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)

*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.

Pg01- Top Standards Compliance Issues for First Half of 2007 The top 10 non-compliance standards are listed and a little detail given on what is involved in making the list. JCSC and PPR team chairs should ensure your practice tracers and PPR rigorously address these issues. Note: The usual 'perforated cards' listing the Top 10s by program were not included in our online version. This review will be further updated once those are obtained

Pg03- Reminder: Revisions to Accreditation Participation Requirement 17 for Hospitals This 'reminder' about the need for MD education and involvement (without retaliation) in reporting safety concerns to TJC is old news (originally published in August 2007 Perspectives, pg11). MDx and StEd should consider making APR 17 an annual handout for general staff (e.g., in annual trainings) and med staff (e.g., in an annual meeting with documentation in minutes or as part of the credentialing/re-credentialing packet). The revision became effective 1/1/08 but was 'inadvertently omitted' from the most recent updates. Ergot this reminder.

Pg04- Correction: Standard Ld.3.50, Element of Performance 9, for Critical Access Hospitals and Hospitals If you obtain interpretive services via telemedical link, your MDx and LDR should understand the small but significant reduction in the credentialing/privileging process exception this correction causes in LD.3.50. Others may skip this one.

Pg04- CDC/WHO Hand Hygiene Guidelines Crosswalk IC will find the only thing new since TJC first published (Patient Safety, Vol 7 #12, Dec 2007, page 6) this crosswalk (included in article) is the announcement of a link to a down loadable version (PDF) of it on the JCR website. The December article had more TJC commentary. You can see our highlighting of key differences (vs. CDC) in our Dec RTP.

Pg08- Promoting Effective Communication—Language Access Services in Health Care [**Ref**] TJC has increasingly been underscoring the importance of effective communication particularly as a factor in avoiding errors and promoting safety. In addition to federal law (Sec 504 of ADA and Title VI of CRA) standards like RI.2.100 and IM.6.20 actually require specific attention to documenting and accomodating language needs of patients. This article gives a good overview of why this is important, suggests steps for addressing it and provides a good mumber of useful reference resources. JCSC, PtAd, PtEd and LDRs should review this article and consider the assessment of language and communication needs it recommends. PEARL - Literature is now discouraging the common practice of using family members (esp children) as interpreters. See Also Cultural and Linguistic Issues in the Informed Consent Process - [*REF*] RI HIghlights Page/July

Pg01- Coordination of Care: A Provision of Care, Treatment, and Services This article is an encouragement for collaborative interdisciplinary care (i.e.,PC.5.50). Two articles (from nursing journals) are cited of organizations describing their new use of an interdisciplinary rounding process. Not much in this for psychiatric facilities used to multi-disciplinary treatment teams, rounds and treatment planning. We don't usually have much difficulty with PC.5.50 unless a core discipline is not participating in rounds/treatment planning or not responding (e.g., consults) or not coordinating (i.e., collaboration problem) their efforts with the rest of the team. FYI: TxTm.

Pg04- Health Care-Associated Infections: Safeguards for Infection-Free Care This is about complying with Standard IC.4.10 and IC should know that active surveillance cultures (ACSs)* is an 'emerging strategy' for prevention and control of MRSA and might find it interesting to know about Hazard Analysis and Critical Control Point (HACCP)**. HACCP is a FEMCA-like process that can be applied in a variety of areas but was originally developed (1960's) to address food safety. This may be a tool worth calling on if your facility has had recurrent concerns with food safety (e.g., contamination).

*Re ACS: SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus (PDF)

**Re HACCP: US FDA/CFSAN HACCP--Hazard Analysis and Critical Control Point {HTML} or Wikipedia {HTML}

Pg06- Bear in Mind the Level of Understanding During Care—Standard RI.2.100 For JCSC, PtAd, PtEd and LDRs, this second February article on RI.2.100 will not be as rich as the one in Perspectives (above) and could be skipped if you only have time for 1. PEARL: Literacy is a stronger predictor of a person’s health status than age, income, employment status, education level, and racial or ethnic group.

Pg04- Evanston Northwestern Healthcare 2007 John M. Eisenberg Award Winner A med-surg facility's successful use of a 'universal surveillance initiative' to reduce MRSA prevalence is presented. Basically an FYI for IC, who might benefit from reading the brief discussion of testing methodologies included.

Pg01- Strategies for Health Care Providers Who Communicate with Family Caregivers: A third Feb article on communication, this time as it relates to NPSG 13 (encouraging Pts and family to communicate about safety. Although the article is med-surg focused, its suggestions for clinicians in their meetings and communications with family members are useful. SW, PtAd, StEd, MD and RN might consider making those tips into a handout. .

Pg02- Nurse group creates staffing Web site: Any LDR, RNx, or HR with concerns about nurse staffing should check out this site. It has some useful references, guidelines and possible ammunition for use with legislators and budget folk.

Pg04- Patient Suicide: Complying with National Patient Safety Goal 15A This is a fair review of general principles (and risk factors) for complying with NPSG 15 that MD and RN might find useful. Its references include the PEARL APA's Quick Reference Guide for Treating Suicidal Behavior that all MD and MDx should be familiar with. See also SL1_1040.20 NPSG15 - Suicide Risk Assessment/Prevention/Treatment - {Info}.

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