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
••RECOMMENDED READING:
••USEFUL LINKS & DOWNLOADS:
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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.
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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. |
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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. |
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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. |
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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.” |
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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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