Perepectives Pg03-Approved: Remaining Component to the Accreditation Decision Methodology for 2009FYI: JCSC. The Joint Commission has just announced the eagerly awaited, final component of the 2009 accreditation decision methodology in the December 2008 edition of Perspectives. As a result, the use of “thresholds” (a set number of not-compliant Direct Impact standards) as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA) have been eliminated.
Consequently thresholds of RFI's will only serve as “screens” for identifying organizations whose survey findings should be subject to a more intensive review by Joint Commission Central Office staff, rather than serve as “automatic” determinants of CA and PDA decisions. This review will be in addition to the review conducted for organizations that meet a Situational Decision Rule for an adverse accreditation decision or for which an Immediate Threat to Life has been declared… [See attached RTP for the rest of this review] by Glenn D. Krasker, MHSA
Letter from Dr. Chassin: The Use of Standing Orders in HospitalsAlthough every hospital was sent this letter, JCSC should make sure that it is reviewed and its implications are fully understood by Phrm, P&T and MDx. CMS and TJC are now in synch on this issue so there is no room for error here. See also S&C-09-10 (PDF) : “Standing Orders” in Hospitals.
December Reference Articles
Source Pg04-Evaluating Your Culture of Safety—Knowing and Growing: Compliance Strategies and Tips for Standard LD.03.01.01[**REF**] LDR, PI and JCSC should note that "at least a baseline cultural evaluation" is to be completed by 1/1/09. Previously, TJC had avoided identifying 'valid and reliable tools' for performing cultural assessment. [Pearl] However, in this article they reveal the following two, free tools that will apparently meet their requirements:
1. Agency for Healthcare Quality and Research: AHQR Patient Safety Culture Surveys. (accessed Oct. 20, 2008).
2. Sexton J. B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 6:44, Apr. 2006.
Pg02-Patient Safety Pulse: Your Patient Safety News:Health Care Groups Develop Infection Control Compendium. [**REF**] The compendium was contributed to by the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, The Joint Commission, the American Hospital Association, and the Association for Professionals in Infection Control and Epidemiology. The focus is on acute care hospitals, but the principles are still valuable and… it is available for free. IC should at least review the following:
• S12 Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals Abstract- Full Text- PDF Version
• S62 Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals Citation- Full Text- PDF Version
• S81 Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals Citation -Full Text- PDF Version
EC News Pg08-Suicide Prevention and the Inpatient Room: Bricks and Sticks and Beyond[**REF**] David M. Sine, ARM, CSP, CPHRM and James M. Hunt, AIA are co-authors of [PEARL] Design Guide for the Built Environment of Behavioral Health Facilities, the bible for in-room furnishings that help prevent suicide. In this article they share updates on some of the latest materials and approaches used to reduce the environmental risk of suicide. Did you know that all bathrooms do not have to be ADA compliant? (refer to Code of Federal Regulations at 28 CFR 36.301(b).) SFT, EOC and E&M should definitely read this article and download a free copy of their Design Guide to help better address EC.1.10, EC.1.20 and EC.8.10
DB: HFAP Accreditation - JCSC: Is anyone aware of a psychiatric hospital in your State, either public or private that is HFAP accredited (Healthcare Facilities Accreditation Program)?
PSQ: Assistance with Post Survey Questionnaires: State-hospital specific feedback on recent survey experiences is a unique and valuable part of the SHCC databases. We really need all the outstanding PSQ's now so that we can analyze them and identify trends in time for January '09. We know this is a bad time of the year for extra work, so we would like to offer a hand. If you have not yet submitted your PSQ, just attach and e-mail or fax (770.389.3700) us a copy of your survey report and our staff will draft a PSQ for you. Please check your status below.
2008/11-tjc-Arizona State Hospital (AzSH)_4Ad1Ca4Fr [PSQ - pending]
2008/08-tjc-Mary Starke Harper Geriatric Psychiatry Center (MSHGPC)_2Ge[PSQ - pending]
2008/08-tjc-Manhattan Psychiatric Center (MPC)_??????*Viol*Polydip*Hisp[PSQ - pending]
2008/07-tjc-Kirby Forensic Psychiatric Center (KFPC)_3Fr [PSQ - pending]
2008/07-tjc-Bronx Children's Psychiatric Center (BCPC)_2Ca*Clozaril[PSQ - pending]
2008/06-tjc-Queens Children Psychiatric Center (QCPC)_!2Ca [PSQ - pending]
2008/06-tjc-South Beach Psychiatric Center (SBPC)_!7Ad1Ca*Consumer Ntwrk [PSQ - pending]
