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Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
Special: 'Pearls'… To Be or Not To Be?
Our Reading Tips Page (RTP) is published online in the first week of each month and is updated as needed throughout the month. We have now been sending ‘Pearls’ to you for 6 months as a pilot. The idea was to extract the most important articles (e.g., References, Alerts, etc) from the RTP and provide them to you in a convenient e-mail near the middle of each month. This was to save you the time of going to our website. Pearls also includes a PDF copy of the full online RTP to expedite sharing it with key staff.
Recently, we improved the RTP with a quick review feature. Alerts and reference articles are now identified in a yellow header (like the one above) with quick jump links to allow you a more selective and rapid reading of newsletter content. You can also access the RTP more directly at www.shccRTP.com.
Given these refinements, should we continue Pearls for the convenience, completely stop the Pearls pilot or discontinue Pearls but still send a PDF of the RTP? Please help us meet your needs by taking 30 seconds to tell us which option you prefer. Cast Your Vote. Thank you.
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Alerts
TJC What's New (2/5/09) - Medication reconciliation National Patient Safety Goal to be reviewed, refined [**Alert** JCSC] "…effective January 1, 2009, survey findings on National Patient Safety Goal 8 (Accurately and completely reconcile medications across the continuum of care) will continue to be evaluated during the on-site survey… (but) … survey findings from NPSG 8 will not be factored into the organization’s accreditation decision… (,) will not generate Requirements for Improvement (RFIs) and will not appear on the accreditation report".
Perspectives, pg03- Update: The Joint Commission's Hospital Deeming Authority Application [**AERT**] In order to successfully apply for renewal of its deeming authority (TJC accreditation affording deemed status for certain CMS requirements), the Joint Commission has had to bring its standards into fuller alignment with CMS. In most cases this has meant a refinement of language, but in some instances, it has meant new standards or elements of performance. Although the modifications and/or additions are still in draft status for the next 6 months, JCSC should definitely obtain, review and distribute them now. Those revisions that are not further refined will need to be implemented (and will be surveyed/scored) starting in July of this year. If you have not already done so, download New & Revised 2009 Accreditation Requirements in Response to CMS Deeming Application
Perspectives pg05- Errata: 2009 Accreditation Manuals, All Programs [**Alert**] Two and a half pages of corrections are provided. Those relevant to psychiatric hospitals include standards in IC, LS, MM, NPSG, UP and PC. Since the corrections are effective immediately, those JCSC
Pt Safety pg01- Preventing Never Events: Stopping Air Embolisms During Surgery : [**ALERT**] No, embolisms are not particularly relevant to state hospitals, but Never Events are! CMS defines them as “serious and costly errors in the provision of health care services that should never happen”. The National Quality Forum (NQF), has defined 28 Never Events that include concerns for psychiatric hospitals such as death or serious disability associated with: elopement; medication error; fall; attempted suicide; restraints or bed rails. Also on the list is any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider; abduction of a patient of any age; and sexual assault on a patient within or on the grounds. JCSC, LDR and PI are strongly encouraged to obtain the full list and consider data collection and intensive analysis of such events just as you would a sentinel event. NQF says such events “… indicate a real problem in the safety and credibility of a health care facility” and CMS is moving to discontinue payment for them. Note: On 1/15/09 CMS published final decision memos that discontinue payment for ("no longer cover") the following medical errors (never events): Wrong procedure, Wrong part, Wrong patient See also:
- MEDICARE AND MEDICAID MOVE AGGRESSIVELY TO ENCOURAGE GREATER PATIENT SAFETY IN HOSPITALS AND REDUCE NEVER EVENTS (CMS Press Release),
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CMS IMPROVES PATIENT SAFETY FOR MEDICARE AND MEDICAID BY ADDRESSING NEVER EVENTS 202-690-6145, 8/4/08
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Reference Articles
Source pg02- 5 Sure-Fire Methods: Verifying New Staff's Identity [**REF**] Standard MS.06.01.03 EP5 requires hospitals to verify that the person who applies for medical staff membership and the person who shows up to provide care are both the same actual person named in the application. Five excellent strategies are listed for checking the applicant’s picture on his/her government-issued ID and comparing this with his/her appearance. Your hospital (especially MDx and MEC) is expected to determine the best strategy(ies) and the most appropriate staff to accomplish this and set a process in place. Five staff members suggested for this duty are: medical staff clerk; security officer; a specific member of the medical staff; a specific staff member in an off-site location where the applicant will be working; or a designated staff member who interacts with the applicant prior to the first day of work.
Source pg05- Featured Standard: Integrating Leaders Into Activities [**REF**] Standard LD.04.04.05 emphasizes the need for leaders to ensure that patient safety activities throughout the organization are integrated, rather than operating in compartments or “silos”. [Pearl] JCSC, LDR and PI should note that surveyors will be looking for evidence of the following as they survey this standard:
1. An effective connection of all activities that may have something to do with patient safety and quality so that safety is promoted, problems are reported, and failures are corrected.
2. Example of an RCA (preferably proactive), including effectiveness of follow-up that has generated learning throughout the hospital which is integrated into practice.
3. A blame-free internal reporting system so that staff members are comfortable reporting what seems to be sentinel event.
Source pg06- Tracer Methodology 101: The Medication Management Tracer This article describes how to conduct a Medication Management Tracer with a Pediatric Focus. However, JCSC, Phrm and P&T can find information useful for any Medication Management Tracer including a list of sample tracer questions and a sidebar “Tips Checklist” of tracer strategies.
EC News pg01- The New "Life Safety" Chapter: What It Applies to and How Organizations Can Comply with It : [**REF**] This is a good review for E&M, EOC and SFT of occupancy types and approaches to comply with the new separate chapter devoted to fire safety, as required by the National Fire Protection Association (NFPA) Life Safety Code. Occupancies include not only health care and ambulatory, but also the occupancies often maintained by state hospitals as group homes (usually lodging and rooming house occupancy) and residential facilities for 17 or more occupants (hotel and dormitory occupancy).
A concise outline of the Occupancy Types is provided in a sidebar. For freestanding business occupancies, the TJC does not require compliance with the Life Safety Code or LS standards; however, these occupancies, like all others, must comply with EC.02.03.02, EP4, which requires the organization to maintain free and unobstructed access to all exits.
Approaches covered in the article are Resolution of LSC deficiencies and creating a Building Maintenance Program. To resolve each LSC deficiency identified by your organization or others, your organization has three options: 1.) Correction within 45 days through a management process or corrective maintenance program. 2.) Obtain a LSC equivalency approved by TJC; or 3.) Create a Plan for Improvement (PFI).
The Building Maintenance Program (BMP) is an optional, proactive way to manage specific features of the hospital’s life safety program. The article provides an overview of various items included in a BMP, such as specific types of doors, grease-producing devices, horizontal exit doors, prohibition of combustible decorations, etc.
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