State & Psychiatric Hospital Compliance Collaborative’s Reading Tips Newsletter (RTN) August 2013, Volume 7, Issue 8
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••WHAT’S NEW for August

  • Fresh SPHCC
    • Guests & Visitors – We welcome you to this Highlights section of our newsletter. As you will see below, it contains a listing of our recommended readings. Starting this month, you also see enhancement of our Downloads section to also include some of the useful links that were previously reserved for members. Although it is only an extract of the full newsletter, we hope you find it useful.
    • Members: Full Text ArticlesFinally here! We are very pleased and excited to announce that our Premium Members (PM) can now obtain full text copies of all of our reviewed articles. Please contact your hospital’s Primary Representative (as listed in your hospital profile) for the username (U) and password (P) you will need. In this Highlights section, click on the special link, Ftxt and you will be taken to the download web page for the indicated article. Click ‘Sign-in’ in the upper right-hand corner of that page. Enter your U, P and download the article. If you would first like to read our review, log on to your Custom Resource Page (CRP) and select Current Newsletter in your Member Content Panel. Find the article you want in the Reviews section. Once you have read the review, just click on the title at the top of any article and follow the steps indicated above. Even if our summarized review of the article is sufficient, you may still want to download the article for one of the tables, charts, sidebars or forms that we sometimes clue you in to. You will only need to log into the publisher site one time per session to download as many articles as you like. “Thanks” again for giving us the idea and being patient while we worked it out.
  • AnchorReading Tips Newsletter (RTN):
    • Tip#8: To read or not to read??? – For our Premium Members (PM), the real question is what to read first? Now, with the convenience of quick, full text access, it may be tempting to go directly to the full source article. If you would like your reading time to be used as efficiently as possible, however, we would still suggest you at least scan through our summarized review first. This will help you decide if the article is worth the investment of more time. It will also provide you with a framework of key points to speed your reading while facilitating greater comprehension. It is like priming your mental pump.



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Reviews, Summaries, Tips & Pearls

PR: Customer Feedback Helps Improve Survey Experience [Pearl: JCSC, LDR] Perspectives, August 2013, Vol 33, #8, Pg 14 #JCp1308_B1

The Customer Value Assessment (CVA) is a two-part survey: the first part is completed after the E-App (electronic application) is submitted; the second part is completed after the on-site survey takes place. TJC says the first part of the CVA helps the survey team know what is important to an organization and provides a more customized on-site survey. The second part tells TJC how well they met your organization’s expectations for their on-site survey.

TIP: If you have an upcoming survey, complete CVA, part 1 with a mind toward constructively influencing surveyors/survey process. Complete part 2 with the idea of improving TJC survey process in general, and advantageously positioning your organization, should appeal or reviews be required.


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TS: Patient Flow Success Stories, Part 3 of 3: Urgent Matters: Hospitals Collaborate to Fix Flow Problems [FYI: GB, LDR, MD, RN] The Source, August 2013, Vol 11, #8, Pg 1 #JCs1308_b2

This third article in the recent Patient Flow series does not specifically relate to our psychiatric populations, but is reviewed for the sake of completing the series. The focus here is on the successful strategies and solutions that a collaborative of hospitals (Urgent Matters/Learning Network II) had in improving patient flow (e.g. reducing ED length of stay and percentage of patients leaving without being seen). A summary of their solutions is available in the Urgent Matters Complete Toolkit.
Tip: Click on the Comment link above this article to see a listing of all 3 of the articles in this series, as well as the introductory article covering the 2014 requirements related to Patient Flow.

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TS: Tracer Methodology 101: Medication Management Tracer in an Urgent Care Facility[®] [REF: MD, P&T, Phrm, RN] The Source, August 2013, Vol 11, #8, Pg 10 #JCs1308_b3

Although the stated focus is on Urgent Care, standards MM.03.01.01 (medication storage) and MM.01.02.01 (look-alike/sound-alike meds) referenced in the article are applicable to hospitals as well. As such, the described scenario; 10 sample questions and included Mock Tracer Tracking Worksheet are relevant and worth reviewing. Key take-home Point: Do not store LA/SA medications alphabetically as it may place them too close together.
Tip: Collect this and other Mock Tracer Tracking Worksheets as handy guides for the staff who perform your mock surveyors. All medication nurses should be able to answer the sample questions.
Tip: If you are expecting survey, use the 10 questions as practice issues for the Medication Management Interview.

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TS: CJCP™: Certified Joint Commission Professional: Focus on Information Management[®] [Pearl: CJCP, IM, JCSC, MD] The Source, August 2013, Vol 11, #8, Pg 7 #JCs1308_b4

This month’s column only provides 3 sample questions. As the title indicates, they primarily relate to IM standards, but they address issues physicians should know.
Tip: Encourage professional staff and key departments to incorporate a ‘Question(s) of the Month’ game-like challenge into their staff meetings. For example, this month’s Question 3 is a little tricky and would be a great one for Medical Staff.

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CMS: Organ Procurement Organizations (OPO) Agreements with Hospitals[®] [REF: CMS, JCSC, MD] S&C: 13-48-OPO, July 26 2013 #CMS1308_b5

As Per CMS Memorandum Summary:

• “OPO Hospital Agreements: Hospital regulations at 42CFR 482.45 (a)(1) require that all hospitals have written agreements in place with their OPO to notify them of an imminent death or of a death which has occurred.”
• “OPO Agreements with Hospitals That Do Not Have a Ventilator and Operating Room: While OPOs are not required to initiate agreements with hospitals that do not have a ventilator and an operating room, they are required at §486.303 (g) to enter into an agreement with any hospital that requests an agreement with them pursuant to the hospital regulations. However, for hospitals that do not have a ventilator and operating room, the agreement may be limited to notification of the OPO by the hospital of imminent death and/or death which has occurred in the facility. “

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ALL: Everybody, CHP: Chaplain, C&P: Credentialing & Privileging, E&M: Engineering & Maint, EOC: Environment of Care, FB: Finance/Business, FdDt: Food services/Dietary, GB: Gov Body, HR: Human Resources/Personnel, HST: Human Service Tech/Aid, IC: Infection Control, IM: Info Mgt/Med Records, IT: Info Technology, JCCAP: Jt Com Certified Accreditation Professional, JCSC: Jt Com Survey Coordinator, LDR: Leadership/Mgt, MEC: Med Exec Committee, MD: Medical Staff, ofco: Officer and/or Committee, PI:Performance/Quality Improvement com/dept, PPR: PPR team mbrs/ldrs, P&T: Phrm & Therapeutics Com, Phrm: Pharmacy,PSY: Psychology, PtAd: Patient Advocate, PtEd: Patient Education, RHB: Rehab/Activity Therapy, RN: Nursing, SFT: Safety,StEd: staff ed & training dept, SW: Social Work, TxTm: Treatment Team, UrUm: Utilization Review/Management,X: Exec, Dir or Chief (e.g., MDx = Medical Director)
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