|
Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
Special Update: Outside Provider C&P (for GB, LDR, MD, JCSC)
Background: Background: Over the last 6 months, member hospitals had been receiving unexpected deficiencies for what TJC surveyors considered inadequate credentialing and privileging (C&P) of outside providers. First it was related to the interpretive services of radiologist but then went on to include physicians in emergency departments or specialty clinics…even in TJC accredited hospitals. For a while this was supported by SIG with the explanation that it was actually a requirement of CMS. This approach was questioned and constructively challenged during recent surveys of Pennsylvania hospitals. Subsequently, there were discussions between CMS and TJC that resulted in a return of TJC to acceptance of C&P work and data from accredited hospitals…at least in PA. Many thanks to PA, NY and AL for their support and contributions to our research. We are hoping there will be a formal announcement on this issue from TJC.
Updated CMS Clarification: If patients are sent to a provider at another Medicare participating hospital, it is not necessary to C&P that provider since that hospital is required to do so. [Based on two conversations with David Eddinger, Lead Analyst for the CMS Hospital Survey & Certification section and the CMS reference document, Survey and Cert Letter 05-04 (S&C-05-04)]
Updated TJC Clarification: “…as long as the local hospitals are Joint Commission-accredited, there is no requirement for additional privileging/credentialing” [4/2/09 by Anne Scott Blouin, RN. PHD, Exec VP. Accreditation and Certification Operations, Joint Commission]
More details, sample contract language and strategy reccomendations: Goto SHCC Discussion Board: Special Topic: New TJC Rigor on C&P
Pearl Quick Jump ••Top••Special••Alerts••Ref Art••Bottom
Alerts
[Alert: JCSC, LDR] TJC announces March 26th Revision of Deeming Application-related Accreditation Requirements (updated 4/7/09 with scoring info). This reduces the number of new and revised requirements from 165 to 87. You can download a 27-page PDF of the revisions, an 86-page side-by-side change comparison PDF and/or replay the related March 26th telephone conference call. Be aware that until CMS makes its final decision on the TJC application later this year there could be additional changes. We will keep you posted.
Pearl Quick Jump ••Top••Special••Alerts••Ref Art••Bottom••
Reference Articles
Perspectives: Pg10- Clarification: The Effect of Disruptive Behavior on a Culture of Safety [••REF••] This article provides useful TJC perspective on the definition of disruptive behavior in general and intimidation in particular. This further clarification of 2009 Leadership Standards is a worthwhile read for LDR and anyone needing to fine-tune their code of conduct.
Source: Pg06- Tracer Methodology 101: Staff Training for Tracers [••REF••] The 'how to' series on tracer methodology continues with this installment actually including a bit of a behavioral health care organization scenario. We believe all hospital LDR and JCSC should conduct practice tracers for improvement purposes as well as survey readiness. This article suggests useful tips, steps and strategies for training staff to conduct tracers. Key concepts include focusing on process improvement vs. staff competency and conducting tracers on a regular basis as part of a culture of safety. The latter practice not only prepares staff but also improves the skills of those who conduct tracers.
Patient Safety: Pg01- Spell It Out: Ensuring Compliance with Do-Not-Use Abbreviation Policies [••REF••] JCSC, MD, P&T, PHRM. There is some concern that compliance with NPSG 0202.01 may have fallen off since its implementation in 2004. We are reminded that between 2004 and 2006 almost 30,000 abbreviation-related medication errors were reported to the U.S. Pharmacopeia (USP) MEDMARX program and most of those originated with the prescriber. [Pearl] Some real life examples are provided along with 10 recommended strategies you should read for improving/maintaining compliance. Download free DNU list, brochure, poster, slide show and training video (3.5 min).
EC News: Pg06- Help for When the Sky Is Falling and You're Facing Evacuations: The National Weather Service and Severe Weather Events [••REF••] E&M can find additional assistance from the National Weather Service (NWS) in making the important decision about the need to evacuate. Hospitals can consult with a 'warning coordination meteorologist' (WCM) by calling your local NWS office•. [Pearl] WCM resource persons not only provide weather warning information, but are also available for outreach, education and training exercises, especially for administrative staff and professional development (free of charge). Hospitals (e.g., Louisiana) subject to hurricanes or flooding should also take advantage of the advance warning provided in a new NWS tool, 'Tropical Cyclone Impact Graphics'. An example of the latter is provided in the article. •Note: The person listed with each local office is usually the WCM and is often at extension 223
SL3
: 2009 Design Guide for the Built Environment of Behavioral Health Facilities: Edition 3.0 [••REF••] E&M
Pearl Quick Jump ••Top••Special••Alerts••Ref Art••Bottom••
For additional information or to leave comments/suggestions, please contact us at www.fieldsinc.com/support.html Thank you.
© 2009 Fields & Associates, Inc. All Rights Reserved.
|
