

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

Most Recent: July 2007 PDF

What's New Summary Pages  [HTML]  

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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 Member Hospital Surveys

• 3/6-7/07 Alaska Psychiatric Institute  (API)  [PSQ - pending]
  
• 3/19-21/07  Tinley Park Mental Health Center  (TPMHC)    [PSQ - pending]
• 3/27-29/07  Chester Mental Health Center (CMHC)   [PSQ done]
• 5/15-17/07 Chicago Read Mental Health Center (CRMHC)  [PSQ done]
• 8/27-29/07  Madden Mental Health Center  (MMHC)   [PSQ done]

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F&A