••WHAT’S NEW:

• New SPHCC
  • New Website – Coming in August 2012!
  • New Membership Options & Benefits – The new SPHCC will have more options and benefits for members and associates to choose from.
  • Current Memberships – All current memberships are automatically extended until our new website is fully operational.

• New TJC Certified Accreditation Professional Program (JCCAP)  See also below
• Surveyors (AOS, DNV and TJC) not to issue citations  concerning medical staff membership on the governing body.  See CMS Spotlight below for more details.

••RECOMMENDED READING:

• Approved: Standards Revisions Addressing Patient Flow Through the Emergency Department[Ftxt]  Perspectives July 2012, Vol 32, # 7, Pg 1 [REF: GB, JCSC, LDR, MDx, RNx] includes focus on BHC pts.

• JCR Launches New Joint Commission Certified Accreditation Professional Program   [PEARL: JCSC, LDR]  Perspectives April 2012, Vol 32, # 7, Pg 7  PI/QI Directors and Joint Commission Survey Coordinators (JCSC) should consider this.

• Approved: Revised Waived Testing EP[Ftxt]    [REF: JCSC, PI, RNx]  Perspectives July 2012, Vol 32, # 7, Pg 13

• Avoiding Patient Boarding Enhancing Flow Through the Emergency Department    [REF: GB,JCSC, LDR, MDx, RNx]  The Source Jan 2012,  Vol 10, # 7, Pg 1

• Everything You Ever Wanted to Know About Performance Measurement at The Joint Commission but Were Afraid to Ask The Source Jan 2012,  Vol 10, # 7, Pg 12 [REF: JCCAP, JCSC, PI]    Fundamental but often confusing concepts and definitions clarified. Self-assessment is encouraged 🙂

• Clarifications and Expectations Managing Barrier Integrity E C News Feb 2012, Vol 15, # 2, Pg 5  [REF: EOC, LDR, SFT]  Explicates fire/smoke barriers and smarter management of access points

••DOWNLOADS:

• R3 Report on Influenza Vaccination (released 5/30/12)
• Prepublication Standard – Revision to WT.04.01.01
• New (BHC) Requirements for Prevention and Wellness Promotion Services
• BHC News – Issue 2, 2012 – latest issue of this quarterly publication (Ohio health homes, BHC PTAC)
• CMS Patient Safety Initiative Pilot Phase – Revised Draft Surveyor Worksheets  for Quality Assessment and Performance Improvement (QAPI), Infection Control, and Discharge Planning
• CMS Form 855A, Medicare Enrollment Application

• See also [Ftxt] and Full Text Articles below

••Additional Updates in:

• Perspectives (PR):  3 more articles
• The Source (TS):    2 more articles
• EC News (EC):       2 more articles

Recommended Readings, Tips & Pearls

RTN Quick Jump••Top••RefRvw••TJC••Perspectives••Source••EC News••TJCOnline••CMS••Internet••New Adds••Abbreviations••Bottom

•PR: – Approved: Standards Revisions Addressing Patient Flow Through the Emergency Department[Ftxt]    [REF: GB,JCSC, LDR, MDx, RNx]   Perspectives July 2012, Vol 32, # 7, Pg 1

In the past, we have pointed out the relevance of the Patient Flow concept to psychiatric hospitals.   Now, with the upcoming changes to LD.4.03.11 and PC.01.01.01 TJC more directly requires the address of safety concerns related to the heightened risks associated with two key issues.  The first is boarding, defined in the article as holding patients in the ED or another temporary location after the decision to admit or transfer has been made. However, the second issue is the provision of services for the vulnerable population of patients who suffer with emotional illness and/or the effects of alcoholism or substance abuse or otherwise present as a behavioral health emergency.  Revisions and additions include the following:
Re: LD.4.03.11 (4 revisions/1 new EP) – Effective 1/1/13 except for EPS 6 and 9

• EP#5 – Hospitals must now set goals for various components of the patient flow process
• EP#6 (effective 1/1/14)- This includes goals for mitigation and management of the boarding process and the recommendation (not requirement) for boarding not to exceed 4 hours 
• EP#7 – Achievement of these goals is to be monitored and evaluated
• EP#8 – Leaders are required to actively improve the patient flow process when goals are not achieved
• EP#9 (new, effective 1/1/14) – Leaders are also to communicate (and collaborate) with behavioral health care providers and/or authorities to ensure proper coordination of care for behavioral health emergencies.

Re: PC.01.01.01  (1 revision/1 new EP) – Effective 1/1/13

• EP#4 – Our Med-Surg hospital cousins must now have a written plan defining the care, treatment and referral processes for patients who are emotionally ill and/or suffering the effects of alcoholism/substance abuse
• EP#24 (new) seeks to ensure greater safety for the boarding of such patients by requiring safe locations, orientation and training of care-taking staff (both clinical and non-clinical); the conduct of assessments/reassessments and provision of appropriate care as needed.

TIP: Psychiatric hospitals should take advantage of the article’s encouragement of communication and collaboration.  Reach out to those hospitals that may have been sources of concern regarding the sending or receiving of your patients.
Tip: Look for and review the R3 Report (Requirement, Rationale, Reference) on this topic later in 2012.
TIP: Review the new and revised requirements for Patient Flow Through the ED included with the article and/or download  Standards Revisions to Address Patient Flow Through the Emergency Department .

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• PR: – JCR Launches New Joint Commission Certified Accreditation Professional Program    [PEARL: JCSC, LDR]    Perspectives July 2012, Vol 32, # 7, Pg 7

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. 

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• PR: – Approved: Revised Waived Testing EP[Ftxt]  [REF: JCSC, PI, RNx]  Perspectives July 2012, Vol 32, # 7, Pg 13

FYI: RN, EP#4 of WT.04.01.01 has been revised for hospitals and BHC programs. “Effective immediately, the revised EP 4 no longer requires organizations to perform quality control checks on each day of testing.”  Instead, these checks are to be preformed as per manufacturer’s instructions for instrument-based waived testing.  The article includes the revised text.

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• TS: – Avoiding Patient Boarding Enhancing Flow Through the Emergency Department   [REF: GB,JCSC, LDR, MDx, RNx]   The Source Jan 2012,  Vol 10, # 7, Pg 1,

This is the second article in an official TJC publication this month that describes the changes related to standards LD.04.03.11 and PC.01.01.01.  See Perspectives above. This article reviews the revisions and additions, and encourages reduction of boarding and improved safety for patients with behavior health care needs.  It also identifies some patient flow measures for evaluation, baseline setting and trend analysis that may facilitate efforts to improve. 

TIP: If you read the Perspectives article first, you only need to read the new content in the last section of this article headed ‘Laying the Groundwork for Success’ starting on page 4.

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• TS: – Everything You Ever Wanted to Know About Performance Measurement at The Joint Commission but Were Afraid to Ask   [REF: JCCAP, JCSC, PI]  The Source Jan 2012,  Vol 10, # 7, Pg 12

Apparently there are a number of common misunderstandings about certain aspects of performance improvement at TJC, particularly as it relates to issues surrounding measurement.  We identified six of these (§) as fundamentals every JCSC should know.  We were going to provide brief answers but thought that might steal an important opportunity for self-examination and constructive motivation.
§ What does ORYX® stand for?
§  What are performance measures and measure sets?
• How does The Joint Commission develop measures?
• Why are measure sets so important?
• What do inclusionary and exclusionary criteria have to do
  with performance data?
§ What are core and non-core measures?
§ What is the difference between accountability measures and nonaccountability measures?
• Why does The Joint Commission have non-accountability measures?
• Who are vendors, and how do they and The Joint Commission ensure the quality of         performance measure data?
• Why do data need to be submitted so frequently?
§ What are the data used for?
§ Where do I go if I have a question about performance measurement at The Joint Commission?
TIP:  Test yourself on the six § questions above, to help decide if you should read the detailed explanations provided in this article.
TIP:  Leaders – Test your PI Director and/or JCSC on the six § questions above to help you determine if the new JCCAP program would be a worthwhile investment.

PS:  We’re not completely heartless… let us know if you have questions about answers for the six § questions.

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• EC: Clarifications and Expectations Managing Barrier Integrity    [REF: EOC, LDR, SFT]      EC News Feb 2012, Vol 15, # 2, Pg 5

This is the same article (word for word) published last month under the same column heading in Perspectives (June 2012,  Vol 32, # 6, Pg 3-5,).  See our previous review of Clarifications and Expectations: Managing Barrier Integrity .

[Index] [Blog] Perspectives [PR] – (July, Vol 32, # 7)

Pg06 – Two Final Rules from CMS Expected to Reduce Regulatory Burden   FYI: JCSC, This article provides a brief capsule summary of the following two recent CMS final rulings:

Re:   [CMS–3244–F] Reform of Hospital and Critical Access Hospital Conditions of Participation

• Medical Staff Membership: Now includes advanced practice nurses and physician assistants,
• Medication Self-Administration:  a patient, their caregiver/support person may administer certain medications
• Standing Orders: Encourages the use of evidence-based preprinted orders and protocols
• Outpatient Services: the requirement for a single director of outpatient services eliminated.
• Governing Body: A multi-hospital health system may be overseen by a single governing body.
• For more details see the Special CMS Section: Review of CMS-3244-F in our June RTN.

Re: [CMS–9070–F] Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction

• E-prescribing: Updates e-prescribing technical requirements 

Pg14 – New R³ Report Examines Standard IC.02.04.01   FYI: IC, JCSC, This third and latest R3 Report on Influenza Vaccination (released 5/30/12) includes the actual requirements, rationale and reference information for IC.02.04.01.  Although this standard does not mandate influenza vaccinations, the strengthened requirements may be challenging.  Note, this standard has also been extended to BHC programs.  Finally, the 4-page report presents some feedback from the field and identifies outstanding issues regarding vaccination rates.

Pg14 – Approved: New Behavioral Health Care Standards for Prevention and Wellness Promotion Services   FYI: BHC, PI,  Effective 1/1/13, new standards CTS.07.01.01-CTS.07.01.03 apply only to organizations that provide prevention and wellness promotion as a discrete community-based service (e.g., suicide prevention).  The standards require written plans, seeking input about community needs and basing services on those needs and available evidence-based  guidelines when possible; identifying relevant community resources, ensuring appropriate staff training and evaluating the services provided.

[Index] [Blog] The Source [TS] (July Vol 9 # 7)

Pg02 – 5 Sure-Fire Methods Complying with Standard MM.01.02.01   FYI: Phrm, P&T, This article presents several recommendations to improve compliance with requirements related to safe use of look-alike/sound-alike (LASA) medications.  Most facilities already use warning labels and/or TALL-MAN lettering and physically separate LASAs when storing them.  Additional suggestions provided here include establishing a policy or requiring both brand and generic names on any LASA prescription and reeducating telephone orders.

Pg18 – CMS Understanding Deemed Status   FYI: GB, JCCAP, JCSC,LDR, The word deem means to regard or consider in a specified way.  TJC is one of a few select organizations that has CMS permission to deem hospitals as being in compliance with the federal requirements/conditions of participation necessary for Medicare certification.  With the proper application, one survey can achieveTJC accreditation and CMS certification.  If your facility is not currently accredited by TJC or not using the TJC survey for certification purposes, this article may provide a useful overview of some important preliminary steps (e.g., submitting CMS Form 855A to your Regional Fiscal Intermediary) in applying for this dual benefit.  It may also be a helpful review for those interested in JCCAP.  See also: Other articles on TJC deemed status

[Index] [Blog] Environment of Care News [EC] (July Vol 15 #7)

Pg01 – Asked and Answered Your questions answered about Plan for Improvement extensions, tented or overhead signs, and more   FYI: EC, EM, LS, This month’s Q&A column on EC, EM and LS issues included:

• Fire Extinguisher Signs – TJC does not specifically require tented or even overhead signs, but the extinguisher’s location must be clearly evident, conspicuously marked, and in no way camouflaged, obstructed or obscured from view. 
• Utility System Labeling – The labeling of utility system controls (e.g., shut off valves) as required by EC.02.05.01, EP8 should include identification of specific rooms and a caution (not to close or open the valve except in emergency).
• PFI Extension Requests – TJC automatically allows a six-month grace period on PFI completion, but after that, requesting an extension for any previously accepted  PFI requires completion of a PFI Change Request found in the PFI menu of your SOC.

Pg02 – Test Your Standards IQ   [PEARL] FYI: E&M, JCCAP, JCSC, SFT This is a series of questions (with answers) on EC, EM and LS issues presented on a bi-monthly basis (started in January) that provide a useful self-assessment and refresher. 

Quarterly Provider Updates

• QPU April – June 2012
  • Issuances for July – September 2012 QPU [PDF, 110KB]
  • Regs-2Q12QPU [PDF, 18KB]
    • No new, state hospital-relevant activity/issues for this release

Mid-Quarter Instructions

• January 2012 Mid-Quarter Instructions [PDF, 37 KB] 
  • Inpatient Psychiatric Facility (IPF) Pricer –Annual Update – FYI: F&B

Spotlight/What’s New

• QPU What’s New – July 2012 [PDF, 22KB]

INTERNET HIGHLIGHTS

Joint Commission Online(JCO) & Website

• TJC Topic Library
  • Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community:A Field Guide – (6/29/12) Same guide as issued in 2011 but with web links
  • Facts about the Official “Do Not Use” List of Abbreviations  (6/28/12)
  • Facts about federal deemed status and state recognition  (6/19/12)

SPHCC Library Additions & Full Text Articles

• 77 FR 29034:
• Full Text Articles
  • Creating and Implementing a Utilization Review Plan, The Source, January 2012, Volume 10, Issue 1  [RT Review]
  • Tackling Top Challenging StandardsTips and Reminders to Support Compliance in EC, EM, and LS, Environment of Care® News, January 2012, Volume 15, Issue 1  [RT Review]
  • New and Revised Requirements for Patient Flow Through the ED (LD, PC) (7/12)    [RT Review]
  • Revised Requirement for Waived Testing (WT) (7/12)  [RT Review]