ALL: Everybody, FB: Finance/Business, CHP: Chaplain, C&P: Credentialing & Privileging, E&M: Engineering & Maint, EOC: Environment of Care, 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, MDx: Medical Director, 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, RNx: Nursing Exec, RHB: Rehab/Activity Therapy, RN: Nursing, SFT: Safety, StEd: staff ed & training dept, SW: Social Work, TxTm: Treatment Team

Pg07- Update: Clarification Process and Periodic Performance Review Process The use of Evidence of Standards Compliance (ESC) is briefly reviewed and TJC's position that corrections made during survey no longer remove an RFI is confirmed. Good News: If you report your PPR to TJC and an issue cited during survey is one you self-identified and the implementation date for your Plans of Action (POA)/Measures of Success (MOS) has not passed, the RFI will stand, but not count toward the accreditation decision threshold (e.g., for PDA). JCSC should read this for the details and consider it good motivation for performing a rigorous and accurate PPR. It may also be impetus for GB who chose non-reporting PPR Options 1 or 3 to reconsider since this saving grace does not apply to them. See also: Facts about the Performance Review and Guidelines for Submission of Evidence of Standards Compliance (PDF)

Pg08- Correction: Rationale for Standard EC.4.16, for Critical Access Hospitals and Hospitals The language change relating to disaster privileges (MS standards) and responsibilities (HR standards) should be noted by EOC, but is not significant.

Pg08- How to Access Your Online Version of The Joint Commission Perspectives^® As a TJC customer you are entitled to receive Perspectives in both the print and online versions. However, you must take action (i.e., activate) to receive the latter. JCSC, if you have not activated your online version follow the directions in this article.

Pg09- Correction: Standard EC.4.20, Element of Performance 4 EOC should note that the ability to conduct separate or simultaneous exercises for EC4.20 has been extended to include EP#4 of that standard

Pg10- Correction: National Patient Safety Goal 3, Requirement 3E Applicability The correction is that 3E is not applicable to the office based surgery program. .

Pg01- Complying with the New Leadership Standard LD.2.40 : [**REF**] Article focuses on the 2nd of 4 new sections of the 2009 leadership chapter and standard LD.2.40. GB, LDRs and JCSC should checkout the ideas for implementing requirements related to conflict management. Key suggestion here is to train more than one person (e.g., entire leadership group) in conflict management.

Pg06- Joint Commission Resources Presents: Practice Leaders: One More Time—Understanding Staff Competency : The Source was begun as the 'how-to' publication for SV/NP. Now TJC introduces a 'Practice Leader' (very knowledgeable and experienced subject/practice expert) who begins to provide 'how-to' on the issue of competency. I say begins because the author promises more 'detail' next month. Much of this intro tries to expand the 2009 Leadership analogy of Pillars to the concept of competency (as bricks and mortar). However, more importantly for HR and RN is the effort spent trying to relate risk assessment to competency. Amidst the (too) creative analogies and new terminology it was all but impossible to find the fundamentals of skills, knowledge and capabilities (refer to TJC Manual Glossary*) most of us have relied on to this point. Read this article to get a feel of the direction and stay tuned. *competence or competency A determination of an individual’s skills, knowledge, and capability to meet defined expectations. pg GL-4, CAMH Update 1, March 2007

Pg11- Communications Checklist - A 1-page check list is provided. It is a good breakdown of communication methods that could be useful to GB, LDRs and JCSC in the communication planning (think Pillar #3) you will need to do for the 2009 Leadership standards in general and LD.3.40 in particular.

Pg01- Tracking Medication Errors - Article moves away from individual responsibility to focus on system and process opportunities/strategies to improve medication error reporting. Useful review for P&T. especially if your reporting rates are uncomfortably low.

Pg02- Patient Safety Pulse: Study Finds Hospitals Lagging in Infection Control FYI: IC. 2 of 5 areas specifically mentioned as lagging were SHCC relevant: Hand Hygiene and Vaccinating Staff Against Influenza.

Pg05- Preventing Assault, Rape, and Homicide in Health Care Settings - Useful review for SFTofco of prevention actions and strategies. See also: Workplace Violence: OSHA Fact Sheet. (PDF)

Pg08- Engaging in Effective Patient/Provider Communication Although this article is primarily about communication surrounding end of life and palliative care, there are a few principles discussed that may be useful to all MD and PtAd. Article references two excellent resources:

1 - The EPEC Project (Education in Palliative and end-of-Life Ccare)
2 - EPERC (End of Life/Palliative Education Resource Center)

Pg01- Sneak Preview: Changes to EC Chapter: Initiative Is Making Standards Clearer, Manuals Easier to Use : In Aug 2006 TJC began the Standards Improvement Initiative (SII) for purposes of clarifying and consolidating standards. That process is expected to be completed by mid 2008 with changes going into effect Jan 1, 2009. Major changes involve EC requirements and the creation of new chapters for Emergency Management and Life Safety. Although there will also be an elimination of a number of EC redundancies (with chapters like PC, IC), TJC says there will be very little change in the actual standards themselves. Still, EC, SFTofco, IC, JCSC and are encouraged to browse this article and catch the sneak preview (online field review) coming in January. For significant 2008 EC changes see also June (Perspectives), Aug and Sep (EC NEws)

Pg04- Department-Specific EC: Clean Linen: Addressing Infection Control in the Laundry: Whether you still operate your own laundry or not, EC, IC and RN should review this article for its useful tips on transporting, storing and handling linens. Their suggestion for doing a risk assessment in this area is also worth considering. CDC has relevant guidelines or SL1:1140.00IC Highlights. See also: Aug ECnews, Pg04- Preventing Occupational Exposure in the Laundry Reducing Worker Exposure to Hazardous Drugs in Linens

Pg08- Safe Patient Handling and Movement: Is the Only Safe Lifting No Patient Lifting?: The CDC's National Institute for Occupational Safety and Health (NIOSH) published a revised Lifting Equation (1994) that recommended the use of 'assistive devices' when lifting more than 35 pounds and specifically exclude the lifting of patients. Although safe patient handling is only implicit in Joint Commission Standards (i.e., EC.1.10, #1,#4,#5), RN, SFTofco and perhaps HR should review this article. Useful RN refs.

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