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Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
••ALERTS: NPSG Field Review, Revised Scoring, Telemed Requirements, H1N1, ••REFS: Target Analysis, Med Mgt Eval, Continuity Tracer, LS Chapter Part 2, H1N1, Hand Hygiene,
••Downloads: 2010 NPSG, Target Analysis Aids, Safe Practice Guide, Hand Hygiene Measurement, ••Free E-Course: Pandemic Influenza Preparedness
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Alerts
Joint Commission - May 12, 2009 - Field Reviews for NPSG and Universal Protocol have begun and will continue for six weeks (6/23/09). Click here for more info or a PDF of proposed 2010 revised Hospital NPSG.
Perspectives pg01- UPDATE: Summary of March Changes from CMS Hospital Deeming Application: [ALERT: JCSC, MD]. This is the Perspective update promised by TJC in the March 26 conference call. As most of you know by now, TJC has been bringing its standards more closely in line with relevant CMS Conditions of Participation (COP). This is a long needed process that has been 'inspired' by TJC's need to re-apply and be re-approved for deeming privileges with CMS. The latest refinement of standards reduced the modified number of new and revised requirements from 165 to 87. And, of that remaining number, TJC assures us that " In most cases, Joint Commission standards already covered these topics, just not in the specificity now required by CMS". However, there are about 37 new EP in 4 areas that would be exceptions to that statement. 2 of these areas apply to our hospitals. The first has to do with seclusion and restraint (27 EP). If you use TJC accreditation for deemed status (as most state hospitals do) then revised Standards PC.03.05.01 through PC.03.05.19 will replace PC.03.02.01 through PC.03.03.31. The second area of exception relates to the history and physical exam (3 EP). The article includes a chart of CMS-Related Changes Scheduled for Implementation April 6, 2009. Audio replay (until the end of this month) and a transcript of the March 26th Deeming Status Teleconference are available. Support materials (e.g., AMP, automated PPR, E-dition) for accredited hospitals will be updated by July 1, 2009
Perspectives pg06- Update: Comparing Joint Commission and CMS Telemedicine Requirements [ALERT: JCSC, LDR, MDx] Bottom line: CMS (S&C-05-04) requires full credentialing and privileging of the LIP by the medical staff at the hospital where the patient is being treated. However, TJC (MS.13.01.01 and LD.04.03.09) can allow a hospital/medical staff to rely on the C&P decision another accredited hospital where that LIP provides similar care. Currently you could be found in compliance by TJC and out of compliance by CMS for the same approach. TJC says they are working on this matter with CMS and further updates will be provided in a future issue of Perspectives. See also the recent SHCC Discussion Board Special Topic: New TJC Rigor On C&P.
CDC: H1N1 Flu (Swine Flu): [••REF••][ALERT: IC] CDC H1N1 Reference Page and CDC H1N1 Guidance (Screening, Treatment, Travel, etc)
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Reference Articles
Perspectives pg04- Update: Target Analysis Methodology for Assessing Hospital Performance [••REF••] Yes, this new methodology for assessing hospital PI will be applied to psychiatric hospitals and their new core measures. That said, JCSC and PI should dig into this enough to be able to properly read and interpret their next set or ORYX reports. A sample report page is included, but more details will be available in an updated version of The ORYX Performance Measure Report User Guide that should soon be available under the “Performance Measurement (ORYX).” section of your TJC Connect website. However, on 5/1/02, Frank S. Zibrat (Associate Director, ORYX Implementation) was kind enough to provide two explanatory documents and permission to share them with our members: • Target Analysis Methodology (revised 3/12/09) • Using ORYX Data Target Analysis
He and his statisticians are also available to answer questions by email (hcooryx@jointcommisssion.org) or phone (630)792-5085)
Source_pg01- Featured Standard: Improving Medication Safety: How Effective Is Your Medication Management System? [••REF••] This is s good overview of TJC recommended approaches for compliance with MM.08.01.01. The article recommends six specific steps for evaluating the effectiveness of your medication management system and further suggests examples of data to monitor and relevant online literature resources (all of which are monitored for relevant updates by SHCC in this newsletter). P&T, JCSC and relevant PPR teams should read this article.
Source_pg06 Tracer Methodology 101: The Continuity of Care Tracer [••REF••] Essentially this is a program tracer that evaluates the process of ordering and following through on diagnostic testing. Although this tracer is primarily 'applicable' to ambulatory health care (AHC) organizations, but TJC leaves itself options to apply it "organizations that provide complex services across the continuum of care". Interpret that to mean if your organization is found to have problems with any aspect or phase of diagnostic testing, you could be subjected to this tracer. JCSC would be wise to consider incorporating this tracer into their practice tracer methodology. The article provides 16 sample questions for the process.
EC News pg01- Completing the Statement of Conditions™: Examining the "Life Safety" Chapter, Part 2 [••REF••] This article focuses on the first of two administrative standards in the LS chapter and its four associated EP.
In EP#1 management responsibilities for the individual (or individuals) assigned to manage LS compliance is detailed in 3 areas (i.e., assessing LS compliance, resolving LS deficiencies and managing the SOC).
There is a particularly useful discussion of EP#3 that confirms the automatic 6-month grace period for meeting PFI deadlines and when extensions need to be requested.
It should also be noted that under EP#4 organizations are now required to have documentation (e.g., when/where inspections occurred and the report's location) about state or local fire inspections
TJC- TJC Announcement: [••REF••] After two years of work with major infection control leadership organizations (e.g., CDC, IHI, WHO and others), the Joint Commission has released a 232-page monogram entitled Measuring Hand Hygiene Adherence: Overcoming the Challenges, It was developed " to help health care organizations (IC, PI) target their efforts in measuring hand hygiene performance"
Misc. (Downloads, Courses, Etc.)
PtSafety pg02- National Quality Forum Updates Safe Practices Guide FYI: LDR, MDx, RNX, PI. Most of the safe practices first released in 2003 and previously updated in 2006 are applicable to psychiatric hospitals. There are now 34 practices including 7 new ones. 4 of these (i.e., Multi-drug resistant organisms, Patient falls, Care of the caregiver, Organ Donation and Glycemic control) are relevant to typical psychiatric populations. Safe Practices Guide for Better Healthcare (2009 Update) was designed to bring attention to key clinical issues for the reduction of risk of error and harm to patients. A few of them are not specifically addressed in CMS or TJC standards and as such are worth being familiar with as a reference for quality improvement activity.
Essential Learning - Pandemic Influenza Preparedness: New, free online training about the Swine Flu (H1N1 Flu). The course offers one credit hour but no continuing education credits. Click here to access the course now.
DecisionHealth - Kevin Ann Huckshorn, RN is now Delaware’s state substance abuse and mental health director. In her former role as Director of Technical Assistance for NASMHPD, she was a nationally recognized expert on seclusion and restraint a good friend and great resource for public psychiatric hospitals. She will be presenting a DecisionHealth audio conference, “Improve Compliance with CMS’s Restraint and Seclusion Requirements,” on Wednesday, June 10 from 2 to 3:30 pm (ET). More details and an SHCC discount to come.
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