RTPp Vol2 #1
19 Jan 2009
January Full Reading Tips Page (RTP) Attached 2009
**ALERTS: 09NPSG, PPR Repop, NY CLIA, New Waived Tests **REFS: SEA #42, Contract Services, Disruptive Behav, Emerg Comm
Special: 2009 PSQ Data Analysis & 2009 NPSG Survey
PSQ Analysis: 25 of our 52 hospital members had Joint Commission surveys since January, 2007. 15 of those hospitals* contributed post survey questionnaires (PSQ). Evaluation of the input indicates:
The top non-compliant standards specific to State Hospitals are largely but not completely similar to those identified by TJC for all hospitals
SHCC members experienced most of their compliance difficulties in 5 particular chapters of standards
There appears to be a trend toward more unannounced TJC surveys for state hospitals occurring before 36 months
A more detailed summary of findings is now available in our first PSQ Data Analysis Report (PDF) and in the new PSQ Analysis section of the SL5 Survey Feedback Library.
2009 NPSG Survey: Because psychiatric hospitals are a small subset of the hospital field it is sometimes challenging to find the relevance of certain TJC requirements. Please make sure there is state hospital input on the refinement of National Patient Safety Goals. Note: the survey will ask you about NPSG 1-3, 7-9, 13, 15 and 16. Review these briefly to note the aspects of these that are unclear, inappropriate or unreasonable for our facilities. Then take the survey. At a minimum, ask for more psych-related examples. Only questions answered 'No' provide an opportunity for your input and comment. Takes 15-20 minutes. Click here and take the survey. Only 1 week left!
Alerts
- Perspectives: Pg01-Update: National Patient Safety Goals Undergoing Review During 2009—No New NPSGs for 2010 Based on compliance difficulties and feedback from the field, TJC has decided to perform 'an extensive review' of NPSG during 2009. Using the Standards Improvement Initiative (SII) process, NPSG will be clarified, revised and some redundant ones may be eliminated. No new goals are to be developed for 2010 when SII recommended changes would take effect. State hospital JCSCand LDR are strongly encouraged to participate in the current survey… . [**ALERT: JCSC **] 1/15/09: In response to our request, TJC has re-opened the 2009 NPSG survey until 1/30/09. Please make sure there is state hospital input on the goals. Click here and take the survey!
The Source: Pg05- Repopulating Your PPR [**ALERT: JCSC **]. Due to changes in the standards manuals for hospitals, ambulatory, and home care, Periodic Performance Review (PPR) tools for these services now require steps to “repopulate” their PPR. This article provides guidance and encouragement to complete the steps as soon as possible so that staff can use their PPR to assist with continuous compliance. Note that behavioral health care, long term care, and laboratory accreditation programs will need to evaluate only those standards labeled as requiring an update. For a summary of key dates/deadlines see also: Nov RTP [**ALERT: JCSC **] - Source Nov 08 Vol 6 #11 Pg03- Going Offline, Staying on Course: What You Can Do When the PPR Is Down
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Centers For Medicare & Medicaid Services
**ALERTS: 09NPSG, PPR Repop, NY CLIA, New Waived Tests **REFS: SEA #42, Contract Services, Disruptive Behav, Emerg Comm
Reference Articles
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Perspectives: Pg10- Sentinel Event ALERT: Safely Implementing Health Information and Converging Technologies [**REF**] This article is essentially a reprint of Sentinel Event Alert #42 which focuses on the prevention of 'technology-related adverse events. Although most of the 13 recommendations are pro-active new implementation strategies, a number are specific tothe post-implemetation phase making this is a must read for IT and LDR. In addition, if like approximately 83% of hospitals in the US, you have an automated dispensing cabinet (ADC), your P&T, RNx, MDx should also download and review a copy of the Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets (PDF). This contains an additional 12 guidelines on such issues as ADC location, number, security, stocking procedures, inventory, etc.
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The Source: Pg02- 5 Sure-Fire Methods: Leadership's Responsibility for Contracted Services [**REF**] Many of our hospitals contract with outside services for staffing and compliance with LD.04.03.09 is challenging. To provide the foundation for monitoring such contracts, this article emphasizes the necessity of establishing clear service expectations and how they will be evaluated as part of the contract. Tips include avoiding a tendency to assume that an agency provides safe and quality care simply because it is accredited. LDR and HR should note the specific strategies covered that include: performing routine, unannounced observation visits; monitoring of patient and staff satisfaction with performance; and auditing of documentation by contractors. Although not a requirement of LD.04.03.09, keeping a copy of the current license for each contracted staff member can help address HR.01.02.05, EP 1 and HR.01.02.07, EP 1.
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Patient Safety: Pg08- Managing Disruptive Behavior [**REF**] The concept of disruptive behavior spans beyond the overt behaviors that are familiar items which most hospitals cover in ethics and orientation programs, such as verbal abuse, harassment, condescending or berating behavior, lack of respect or physical abuse. Disruptive behavior that is identified most in hospital settings consists of more covert interference with communication, team performance, or safe patient care. Some examples are staff who constantly criticize other members of the patient care team, those who incessantly complain without taking any positive action, and those who obviously do not pay attention in meetings. The article outlines steps for LDR, HR, TxTm, MD, RN and others to take to address disruptive behavior and a side bar that encourages the proactive use of a Code of Conduct. See also The Doctors Company PowerPoint on Disruptive Behavior by Sue Dill Calloway, RN, MSN, JD submitted by Phillip Ward (Bryce PI Director) and Pam Ward (ADMHMR) with useful references and special relevance for physicians.
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Environment of Care: Pg06- Emergency Management's Six Critical Functions: Function 1: Emergency Communications - How to Keep the Lines Open [**REF**] The standard EM.02.02.01—Emergency Communications is discussed, including each Element of Performance. The article provides useful assistance for EOC and E&M to understand each EP. Sidebars include: ”Key Tips for Emergency Management Communications”; “Tips for Notifying Outside Staff of an Emergency”; “Tips for Notifying In-Building Staff of an Emergency” ; and “Tips for Backup communications Systems”.
**ALERTS: 09NPSG, PPR Repop, NY CLIA, New Waived Tests **REFS: SEA #42, Contract Services, Disruptive Behav, Emerg Comm
F&A
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