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Alerts
Perspectives Pg01- The 2009 Accreditation Decision Process: A Closer Look at Central Office Reviews [ALERT: JCSC] Last December, TJC announced that the number of direct-impact RFIs would no longer serve as an automatic trigger for CA or PDA. Instead the numbers depending on the size and complexity of your hospital (aka 'band;) would trigger a central office screening (i.e., a more in-depth evaluation of your survey results) for possible CA or PDA. This update only describes 2 possible outcomes of that screening (vs. 3 outcomes in December article and it fails to include the earlier chart indicating the triggering number of direct-impact RFIs. However, it does provide useful examples of Central Office Survey Report Review Objectives that LDR and JCSC should review. See our 2008 Dec RT review by Glenn D. Krasker, MHSA for more details.
TMFSH June Survey of staffing effectiveness standards suspended; interim EPs being field reviewed: [ALERT: JCSC, HR, PT] Effective immediately, survey of the Staffing Effectiveness standards (PI.04.01.01 for hospitals and HR.1.30 for long term care organizations) has been suspended. Two interim elements of performance, EPs 12 and 13 at PI.02.01.01 (PI.2.10 for Long Term Care) are being field reviewed until 7/22/09. See Field Review: Staffing Effectiveness in our June RT.
SHCC Calendar:
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Reference Articles
Source Pg06- Tracer Methodology 101: The Violence Tracer [•• REF••] Although the Violence Tracer is a program-specific tracer for behavioral health care programs, it (or a variant thereof) can be triggered in any setting. JCSC and LDR would be wise to incorporate this tracer into your survey preparations (e.g., practice tracers) and use it as a PI tool to help assess and improve the management of violence and reduction of such risks. Review the sample questions and tips provided in this article.
Patient Safety Pg01- Protecting the Patient: The Joint Commission Collaborates on Developing Infection Prevention and Control Compendium: [••REF••] Four major healthcare organizations (SHEA, IDSA, AHA, APIC) have joined with TJC to produce the A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals that organizes all the evidence- based strategies that have been found to prevent those HAIs causing the greatest mortality (including MRSA and CDI) into practical guideline that can serve as a one-stop prevention resource. Strategies are organized into 4 categories. Basic practices and Special approaches for certain high-risk populations have good or moderate evidence to support their use (i.e., A or B-level recommendation). Level C recommendations are categorized as 'Unresolved issues'. There is a final category of approaches that should not be implemented. The guideline also includes performance measures and patient guides (http://www.preventinghais.com/) for each HAI. IC and related PPR should not only review relevant sections of the compendium, but strongly consider performing a gap analysis between your current approaches and their A or B-level recommendations to better ensure compliance with NPSG.07.03.01, NPSG.07.04.01 and NPSG.07.05.01 that TJC says were directly influenced by the compendium.
EC News Pg05 - Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This is the same article first published in June Perspectives. See review in our June RT.
EC News Pg06- Mitigating Life Safety Deficiencies with ILSM: Examining the "Life Safety" (LS) Chapter, Part 3 [••REF••] This is the 3rd in a series of articles on the new LS chapter. It is an excellent review of ILSM compliance requirements for SFT, E&M, LDR, EOC and JCSC. The first thing to be noted is that the implementation of ILSM measures are not just for periods of construction, but 'any time there is a Life Safety Code deficiency that cannot be immediately addressed'. The article also places emphasis on the requirement for an ILSM policy (LS.01.02.01, EP#3). The author sees all the subsequent EP's being dependent on having a comprehensive, written, and regularly reviewed ILSM policy. There is also a brief overview of the 11 ILSM activity options to be considered in that plan. Note: Parts 1 and 2 were presented in the Feb and May issues of EC News and also reviewed in our Feb and May RT newsletter
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