1 Apr 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)
.
***SHCC Security Upgrade on 4/3/08***
On Wednesday evening, 4/3/08, we will be updating our password security system. You will still have the same password for the next several months. However, if you saved your password on a bookmarked page, you may have to re-enter it manually and remake your bookmark. We apologize for any inconvenience.
If you have questions or problems please call customer service at (404) 437-7463
.
THE JOINT COMMISSION (TJC and JCR)
.
.
Publications
Joint Commission This Month For State Hospital Associations ( April 2008)
[Note: All of the 2008 issues of this publication have been significantly delayed. April is now the most current issue. When a more current issue becomes available it will be reviewed and posted.
Accreditation
EC.4.11 EP 9, 10 EC.4.12 EP 6
EC.4.13 EP 7 EC 4.14 EP 8, 10
EC.4.15 EP 2, 3, 5 EC.4.16 EP 2, 3
EC.4.17 EP 4 EC.4.18 EP 4, 5, 6
- Countdown to 2009: Free electronic manual This November, in addition to the ususal hard copy standards manual, TJC will provide a free single-user 2009 electronic version of the manual that it is calling an "E-dition". More detail coming in Sept. PDF versions of the standard manual will be available on your TJC intranet starting in July and continuing until print versions are published in Sept. FYI: JCSC,
Patient Safety
Public Information
*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 (April, Vol 28 #4)
Pg01- Approved: Methodology for Conducting Unannounced Surveys Within an 18-39 Month Window [**REF**] TJC reports that at its Feb 2008 Accreditation Committee meeting it approved the methodology for conducting unannounced surveys within the 18-39 month window. It is not clear how this is different from what was approved back in March of 2003, but the article offers best review to date of this issue and its related billing. Worth reviewing by JCSC, LDR and F&B.
Pg05- Strategic Surveillance System (S3): Dispelling the Myths This article addresses mis-information about S3 such as its data being used against hospitals at survey time or for predicting unannounced surveys. If not already using S3, JCSC, IT and LDR may wish to revisit this tool around mid year when TJC indicates it will provide comparison groups for psychiatric hospitals. Please let us know if you have made use of S3 {FdBk}
Pg07- Correction: Standard MS.4.30, Element of Performance 1, for Critical Access Hospitals and Hospitals The correct scoring category designation for EP 1 of Standard MS.4.30 should be “A.” JCSC and MS should note that although TJC has internally corrected the error, the PPR will continue to indicate category “B” until it is updated in January 2009.
.
[Index] The Source (April Vol 6 #4)
Pg01- Survey Challenges: Reducing Unanticipated Adverse Events: Complying with Standard PI.3.20 This article gives an overview of various aspects of the required ongoing proactive safety program that may be of interest to PI and RNx. (Note that the standard PI.3.20 is currently under review and is planned to be moved back to the LD chapter in 2009; however all programs being surveyed during 2008 need to comply with current PI requirements.) As a major component for the proactive safety program, most psychiatric hospitals use a Failure Mode and Effects Analysis (FMEA) approach to select and engage in the required year-long analysis of a high risk issue annually. Additional proactive strategies that the article encourages include participation in voluntary error reporting systems, campaigns to reward staff for reporting near misses and errors as well as standardization of processes. A useful sidebar lists seven clear steps for nurses to take to prevent adverse events. The intent is to integrate these and other elements into strategies that build an effective, proactive safety program. TIP: Some psychiatric hospitals list the various components of their comprehensive proactive safety program on one page for staff training and for surveyor reference - by VK
Pg04- Areas Affected by Quality of Care: Connecting with Standard HR.1.30 HR, RNx and PI should note this review of approaches to Staffing Effectiveness (HR.1.30), a standard that many psychiatric hospitals report to be a burden. The intent of the standard is to identify and address nursing shortages as well as skill mixes for clinical staff that may be related to specific quality of care concerns in your hospital. The article gives some guidance for selection of indicators and selection of at least two units/divisions for measurement, but you need to follow the standard for very specific guidance. TIP: Some psych hospitals successfully combine one staffing effectiveness indicator with their data collection requirements for PC.12.180 regarding restraint and seclusion. One interesting point is that, rather than having a focus on nursing and medical leaders, the author indicates that the multidisciplinary team to address staffing effectiveness should include minimally the following: human resources, clinical services, performance improvement, patient safety, leadership, risk management, finance/payroll, and information management. - by VK
Pg06- Restraint or Seclusion Variables in Standard PC.12.30 RNx, StEd and C&A should find this is a good overview of training staff to be competent to minimize the use and to ensure safety when applying restraint or seclusion. The author describes a CQI project for a behavioral health partial hospital that taught staff to focus on developmental variables. The article lists ten points to include as part of training sessions and presents some teaching methods. Probably the most important point addressed is the need to monitor individuals and to use assessment data from admission regarding problematic behavior so that it can be managed. TIP: Psychiatric staff who manage behavioral crises effectively have a clear process for using information that they keep in a readily accessible location for each individual regarding challenging behaviors. The information includes any known triggers, de-escalation techniques, interventions that are not successful, etc. The information is updated at de-briefings if an episode of seclusion or restraint is required and some hospitals give the patient his or her own copy. - by VK
.
[index] Patient Safety (April Vol 8 #4)
Pg01- Implementing National Patient Safety Goal Requirement 3E: A Model Plan [**REF**] Although the article is written from the perspective of acute care hospitals, Phrm and P&T should find the suggested implementation steps and checklist a useful resource. Note: The first milestone should now be in place!
Pg03- Medical The 'Top 5 in the News' column included the following tidbits: A) "Patients who experience cardiac arrest (NPSG 16) in a hospital are more likely to die if the arrest occurs after 11 P.M. than if it occurs earlier in the day, according to a study in the February 20th issue of the Journal of the American Heart Association." B) "A new analysis of the nation’s death rates recently released by the CDC found that the suicide rate (NPSG 15) among 45 to 54-year-olds increased nearly 20% from 1999 to 2004."
Pg08- Improving Control of Concentrated Electrolyte Solutions As far as we know, none of our members use these solutions. However, if you do, this would be a useful article (for Phrm, P&T and RN) and we would ask you to please give us some feedback. Please let us know if your facility uses concentrated electrolytes {FdBk}
Pg11- Clinical Pharmacists Seek Ways to Address Medication Errors FYI: Phrm,. Article is a discussion of three Pennsylvania-based organizations that are addressing polypharmacy issues via participation in a fellowship program funded by the Jewish Health Care Foundation. Our research discovered that there are actually more projects under this fellowship than were described in the article and 2 of them address issues more relevant to us (e.g., polypharm and falls/NPSG 9, In-to-out patient transitions). Project results are expected by year's end. We have requested additional details from the University of Pittsburgh and will keep you posted.
[Index] Environment of Care News (April Vol 11 #4)
Pg01- Planning for an Evacuation: Hospital Shares Lessons from California Wildfires Much of the same kind of information presented here has been provided in earlier articles following 9/11 and Katrina. Still EOC, SFTofco and LDR may find this a useful quick review of key issues specifically related to evacuations and standards EC.4.11- EC.4.18.
Pg04- Award-Winning Healing Garden: Nature's Power Aids Recovery at Schwab Rehabilitation Hospital This piece describes a roof-top garden approach by a Chicago Rehab hospital. However, many of our facilities have little-used courtyards (not to mention acerage) that might be advantageously revitalized as a 'Healing Garden'. In the context of EC.8.10 LDR, PtAd and RHB are encouraged to give this a read.
Pg08- A Global Perspective on Hand Hygiene: Meeting the World Health Organization Guidelines on Hand Hygiene in Health Care Background about WHO guideline development and applicability (outside the US and smaller communities) and some comparison with CDC is provided. Also includes a useful sidebar on 'Factors That Influence Compliance with Hand Hygiene Practices' However, we would refer IC, EOC and RN interested in the comparison to the CDC/WHO Hand Hygiene Crosswalk in the Dec 2007 issue of Patient Safety (refer to SL4_ December RTP or SL1_1140.00 IC Highlights)
.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
.
INTERNET HIGHLIGHTS
National Association of State Mental Health Program Directors (NASMHPD)
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].
.
.
F&A
|
