| State & Psychiatric Hospital Compliance Collaborative’s Reading Tips Newsletter (RTN) September 2012, Volume 6, Issue 9 |
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••WHAT’S NEW:
••RECOMMENDED READING:
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••Additional Updates in:
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| Recommended Readings, Tips & Pearls |
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•PR: – Clarifications and Expectations: Managing Corridor Clutter—Part 2 [REF:EOC, RN, SFT.] Perspectives September 2012, Pg 1, Vol 32, # 9 This article briefly summarizes what was presented in its Part 1 and then moves on to describe corridor exceptions for items such as wall mounted hand rub dispensers and retractable computer desks if no more than 26 inches wide and projecting less than 6 inches into the corridor. More than 6 inches can be allowed for monitors and exit signs if they are higher than 6 feet 8 inches from the floor. In addition there is a useful definition of ‘equivalency’ and brief reviews of key issues related to latching patient room doors and the fire rating of corridor walls. Regarding the former, it should be noted that while self-closing devices are not required for those doors, they must latch and your fire plan must include a process for ensuring those doors are in fact latched during a fire emergency (e.g., staff check every patient room and close/latch the door).
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• TS: – SWIFT: A New Tool for Identifying Prospective Hazards [Pearl: JCSC, LDR, PI] The Source September 2012, Pg 1, Vol 10, # 9 This article presents The Structured What-If Technique (SWIFT) as a proactive team-oriented risk assessment process that is faster (and easier) than FMEA as required by TJC every 18 months (LD.04.04.05). To increase speed, SWIFT makes heavy use of brainstorming in response to “thought-provoking guide words with a question-based format ” and focuses more on high-level processes. FMEA is a more detailed, in-depth and therefore more time consuming process. SWIFT is touted as a useful time-saver that would allow more potential hazards to be proactively analyzed. It was also recommended as a first step in a staged approach that might go deeper (ala FMEA) if warranted by the SWIFT findings. A useful illustration of the process flow and some sample guide words are included on page 4. Mapping the process (e.g., flowcharting), preparing good guide words, using an expert facilitator and choosing knowledgable team members are other important keys to the effectiveness of this process. For more details about SWIFT and its use in healthcare see:
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• TS: – 5 Sure-Fire Methods: Complying with Standard RC.01.01.01 [REF: BHC, IM] The Source September 2012, Pg 2, Vol 10, # 9 The Source also focused its ‘5 Sure-Fire Methods’ column on this same standard in September, two years ago (click on Complete and Accurate Medical Records (2010) below). Apparently, this standard continues to be highly problematic for the field. Then as now, the greatest difficulty seems to occur around RC.01.01.01 EPs 11 and 19. This time, however, the article gives greater address to the compliance difficulties of this standard for BHC organizations. The article cites the more spread-out nature of many BHC organizations as a possible contributing factor to deficiencies related to the ability to track the location of all components of a record. The mundane recommendations for improving compliance included conducting audits, more staff education and moving toward electronic medical records when feasible. Recommended strategies from last year’s article also included the use of date-time stamps and increasing staff accountability. [expand title=”Complete and Accurate Medical Records (2010)”] 5 Sure-Fire Methods: Complete and Accurate Medical Records [REF: MDx, MD, IM] The Source, September 2012, Pg 2, Vol 8, # 9 Hospital rates of non-compliance with Standard RC.01.01.01, have increased from 49% in 2009 to 62% in the first half of this year. TJC reports that most of the difficulty was related to the requirements for dating (EP 11) and timing (EP 19) of all entries (including orders). The noncompliance rate for our state hospital members reported in post survey questionnaires (PSQ) over the same 18-month period was only 30%. However, EP19 was their most common concern as well. The article’s recommendations included:
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• TS: – Tracer Methodology 101: Individual Medication Management Tracer in a Residential Behavioral Health Care Program [REF: BHC, MD, MDx, Phrm, P&T] The Source September 2012, Pg 6, Vol 10, # 9 Orientation and training should be in place to make sure staff are competent in the ‘basics’ of medication storage, side effects and safe administration. The article also encourages attention being paid to issues such as safe storage (of pills and liquids), management of medications brought by patients, requests for PRN medication not yet ordered, self-administration and the effectiveness of communication in related contract relationships (e.g., physicians, pharmacies). The balance of the articles briefly describes the sequence of events of a medication management tracer conducted in a residential setting. [Pearl] The scenario and sample questions are worth reviewing.
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• TS: – New Sentinel Event Alert:Safe Use of Opioids in Hospitals [REF: MD, MDx, Phrm, P&T] The Source September 2012, Pg 9, Vol 10, # 9 Sentinel Event Alert (SEA), Issue 49 (8/8/12) largely focuses on the use of opioid medication in pain management. While these medications may not be employed as frequently in psychiatric hospitals, awareness of their potential adverse effects (including dizziness, delirium, hallucinations and falls) and potentially harmful interaction with other medications (e.g., benzodiazepines) is still important. The alert also emphasizes the importance of accurate pain assessment and appropriate management techniques. The article also provides a few best practice recommendations for avoiding accidental opioid overuse. The 5-page SEA 49 [®] contains an additional 8 actions suggested by TJC to make the use of opioids safer. |
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• TS: – JCCAP™ Joint Commission Certified Accreditation Professional™: Be Ready for the Exam [Pearl: JCCAP, JCSC, LDR] The Source September 2012, Pg 1, Vol 10, # 9 When TJC announced the JCCAP initiative in July we identified it as a useful opportunity for the Joint Commission Survey Coordinator and leadership of your organization to consider (see our review of JCR Launches New Joint Commission Certified Accreditation Professional Program). This article continues to encourage participation in the program for which applications are now being accepted. It provides another review of the program, its benefits, eligibility criteria, two sample questions, brief description of the 150-multiple choice type test and announces that the first exam will be offered in January 2013. It also presents two new resources.
TIP: If you are currently the JCSC for your organization and/or are interested in becoming a JCCAP, pay attention to our reviews that note JCCAP applicability in the description line (e.g., this review). We identify these as articles that may also provide useful review information. Our reviews of these articles are being collected and can be subscribed to as an RSS feed to help with your exam preparations. [expand title=”JCR Launches New Joint Commission Certified Accreditation Professional Program”]
If you have been working as your hospital’s Joint Commission Survey Coordinator (JCSC) for at least 3 years and can correctly answer at least 120 of 150 questions on the TJC survey process, you could receive the new 3-year certification being offered by JCR starting 9/5/12. In addition to the recognition, the certification might well help the individual with career development and it will provide discounted access to TJC’s new Accreditation Resource Center (ARC). Since certification offers your organization the benefit of assured survey process knowledge and a new potential hiring criteria, it might be willing to spring for the $375 application fee. More details on the eligibility criteria, application process, an FAQ and a couple of sample test questions are available. TIP: Review the recommended readings (references and pearls) from past issues of this newsletter as part of your study process for the JCCAP exam. [/expand]
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• EC: – Tracing the Environment of Care: A sample fire safety mock tracer you can use [REF: EOC, E&M, SFT, JCSC] E C News September 2012, Pg 8, Vol 15, # 9 A mock EC tracer usually begins where a particular safety or security incident has occurred. Usually, much of the surveyor’s discussion with staff will be about their role in preventing/minimizing the particular risk in question and how they would appropriately respond. Here, a mock tracer scenario is presented that focused on aspects (i.e., priority focus areas (PFA)) of communication, orientation & training and physical environment as it related to the fire safety issue of the methods of entrance and egress through a hospital’s mechanical rooms. One nice aspect of this scenario is that it shows linkages between the scenario events and a set of sample questions.
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| THE JOINT COMMISSION (TJC and JCR) |
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[Index] [Blog] Perspectives [PR] – (September, Vol 32, # 9) Pg01 – Approved: 2013 Accreditation and Certification Decision Rules FYI: JCSC, LDR. Accreditation decision rules for 2013 go into effect on January 1st. Most of the changes were edits designed to clarify already existing rules. However new Contingent Accreditation rules have been added to address “systematic patterns or trends of noncompliance” (CONT03) and issues related to licenses, registrations (CONT06), PFIs and ILSM (CONT07). The specific language is provided on pages 9-15. Pg05 –Joint Commission Releases New Speak Up Video on Patient Rights FYI: PtEd This is a 60-second public service announcement. However staff should note that it describes rights including: |
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[Index] [Blog] The Source [TS] (September Vol 9 # 9) NA |
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[Index] [Blog] Environment of Care News [EC] (September Vol 15 #9) Pg01 – The Hazard Games: “Disaster Olympix” teaches hospital staff how to handle calamities FYI: JCSC, E0C, E&M, SFT. “If you want to get someone to pay attention and learn, turn their work into play”. This is the core concept underlying a Los Angeles hospital’s successful integration of friendly, game-like competition into disaster drill preparedness. Games like Don’t-spill-the waste relay race and Disaster “Jeopardy”™ add fun to the process of learning and practicing principles/skills of disaster preparedness. Check out the full article for more ideas. [Note: F&A has developed ‘Compliance Games’ to achieve a similar end with National Patient Safety Goals] Pg06 – Clarifications and Expectations: Managing Corridors, Part 2 Understanding requirements for doors, corridor walls, corridor air supply, and more FYI: EOC, RN, SFT, For a second month, Perspectives and EC News are running the same article as part of their Clarification & Expectations column. See our review of the Perspectives article above.
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Joint Commission Website (JCW)
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SPHCC Library Additions & Full Text Articles
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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, 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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