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)

 .Refs:  LD Planning Process

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THE JOINT COMMISSION (TJC and JCR)
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Publications

Joint Commission this Month  (October 2007)

Accreditation
•    Revised fire-safety equipment maintenance standard - EC.5.40 (fire-safety equipment maintenance) has been revised to align with recent revision requirements of NFPA 80.  Key change extends the timeframe from four years to six years for the ongoing testing of fire and smoke dampers for hospitals.  See also Extra/Confirmed below.
•    Standards Improvement Initiative update - Improvements to the standards are to go into effect January 2009

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

• TJC wants  your opinion about improving This Month  (online survey)

• "Illinois is the first state to require hospitals to test all patients in intensive care units for methicillin resistant Staphylococcus aureus (MRSA) and to isolate infected patients. " TJC Perspectives on Patient Safety (Oct 07 page 2)

Free audio conferences

• October 12   “Assessing Organizational Capacity for Change:  How Does Your Hospital Measure Up?” 
• October 24     Standard MS 1.20 (Note new call topic)
• October 25      New Leadership standards that take effect January 1, 2009, with an introduction to the   revised Medical Staff standard
• November 1     Continuation of the Leadership standards discussion, plus an in-depth look at the revised Medical Staff standard that takes effect July 2009
• November 8    Hospital Leadership:  Administration, Governance and Medical Staff Working Together 

[Index]                                Perspectives (October, Vol 27 #10)

Pg01-  An Interview with Dr. Mark Chassin,Next President of The Joint Commission:  3 more pages of background on the new Pres in Q&A format.   [Abstract]

Pg05-  APPROVED: Revised Public Information
Policy:  Beginning Jan 1, 2008 info about specific complaints (i.e., standards that were investigated) can be revealed even to the complainant.  TJC has announced this before (see Sept 'This Month') but full text is available in this article.  FYI: JCSC, PtAd.  [Abstract]

Pg08-  Correction: Standard MS.1.20 Effective Date - "the correct effective date for the revised Standard MS.1.20 (Gov Body accountability) is July 1, 2009."  FYI: JCSC, MEC, GB [Abstract]

Pg09-  UPDATE: Standards Improvement Initiative:  The HR (comparison), MM (comparison) and EC (comparison) (not mentioned in the article) chapters are up for review and comment on proposed changes through the end of this month/first week of Nov.  Even if you don't plan to comment it would be a good idea for JCSC, HR, P&T, EOC to download a copy for the heads up.  Tip: Save time. First read the "Guide to Viewing Reports" and then download each chapter's  "Comparison of Current to Revised Chapter" for a faster review.  [Abstract]

Pg10-  September 2007 Accreditation Manual Updates Mailed.  FYI JCSC. [Abstract] .

[Index]                                    The Source (October, Vol 5 #10)

Pg01-  Reducing Pediatric Medication Errors:  If your facility has a Child program, your P&T should review this article and the useful Evaluation Checklist for Medication Management in Pediatric Populations in figure 1 on page 6.  Reference is made to the USP, the American Academy of Pediatrics (AAP), and the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP)*  for additional guidelines. [Abstract]  *Note: We couldn't find relevant guidelines here. Let us know if you do.

Pg03-  Joint Commission Infection Control Standards and Revised CDC Guidelines: (Compliance with Standards IC.3.10 and IC.4.107):  In June 2007 the CDC updated and expanded its 1996 Guideline for Isolation Precautions in Hospitals.  The new guidelines are entitled Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Although they have not been officially adopted into TJC standards yet, ICofco are encouraged to review the new guidelines and ensure familiarity with the Six Major Targets for Infection Control suggested in the article. [Abstract]

Pg04-  Organization wide Planning Processes and the Leadership Standards (Compliance with Standard LD.3.30):  FYI LDR , PI and JCSC.  This article encourages the planning function required by LD.3.30 (effective  Jan 09,) in general and provides a brief overview of FMEA, RCA, Balanced Scorecard and Six Sigma.  PI may want to expand their knowledge on the latter two concepts.  See also SL1: 1210 PI - Data Analysis, Oryx, Core Measures, Etc  [Abstract]   See also SL1_1220 LD Planning, SL1_1210 PI Data Analysis

Pg07-  Pandemic Influenza Preparedness 2007Update (Compliance with Standard IC.4.15):  ICofco should be aware of the new (April 2007) OSHA  guidelines entitled Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers.(PDF).  Hint: We note more TJC articles referencing  various precautions (e.g., standard, contact, droplet and airborne).  Be sure you understand and are able to talk about these and their applicability to your facility/patients. [Abstract]  see also: • APIC:  Position Paper: Improving health care worker influenza immunization rates  (PDF)

Pg09-  Miami Valley Hospital Moving Safety Program: Sustaining the Momentum in Fall Prevention:  This is a spotlight on Success article.  FYI: your coordinator of fall reduction program, JCSC and SFTofco. [Abstract]

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[index]                                      Patient Safety (October, Vol 7 #10) 

Pg01-  Preventing Medication Errors Associated with Drug Suffixes:  This is a relatively long article that makes one aware of a potential problem but does not provide much in the way of practical solutions (e,g,perform an FMEA on all new drugs).  FYI: Phrm, P&T.   [Abstract] 

Pg07-  Strategies for Complying with the Time-out Before Surgery Requirements:  If you have a dental dept have them review the Tips and Strategies for Meeting the Universal Protocol Time-out Requirement in the sidebar on page 8   [Abstract]

Pg10-  Sharing Ideas to Save Lives: Highlights from JCR’s 2007 Infection Control Conference:  Idea of  'Creating a “Zero Infection” Culture' is introduced and encouraged.  FYI: ICofco.   [Abstract].

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

Pg01- Making Sure HCWs Are Vaccinated for Flu: Lack of Vaccination Can Result in Fatalities Among Vulnerable Populations - The article tells us that our staff can be a key cause of flu outbreaks (many of those infected are asymptomatic) and yet less than 40% get  immunized.  This article should be read by ICofco, LDR (esp RNx) for its encouragement and advice on increasing rates of staff immunization.  Contains useful chart addressing common points of staff resistance.  [Abstract]  See also:  APIC position paper: Improving health care worker influenza immunization rates  (PDF)

Pg04- Importing Existing Excel Spreadsheets into the e-PFI:  For those of you who used Excel spreadsheets to manage your Life Safety Code deficiencies, you can now import that info directly into the eSoc if you modify you form to match TJC's template exactly.  Detailed instructions provided. FYI EOC and JCSC.   [Abstract]

Extra/Confirmed- Frequency of Damper Inspections Have Changed -  FYI SFTofco and EOC.  It is now officially in print (see 'This Month' above).  Because of changes in NFPA 80, TJC's required frequency for fire/smoke damper inspection in hospitals has been extended from 4 to 6 years.  (More Details)

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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  
  

   

SHCC Additions

Recent Surveys

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

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F&A