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)

Accreditation
- New Consideration given to previously identified compliance issues through full PPR and PPR Option 2 See the Nov RTP where we commented on this when it was first* announced in last month's Perspectives
- Elimination of track record requirements and Early Survey Policy -Option 2 See the Sep RTP where we commented on this when it was first* announced in that month's Perspectives. This only applies to initial surveys
- Joint Commission Announces Task Force on Implementation of MS.1.20
- Although MS.1.20 does not become effective until July 2009, it has already stirred a fair amount of concern in the field. TJC has responded by establishing a 15-member task force that "will analyze the potential impact of implementing the revised standard" and "suggest mitigating remedies that will support achievement of the objectives of the standard revision". Report of the task force is expected during the February 28-March 1, 2008 Board of Commissioners meeting. MDx should stay tuned and track this issue.
- Field review of proposed Life Safety chapter Comments and feedback will be solicited through January 22. Field Review. Online Survey. http://www.jointcommission.org/Standards/FieldReviews/lsc_field_review.htm. (Contact: Jeff Conway, jconway@jointcommission.org)
- Standards Improvement Initiative update Comments/feedback being solicited for the first half of the Provision of Care, Treatment and Service chapter through January 17. Online Survey. Even if you don't plan to comment it would be a good idea for JCSC, RNx, MDx to download a copy of the proposed revisions 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. (SII)
Communications
- Coming soon to Quality Check®: CMS 30-day mortality measures (mortality measures are for heart attack and heart failure)
- 2008 Ernest Amory Codman Award - Applications now available. New Codman Website

*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.

Pg04- Joint Commission Requirement: Approved: 2008 Thresholds for Conditional Accreditation and Preliminary Denial of Accreditation - The triggering number of RFIs for Conditional Accreditation is still 10 for small hospitals (< 100 beds) but has risen to 14 for large hospitals (≥ 100 beds). The number for Preliminary Denial of Accreditation remains 14 for small hospitals but increased to 18 for large hospitals. FYI: JCSC.

Pg07- Update: Standards Improvement Initiative - The Standards Improvement Initiative (SII) continues to roll along with more chapters being reviewed and revised for clarity of language, logic, etc. There is even some consideration being given to a new approach to scoring and the accreditation decision process. Such possibilities make SII worth monitoring as we approach the January 2009 implementation date for these changes. Mock surveys using the improved standards are to begin in the first quarter of 2008. Please let us know if you are selected. FYI: JCSC.

Pg01- Complying with a New Leadership Standard: Disclosure Methods and Solutions—The Power of Positive Communication : [**REF**] Article provides insight about the importance of complying with LD.2.30 (e.g., "…civility is maintained between leaders so that the safety and quality of care is not compromised by conflict".) and some suggestions for compliance. LDR should read this to help inform their planning process for the January 2009 implementation. Also take advantage of recent conference call discussion materials on the new leadership standards (10/25 and 11/1)

Pg04- Accreditation Essentials: Top Compliance Issues for 2006—Standards PI.3.20 and HR.4.10 : This article plugs the use of FMEA for compliance with PI.3.20 and gives a rudimentary overview of the process. A similarly elementary review of credentialing is given for compliance with HR.4.10. The only take home from the latter is a reminder of the requirement to verify identification with picture IDs. FYI: PI and HR. [For more info on FMEA goto SL1: 1210.02 PI]

Pg06- Accreditation Essentials Link: Transfer or Discharge and the Continuum of Care - This article provides a reminder of the importance of NPSG 2E (handoff communication) in relationship to transfers and (especially) discharges (PC.15.30). MD and SW might find it useful to review the brief section on 'Compliance with PC.15.30' to ensure your discharge process and summaries measure up.

Pg08- Joint Commission Resources Presents: Practice Leaders: Population-Specific Staff Competence - Although it does not really feel like a Part 2 to last month's article, it is more meaty. If your hospital serves special populations (e.g. children/youth, geriatric, forensic, MR/DD), HR and discipline chiefs (MDx, RNx, SWx, PSYx) should find it useful to review the suggestions for defining population-specific staff competence.

Pg01- Medication Reconciliation at Admission - For MD, P&T and JCSC the take homes in this article are the 2 sidebars that provide a useful review of the Med Rec process. Could be a useful handout. Scan the rest of the article if you have time.

Pg02- Patient Safety Pulse: Your Patient Safety News - If your program has residents, the statistic referenced here is probably not surprising. However, the additional finding that much of that error was attributable to the failure of the attending physician to properly oversee/supervise their work is well worth noting by MD, MDx and P&T.

Pg03- New! Notes from the Field: Positioning Your Organization for Patient Safety - 4 steps are identified for helping your hospital define an appropriate approach to safety. Although fairly obvious and generic LDRs might find the steps a useful if you have concerns about the organization of your safety efforts and are considering refinements.

Pg06- CDC/WHO Hand Hygiene Crosswalk - [**REF**] Hallelujah! TJC has finally produced a crosswalk that IC should find quite useful. Beyond WHO's expanded application of hand hygiene (e.g., after pt contact) and its simplification/clarification of some terminology, the biggest differences we see are:
1 - WHO specifies no time frame for hand-washing. Emphasizes technique
2 - WHO discourages artificial nails in all settings (vs CDC's hi risk only)
3 - CDC prohibits glove reuse while WHO allows (not encourages) it

Pg11- Focus on Five: Evaluating Patient's Risk for Falls - [**REF**] Article identifies 5 key elements to include in a fall risk assessment/prevention program and contains several useful references for MD, RN, SFT. See also: Fall Prevention overview by Premiere Inc Healthcare Alliance

Pg01- Emergency Management Standards: Complete Text for Critical Access Hospitals, Hospitals, and Long Term Care : First officially published in Perspectives, June 2007 (refer to June RTP), the revisions for EC.4.10 (Emergency Mgt) are presented in detail (revised text shown with underlines/strikeout) and with a summary of the key changes. EOC, SFTofco and PPR for EOC should review this article as a double check for compliance with these revised standards that become effective Jan 1, 2008.

. Quarterly Provider Updates

Mid-Quarter Instructions

What's New