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Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
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Special: State Hospital Citation Trends
The preliminary evaluation of data from 14 member-submitted post survey questionnaires (PSQ) for the first six months of 2009 has now been completed. Only two of the 2008 TJC Top Standards were frequently found out of compliance in our hospitals. They were NPSG 2C [NPSG.02.03.01] cited in 64% of our PSQ but only 37% of all TJC hospitals and HR.1.20 [HR.01.02.05] cited in 57% of our PSQ but only 22% of all TJC hospitals. JCSC (especially those expecting survey this year) should review the rest of the deficiency trends found in our preliminary analysis entitled PSQ Data (Jan-June 2009).
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Alerts
Aug 27, 2009 News Release: SE Alert #43 - Leadership Committed to Safety
TJC continues to advocate for greater involevment of leaders (i.e., execs, senior managers, admin/clinical leaders, and governing body) in issues of hospital safety. The latest SE Alert recommends a series of 14 specific steps leaders shoud take to improve patient safety.
9/2/09 TJC E-mail: The Joint Commission is seeking comments on candidate measures for assessing and treating tobacco, alcohol, and other drug use and dependence. Specifically, these eight measures address screening/assessment; treatment including brief interventions and if applicable, medication; and follow-up after hospital discharge. The measures will be posted for a 30-day public comment period beginning September 1. Click here to review and comment on the measure
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Reference Articles
Perspectives v29 #9, Pg09- Free Help for Meeting Infection-Related NPSG [••REF••] TJC allotted one year (with quarterly milestones) for the full implementation of HAI-related NPSG 7 by January 1, 2010. Longer lead times usually suggest a greater effort is needed to comply. It can also be the basis for greater accountability once the measure is fully in effect. With that in mind, IC and RN should take advantage of a free online education program offered by TJC to support compliance and implementation for NPSG 07.03.01, 07.04.01 and 07.05.01. Just be aware that the 76-slide webinar with narration by Louise Kuhny, RN, MPH, MBA, CIC and Barbara Soule, RN, MPA, CIC lasts a little over 58 minutes. You will need to log on to your TJC Connect website to access it.
Patient Safety v9 #9, Pg01- Helping Patients Stand Tall A Primer on Fall Prevention in Health Care [••REF••] RNx, RN and other clinical LDRs should find value in several aspects of this article. It provides useful examples of risks factors and suggests some scales for evaluating them (e.g., Morse Fall Scale, Hendrich Fall Assessment. It gives a reference to the VA's tool for fall prevention and mentions some creative approaches to increasing staff awareness of patients at risk. However, the most useful part of the article may be the pointers it provides on using simple statistics to evaluate and guide your fall prevention program. It gives easy formulas for establishing fall rates and also encourages looking at the subsequent rate of injuries related to those falls. See also SHCC Risk of Falls
Source v7 #9, Pg01- Steam Sterilization Strategies Subhead: Complying with Joint Commission Requirements [••REF••] This is the first of two articles presented in separate TJC publications (see related Pt Safety article below) on the topic of steam sterilization. Although it was later clarified, one of our hospitals received a sterilization-related citation during its June 2009 survey. It was attempted by a physician who is used by TJC to conduct a relatively large number of state hospital surveys. As such, we think IC and Dentistry should review this article. At the very least, review the special panel entitled 'What Surveyors Are Looking For?"
Patient Safety v9 #9, Pg08- Preventing Surgical Site Infection: How to Use Rapid Cycle Sterilization of Surgical Instruments [••REF••] Ordinarily we would not review an article highlighting issues related to surgical sites. However, given the context referenced in the related Perspectives article above, we think IC and Dentistry should review the special panel entitled 'What Will Joint Commission Surveyors Consider?"
EC News v12 #9, Pg04- Designing and Maintaining Buildings to Minimize the Effects of Fire: Examining the "Life Safety" (LS) Chapter, Part 4 [••REF••] This 4th article in a series on the Life Safety Chapter focuses on LS.02.01.10. It provides a good overview of the requirements related to A - height, construction and sprinklers, B - building separations/penetrations and C - fire door features (e.g., closing, latching, gaps, protective panels, decorations). This is well worth reading by E&M, SFT.
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