2 Mar 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)
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THE JOINT COMMISSION (TJC and JCR)
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Publications
Joint Commission This Month For State Hospital Associations (March 2008)
Accreditation
- MS.1.20 Task Force to continue its work Significant field discomfort with MS.1.20 is the likely cause of this continuation. Check out the 11/1/07 audio conference on this subject and you'll get a sampling. No change in the intended July 2009 effective date but this task force to make its recommendations next month. Stay tuned.
- Methodology established for conducting surveys in 18-39 months See review in Perspectives below.
- New scoring and accreditation decision process approved HOT! FYI: LDR and JCSC A "new, improved and simplified scoring and decision process" is to go into effect on Jan 1, 2009. Proposed changes are to be finalized and published (both the renumbered standards and a comparison table) 7/1/08 on the TJC website and your extranet site. Print versions should be available in September, 2008. This is all part of the Standards Improvement Initiative (SII) an if you have not been paying much attention before, you may want to catch up by reading 'Standards Improvement Initiative: An Overview' (PDF) and/or our review of Standards Improvement Initiative Update in the January RTP (The Source, Vol6,#1).
- Standards Improvement Initiative update Click the proceeding link for the latest timeline.
- reviewing recent related articles in the Accreditation & Survey Process (ASP) Highlights page (SL1 - 1010)
Certification NA
Performance Measurement NA
Public Information
Communications
*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 (March, Vol 28 #3)
Pg04- Update: Methods to Transmit Fire Alarm Signals: Manual Transmission Permitted Under Certain Circumstances Following NFPA 101-2000, 9.6.4, TJC now permits (if the conditions described in the article are met) the use of a manual transmission method for fire alarms. A sidebar briefly highlights the less frequent (annually) testing required for Digital Alarm Communicator Transmitter [DACT] systems. FYI: EOC, SFT.
Pg09- Update: Standards Improvement Initiative SII is now in its 2nd phase and will begin refining current standards (vs. adding new ones) in the Behavioral, Lab and Long Term Care Programs. The SII timetable through Jan 2009 is included. FYI: JCSC
Pg10- New Patient Flow System Tracer for Critical Access Hospitals and Hospitals TJC implemented this new system tracer at the beginning of this year to evaluate patient flow problems. MDx, RNx and case coordinators should note the article's reference to 'restricted' care suggesting that delays or untimely access to patient care could be the likely trigger for this tracer. The article also warns us that while LD.3.15 is the only place the term 'Patient Flow' is used, there are other related standards that may also be impacted/cited.
Pg11- Update: Sentinel Event Statistics This is the same announcement reported in last month's RTP in the 'This Month' section. FYI: JCSC
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[Index] The Source (March Vol 6 #3)
Pg04- Medical Staff Communication: Cornerstone of Care Coordination—Standard MS.2.20 Much of what this article encourages in the way of multi-disciplinary team processes is old hat for psychiatric programs, but MD should take note of the growing emphasis on effective communication for the medical staff. This time it is as a function of MS.2.20 that focuses on the requirement for coordination of care. Even structured communication techniques like SBAR (ala NPSG 2E - Handoff communication) are increasingly being suggested for physicians. MDx and StEd might consider this as a handout (for a medical staff meeting or LIP orientation packet) to increase awareness and as supportive education for the Six General Competencies (i.e., Interpersonal and Communication Skills).
Pg06- Maintaining Existing Privileges—Standard MS.4.40 If your medical staff is still refining its approach to Ongoing Professional Practice Evaluation (OPPE), MS.4.40, your JCSC and MEC should find this article useful. It includes some suggestions (e.., "It is imperative that the medical staff determine red flags to indicate when further investigation is necessary") and a couple of tools (e.g. questionnaire for assessing patient perceptions of MD preformance) that TJC thinks are worthwhile. Tip: Most useful TJC explication of this topic so far. Article references included:
• Understanding Focused and Ongoing Professional Practice Evaluations {Info]
• Measuring patient views of physician communication skills: Development and testing of the Communication Assessment Tool (Be aware there is a $31.50 cost for this by a company called Science Direct)
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[index] Patient Safety March Vol 8 #3)
Pg02- Patient Safety Pulse: Your Patient Safety News
- Physicians: Medical Error Reporting Systems Do Not Measure Up: FYI: MDx and P&T. Report of study that says MDs would report more errors if reporting systems were better and their suggestions for improvement.
- Blacks, Hispanics less likely to receive pain medications: as per study in the January 2nd issue of the Journal of the American Medical Association.
- Increasing diabetes screening recommended: American Diabetes Association (ADA) now recommending more screening of patients for pre-diabetes and early preventive measures to stop progression to type 2 diabetes. 2007 ADA Clinical Practice Recommendations
Pg03- Notes from the Field: When Medication-related Technology Doesn't Work Correctly Useful discussion of key considerations for organizations evaluating or implementing various medication-related technologies (e.g., CPOE) IT, Phrm, P&T should note the encouragement for developing more awareness about health care informatics and the related references/resources provided. Also check out the Sidebar: Mitigating Risks During the Medication Management Process.
Pg04- Strategies for Improving Health Literacy This topic is occurring more frequently in TJC literature suggesting LDR, PtEd, PtAd StEd and others invested in effective patient participation (NPSG 13) should attend to this issue and take note of the strategies (e.g., Rule of 15) and related freebees (e.g., US Pharmacopeia - USP pictograms or Readability Toolkit created by The Group Health Center for Health Studies (CHS) in Seattle, Washington) in this article. See also [**REf**} Accreditation Essentials: Cultural and Linguistic Issues in the Informed Consent Process July Source Vol5,#7 (review in 2007 July RTP) PtEd see also: NIH: free plain language internet-based training course
[Index] Environment of Care News (March, Vol 11 #3)
Pg01- Special Populations in Emergency Management: Sinai Health System Decontamination Drill Mainstreams Special Populations If any portion of your patient population has significant physical or communication limitations, this article is worth browsing by SFTofco and may have useful ideas for your next disaster drill. FYI: Those treating the deaf (CRMHC, GMPH).
Pg04- Q & A This article address several EC-related FAQ to include Conducting Environmental Tours; Testing of Automatic Transfer Switches; Management of Hazardous Wastes. EC and SFT should pay particular attention to the issue of proactive risk assessment for security risks (EC.2.10). JCSC will also find a useful clarification on e-SOC management for those who share building space with another HCO.
Pg08- Case Study With Expert Commentary—Portable Oxygen Storage: Safety Through Inventory Management: Cleveland Clinic's Elegant Solution EC and SFT will find this case study provides good review of key risks and requirements related to portable oxygen storage. EC News provided a more comprehensive review in Volume 10, #6, June 2007 EC 101: Safe Oxygen Cylinder Storage: Following Cohesive Guidelines (review in 2007June RTP)
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
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- February 8, 2008 - Ref: S&C-08-12 Re: Hospitals – Revised Interpretive Guidelines for Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Orders; Securing Medications; and Post-anesthesia Evaluations Final Rule. {HTML} {PDF} FYI: JCSC, MDx, RNx, P&T
- Vol1 #1 - Re: Case Management/Targeted Case Management (DYN?) LDR, FB
INTERNET HIGHLIGHTS
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: Includes presentations on suicide
Centers for Disease Control and Prevention (CDC)
- Hand Hygiene Interactive Education Free online Course including 60-second hand hygiene video can be completed in less than 15 minutes. Good review. StEd, RN
SHCC Additions
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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