2 Jan 2008
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: Culture of Safety, 96-hr Sustainability .
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations (January 2008)
*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 (January, Vol 28 #1)
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[Index] The Source (January, Vol 6 #1)
Pg04- Creating a Culture of Safety: Conference Call on Revised Leadership Standards - [**REF**] Changes in the new Leadership Chapter (effective Jan 2009) and implementation of the revised standard MS.1.20 (effective July 2009) are inter-related, important enough that LDR, MDx and JCSC should put in the extra effort it takes to keep up on these topics. although TJC is still clarifying and refining issues related to these topics, you need to begin advance planning for both now. That planning should be guided by the best available clarification so review this article, the referenced conference calls (11/1/07 and 10/25/07) and the SHCC highlights pages for Leadership and Medical Staff for relevant background.
Pg04- Accreditation Essentials: Are Your Patients, Clients, or Residents Involved in Their Care? - This may seem like a fluff piece, but in the context of increasing expectations for creating a 'culture of safety' (as required by new leadership chapter), patient involvement is right, required (i.e., RI.2.30) and a smart thing to encourage. PtAd, CHP, LDR and RNx should review this article and determine whether or not there are opportunities to improve the 5 key elements it suggests for shared decision making (SMD) and meaningful patient involvement.
Pg04- Standards Improvement Initiative Update - This is a good overview and update on the Standards Improvement Initiative (SII) that JCSC and LDR should be keeping abreast of. For more details and access to the related feedback surveys goto: http://www.jointcommission.org/Standards/SII/ PS: State Hospitals are strongly encouraged to provide feedback on the development of these standards to help make them more relevant and helpful (or at least less irrelevant and hindering)
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[index] Patient Safety (January, Vol 8 #1)
[Index] Environment of Care News (January, Vol 11 #1)
Pg04- Preparing for Catastrophes and Escalating Emergencies: Answers to Questions About 96-Hour Sustainability Requirements, Escalating Scenario Exercises - [**REF**] - This is the best explanation we have seen to date of the issue of 96-Hour Sustainability (to include identification of several acceptable responses and what needs to be in your EOP related to it) and how to conduct the Escalating Scenario Exercises. Must read for SFTofco and EOC .
Pg04- EM Case Study: Preparing for a Pandemic: How the Health First Hospitals of Brevard County, Florida, Developed a Pandemic Influenza Plan - WHO has raised the pandemic threat level of the avian flu to Phase 3 (out of 6) because its high risk of death. IC may find it useful to scan the case study (Note - the link provided to their Pandemic Influenza Plan does not work). It also provides several references to other pandemic preparedness planning resources as follows:
• http://www.pandemicflu.gov
• http://www.cdc.gov/flu
• http://www.who.int/csr/en/
Pg04- Fighting a Silent Enemy: Remediating Mold Before It Causes Harm - Many of our older facilities have mold problems, especially in the shower areas. This is a light review, but IC and EOC may find it useful to be reminded that in order to remediate a mold problem one needs first to eliminate the underlying water problem. A case example is included.
Pg04- Designing for Diversity: Cultural Comfort Makes for Happier, Healthier Patients - This article talks primarily about interior space touches that can help accommodate diverse patient populations in longterm care settings, but PtAd, CHP and E&M might find a few useful tips.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- October - (PDF) (contains 4 hospital-related items primarily related to claims, payment issues and a corrected ommission, CMS-3835-F2, that references psych hospitals but involves no changes for us.) FB
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NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS (NASMHPD)
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Presentations From the Winter 2007 Commissioner's Meeting - December 9-11, 2007, in Scottsdale, Arizona - Note presentations on suicide
SHCC Additions
- SL1: Highlights - pages have been added and/or updated for all chapters
- SL1: TJC 1000 - Section reorganized - new info on accreditation and survey processes
- SL2: CMS 2000 - Section reorganized - new info on regulations and guidance
- SL3: Federal Registry (FR) Find a Document (HTML) - for hard-to-find CMS rulings, etc
- SL6: FAQ - Frequently Asked Questions - New Feature!
- SL7: Premium Products Library - Now in new location as SL7
Recent Member Surveys (SL5)
- 3/6-7/07 Alaska Psychiatric Institute (API) [PSQ done]
- 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]
- 9/10-12/2007 Alton Mental Health Center (AMHC) [PSQ done]
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F&A
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