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:  Disruptive Behavior, Governance & Safety, Governance Structure

Joint Commission this Month  (September 2007)

Accreditation
•    Revised Public Information Policy - Anyone (including  complainants) inquiring about a specific complaint at an accredited organization, will be given information about the specific standards that were the subject of the complaint investigation.
•    Standards Improvement Initiative update - Improvements to the standards are to go into effect January 2009
•    2008 accreditation decision rules approved - 2 new decision rules were added to Denial of Accreditation.

Patient Safety
*    Study indicates abbreviations pose threat to patient safety - A new study published in the September 2007 issue of TJC's Journal on Quality and Patient Safety found that almost 5 percent of all errors reported to MEDMARX® (a national database for medication errors) from 2004-2006 were related to abbreviations

In The News
• Quality Check® enhancements - Will include organizations not accredited by The Joint Commission

• The Joint Commission 21ST Annual Conference set for November 12-14 in Chicago

Free audio conferences

• 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

*Audio conferences usually begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Accredited facilities are sent call announcements about one week before  a call. If you missed the call,there are several make up options:  1 - A replay may be available for 60 days afterward. 2 - A written 'Discussion Brief' or a call transcript is usually posted within two weeks.  3 - Download and listen to an MP3  when available.  Access these options on  the TJC Website, your Connect extranet or goto SHCC Calendar for date of missed call.. 

[Index]                                                            Perspectives (September, Vol 27 #9)

Pg01- Mark R. Chassin, M.D., Named President of The Joint Commission - This is now old news, but if you would like more, this article provides a picture and more background. [Abstract]

Pg03- APPROVED: Revisions to Standard MS.1.20 - This article is a must read for MDx, MD and MEC.  It is also relevant for GB.  There are significant changes in MS.1.20 that focus largely on: 1- avoiding conflict around appropriate representation of medical staff issues/views by the MD and 2- what must appear in Medical Staff bylaws vs. in rules/regulations, policies or procedures.  An important distinction is made between 'process' and 'procedural detail' that will need to be properly understood to achieve compliance. Changes do not go into effect until 7/1/09, but do not procrastinate.   [Abstract]

Pg07- APPROVED: Elimination of Track Record Requirements for Initial Surveys and Reviews - JCSC take note. This is potentially good news for hospitals that are seeking their first accreditation or those considering re-establishing a lost accreditation.  For everyone else, track record requirements will continue to be applied for now.   [Abstract]

Pg08- RETRACTION: June 2007 Perspectives, Testing Frequency for Dampers - TJC acknowledges an error in the damper-related clarification it provided in the box on page 19 in June Perspectives.  Modification of EC.5.40 is apparently still under consideration.  E&M and EC plan authors be advised.   [Abstract]

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[Index]                              The Source (September, Vol 5 #9)

Pg01-  Building a Concrete Culture for Handling Disruptive Behavior [**REF**] Although the new leadership standards do not go into effect until 1/1/09, they will be published in Update 2 of the CAMH and are already being explicated.  LDRs should start reading and paying attention now.  This article describes 3 new, specific responsibilities relating to disruptive behavior and gives examples.  MDx should also read since an ISMP study reports MDs as the most common offenders.  Consider sharing with Med Staff.  [Abstract]   See also:

 "Intimidation: Practitioners speak up about this unresolved problem (Part I)"  Click here
  "Intimidation: Mapping a plan for cultural change in healthcare (Part II)"  Click here

Pg03-  Accreditation Essentials: Organization Governance Monitors Safety and Care Issues - [**REF**] The requirements of the new leadership standard LD.1.30 encourage the governing body to be actively (and appropriately) involved in oversight of safety and quality care.  The role of state MH authorities as a governing body may receive more attention as a result of these new standards.  As such, GB should review the new leadership standards in general, but start with this article and then read LD1.30.  Note: the GB is referenced in at least 10 of the new standards (1.-10,-30,-50,-70, 2.-10,-20,-30,-40, 3.10 and 4.20)   [Abstract]

Pg05-  Accreditation Essentials Link: Defining the Leadership and Governance Structure [**REF**] This article is basically another plug for more active involvement of the GB.  However, at the end, it also contains a Pearl: a listing of 7 ' key practices that leaders should … be familiar with'.  GB and LDR should also consider this a list of topics they are prepared to talk about in a survey leadership interview.  Hint, hint.  [Abstract]

Pg07- Tuberculosis: Common Factors Associated with Exposure and Treatment - Even a cursory review of the literature (or internet) suggests TB is an issue state hospitals need to be aware of*. This article shoots to increase awareness of TB risk and describes 3 levels of TB control (Administrative, Environmental and Respiratory).  ICofco should read this article and at minimum, consider conducting a TB risk assessment.  Pearl 1: Sidebar 1 contains a listing of TB Applicable Joint Commission Standards.  Pearl 2: cough etiquette panel (poster idea)**  Pearl 3: updated CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.  [Abstract]  *See also: Hepatitis, TB Rates Found `Alarming' Among State Hospital Patients. Psychiatr News February 3, 2006 Volume 41, Number 3, page 5, ** see also CDC: Cover Your Cough Posters 

Pg09- Massachusetts General Hospital: Addressing Spiritual and Personal Beliefs in Care  - RI.2.10 requires (among other things) respect of spiritual beliefs.  CHP and StEd should review the highlighted Mass General program that encourages spiritual education of providers and appropriate incorporation of spirituality into the provision of care.  [Abstract]   .

[index]                                   Patient Safety (September, Vol 7 #9) 

Pg01- Part II. Maintaining Expert Teams Improving teamwork through evaluation and reinforcement - Although not quite as meaty as July's Part I, this is a useful completion of the series focusing on strategic use of debriefing, simulation, observation and measurement.  Pearl: Sidebar 2. Including Patients and Families on an Expert Team.  "TeamSTEPPS™, an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals", is again featured  LDRs and TxTms should read.  [Info]  [Toolkit]   Part II [Abstract]. Part II [Abstract]

Pg07-  A Global Perspective on Hand Hygiene: Meeting the World Health Organization Guidelines on Hand Hygiene in Health Care - 2 months after announcing changes in NPSG 7C that allowed the use of WHO guidelines in lieu of CDC guidelines, TJC provides a link, a polite description of the WHO guidelines and a perfunctory comparison of WHO to CDC.  FYI for ICofco.  [Abstract] 

Pg11-  Reduce the Risk of Skin Tears: Shielding the protective layers of skin from harm - Light but useful review of skin tear causes/prevention for RNs.  StEd might consider this for brief mention in annual trainings. .  [Abstract]

[Index]         Environment of Care News (September, Vol 10 #9)

Pg01- Revised Emergency Management Standards for 2008 Moving to an All-Hazards Approach - This is a follow-up to last month's piece on the same topic.  Not much new but the case study may be worth a brief review by EOC.  [Abstract]

Pg06- Radiation Safety: Need-to-Know Information for Environment of Care Leaders -  If you are one of the few state hospitals still having X-ray equipment on site, have your SFTofco and EOC review this article and EC.3.10.  [Abstract]

Pg08- Sounding a Sentinel Event Alert on Emergency Electrical Power Systems: Gap Analysis Reveals What Generators Can Handle - This article highlights Sentinel Event Alert 37 (TJC's most recent, released 9/6/06) and its encouragement to "go above and beyond current Joint Commission requirements and NFPA testing requirements in proactively assessing vulnerabilities, assuring sufficient electrical power during emergencies.  Bottom line: SFTofco and EOC should review SE #37 and give serious consideration to doing a gap analysis.   [Abstract]

Extra- Frequency of Damper Inspections May Change -  FYI SFTofco and EOC.  Although we have not yet been able to find it officially in print, we are hearing from reliable sources that because of changes in NFPA 80, TJC's required frequency for fire/smoke damper inspection in hospitals may be extended from 4 to 6 years.  Stay tuned for more on this when we have confirmation.   

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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).

• 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  
  

   

SHCC Additions

.Recent Surveys

• 2007/05/15-17 Chicago Read Mental Health Center (CRMHC)  [PSQ]
  

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F&A