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Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
••REFS: TJC Confidentiality, MM.03.01, Suicide Tracer, Part 1/2 Delirium, Just Culture, Fire Egress, Leadership Paper, SX Training ••PEARLS: Confusion Assessment Method (CAM)d, ••DWNLDS: CAM, MM.03.01 BoosterPak, Just Culture, Animal Assisted Tx , Leadership Paper
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Alerts
Our Collaborative To Include ALL Inpatient Psychiatry! In January 2010, The State Hospital Compliance Collaborative (SHCC) will become the State & Psychiatric Hospital Compliance Collaborative (SPHCC). We will be welcoming private psychiatric hospitals as well as inpatient units within general hospitals. In 2011 we will add community mental health.
Discussion Board (DB) To Have Monthly Themes: The DB was originally envisioned as a rapid, interactive forum for peers. To work well, it requires a group of participants to frequently check and respond to issues being raised. However, our members have been telling us they have the interest, but not that kind of time. Starting in January the DB will shoot for more depth at a slower pace. Each month it will focus on a topic selected from our PSQ top compliance issues or other compliance concerns collected from members. An associate will provide a lead article and request questions, feedback, supportive samples/examples, tips, etc. The best of these will be saved in our FAQ library. January's topic will be CMS & Active Treatment.
Free Luncheon 'Compliance Sliders' (LSC): On January 27th, 12:15 EST and 12:15 CST, SPHCC will present a free mini-webinar on Active Treatment Compliance Strategies. There will be a 10-15 minute presentation addressing the overall topic and key issues raised on the DB with a final 15 minutes of open line Q&A.
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Reference Articles
Perspectives v29 #12, Pg03- Protecting Organizations' Confidential Accreditation Information [••REF••] GB, LDR and MD should find this a useful review of TJC's position on protecting confidential information (including that related to sentinel events/RCAs) from our hospitals. Those uncomfortable with sharing such information with TJC should note the following statements from the article. "The Joint Commission has never been compelled to produce confidential accreditation information in response to any state court–issued subpoena, whether issued by a court in or outside of Illinois". "The Joint Commission is aware of no case where the confidentiality of sentinel event–related information was lost because it was shared with The Joint Commission."
The Source v7 #12 Pg01- Joint Commission Now Giving “Booster Shots” for Standards Compliance First BoosterPak Focuses on Safe Medication Storage [••REF••] Last month in an article on Redesigning (Its) Process(es) with Lean Six Sigma, there was a brief mention of the development of BoosterPaks for problematic standards. The first BosterPak (BP) became available on 11/19/09 and is a well-designed compliance reference and resource for the Standard MM.03.01.01. This particular standard has been cited more in more than 30% of TJC hospitals every year since 2005. In the first half of this year 21% of our members also reported this citation. Although the article does not provide links, TJC says it sent announcements of the BP to all hospitals. JCSC, Phrm, P&T, RNx and MDx should at least review the first 22 pages of this 33-page compendium by going to BoosterPaks in the What's New section of your TJC Connect site or downloading BP_MM_03_01.pdf. The contents include implementation expectations (Pgs 2-11), the survey assessment process (Pg 12), FAQs (Pgs 13-15), key definitions (Pg 16), special issue discussion (e.g., Crash Cart Storage) (Pgs 17-22) and additional references and links.
The Source v7 #12 Pg06- Tracer Methodology 101 The Suicide Prevention Tracer [••REF••] This program tracer is specifically applicable to psychiatric hospitals, hospitals with inpatient units and crisis stabilization units that are part of a behavioral health care program. It is designed to evaluate the effectiveness of organization's suicide prevention strategies/efforts and issues/processes that might contribute to suicide attempts. JCSC, RNx, MDx, Psy and TxTM should note the emphasis on staff education/competency, take advantage of the suggested sample questions and incorporate this tracer into survey prep and ongoing risk assessment efforts.
Pt Safety v9 #12, Pg05- Caring for the Delirious Patient, Part 1 of 2: Assessing for Risk Factors and Signs of Delirium [••REF••] MDx and RNx (especially those at facilities with geriatric populations) will find this article a good review. It reminds us that not all delirium are agitated and that mortality rates for delirium are as high as those for myocardial infarction. The article also includes a useful table of risk factors. Because it presents in multiple forms and can not always be accurately evaluated in basic conversation, there is a suggestion for the use of formal assessment tools like the [Pearl] Confusion Assessment Method or CAM {Info} (PDF) . The authors encourage all patients over age 70 to be formally assessed regardless of their risk factors. An e-mail address for requesting CAM permission is also provided.
Pt Safety v9 #12, Pg08- Column: The Growth of a Just Culture [••REF••] This is an edifying introduction and overview of 'Just Culture'. If you have ever wrestled with the appropriate management response to staff error, system failure or near misses, the emerging concepts and tools that are part of 'Just Culture' are worth becoming familiar with. GB and LDR should read this article before the next serious incident or sentinel event occurs. See also: The Perception of Just Culture Across Disciplines in Healthcare, Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability, Our long journey towards a safety-minded Just Culture
EOC News v12 #11, Pg01- Ensuring Appropriate Means of Fire Egress: Examining the "Life Safety" (LS) Chapter, Part 5 [••REF••] Part 5 in this series of LS Chapter reviews focuses on the 32 EP of LS.02.01.20. The EP are divided into 5 groupings covering Doors/Exits, Corridors, Suites, Travel Distances and Exit Illumination/Signage. It is a useful review for EOC and SFT.
TJC Online 12/2/09, "Leadership in Healthcare Organizations” white paper now available: [••REF••] The white paper is entitled “Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards”. It was Paul Schyve, M.D., senior vice president of TJC, as a publication of the Governance Institute, a membership organization serving not-for-profit hospital and health system boards of directors, executives, and physician leadership. The 35-page document is a solid review of 2009 Leadership Standards with supportive rationale and references. GB, LDR should find it a useful resource.
SL1: 1120.30 Sex Offender Resources [••REF••] includes Sex Offender Risk Assessment; Practical Application in Community and Institutional Settings a downloadable, 3-part free training for SX [Found/Rec by LRC]
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