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Heather Comak

Heather Comak is the Assistant Director of the Association for Healthcare Accreditation Professionals and a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety. Contact Heather by e-mailing her at hcomak@hcpro.com.

Joint Commission announces field review for med rec

The Joint Commission has announced the field review of its revised medication reconciliation requirement, which it has designated as National Patient Safety Goal (NPSG) 03.07.01.

The field review comes after The Joint Commission announced it would make the existing medication reconciliation goal (NPSG 8) one with which hospitals had to comply, but about which they would not be surveyed. The 2010 NPSGs contain language about medication reconciliation, but the field has widely expected an announcement about what will become of the goal.

The accreditor had previously said it would update the goal because it had received feedback from the field indicating that hospitals felt the goal was too difficult to implement. Last February, The Joint Commission said it would “evaluate and refine the expectations for accredited organizations.” The field review is the result of this refinement.

The revised goal is designed to work in tandem with other medication management requirements. It requires providers to maintain and communicate accurate information regarding a patient’s medications. Specifically, the goal would require hospitals to:

* obtain medication information from patients at admission

* compare that information with the medications ordered for the patient and identify discrepancies

* communicate to the patient at discharge information about the medications he or she should be taking

* impress upon the patient the importance of managing his or her medications outside of the facility.

The Joint Commission is asking for feedback from the field through May 11, although it would prefer feedback by April 30. The standard will be tested in the field prior to implementation. If you’d like to offer your feedback, and to see the full text of the proposed goal, visit The Joint Commission’s page about the field review.

Do you have any initial reaction to this proposed med rec goal? My sense from the field that any change would be a good one, and this seems to really simplify the goal.

Joint Commissions opens proposed version of MS.01.01.01 (formerly MS.1.20) for comment

The Joint Commission (TJC) has released a proposed version of MS.01.01.01 (formerly MS.1.20) and it is seeking comment on the proposed version between yesterday (Dec. 17) and January 28.  TJC convened a task force beginning in January 2008 after it received negative feedback from hospitals and physicians about the proposed standard. The task force consisted of professionals from the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals, and National Association Medical Staff Services.

The new MS.01.01.01 attempts to improve the current standard using the following principles (according to TJC):

  • A well-functioning relationship between the governing body, hospital leadership, and the medical staff is essential to the delivery of high quality, safe care.
  • Effective communication is the lubricant that keeps relationships functioning well; it therefore is important that structures and processes support it.
  • Well-functioning relationships also depend on all parties knowing what is expected of them, and being able to live up to those expectations

You can read the proposed standard by clicking here and you can access the survey about the proposed standard by clicking here.


Joint Commission launches Center for Transforming Healthcare

The Joint Commission announced a new effort to address the nation’s biggest issues in terms of quality care and patient safety yesterday when it launched the Center for Transforming Healthcare. At the crux of the Center’s approach to improving patient safety is using Lean and Six Sigma to improve processes and address some of the challenges facing caregivers and patients. It hopes to offer specific guidance on how to solve issues like preventing healthcare-acquired infection, ensuring medication safety, coordinating safe patient handoffs, and focusing on surgical safety.

This not-for-profit has coordinated with some of the nation’s leading health systems to work on some of the above mentioned issues. You can find the full list by clicking here.

I did find it useful to know that starting midway through 2010, hospitals that are Joint Commission-accredited will be able to utilize an application on the site that will work with each facility individually to develop custom solutions.

You can find more information about the Center here.

Joint Commission releases Sentinel Event Alert

The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)

The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.

The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.

You can read the full list of recommendations, as well as the Sentinel Event Alert here.

Joint Commission asking for more input on standards

If you’ve got any opinions or concerns about the Joint Commission’s proposed staffing effectiveness requirements, you’ve got about five weeks to make your voice heard. Field review of the proposed Elements of Performance (EP) for hospitals and long-term care facilities is underway, with the Joint asking for comments to be submitted by July 10 (although the field review will remain open until July 22).

The changes are in response to complaints that compliance with the current staffing effectiveness requirements (standard PI.04.01.01 for hospitals and HR.1.30 for long-term care) consumes substantial resources without providing significant improvement in quality and patient safety. The proposed EPs fall under PI.02.01.01 (currently PI.2.10 for LTC) and are as follows:

  • EP 12 focuses on the use of outcomes data to guide staffing effectiveness analysis
  • EP 13 calls for leadership to review analyses of data related to staffing issues

Click here to review and comment on the proposed EPs.

Joint Commission requests feedback on cultural, communication standards

The Joint Commission asked yesterday for review from the field of its newly released proposed standards in effective communication, cultural competence, and patient-centered care. The standards, which would not be implemented until January 2011 at the earliest, represent an effort by The Joint Commission to place a greater emphasis on addressing disparities in care for certain patient populations. The standards also recognize how important solid communication is to delivering safe patient care, and that often communication can be ineffective with patients who face language, cultural, or physically debilitating barriers.

For the most part, the ideas behind these proposed standards are not completely new to The Joint Commission. There are existing standards that target the need for effective communication, patient-centered care, and cultural sensitivity. However, this will be the first time that these are specifically called out as an area of focus. The proposed standards encompass revisions and additions to 17 chapters for hospitals.

The proposed revisions can be found on The Joint Commission’s Web site.

Seems to me that this is more positive change coming from The Joint Commission. What are your thoughts? Do more standards not always mean good things? In this case, I think it will be a welcome addition to the existing standards.

Check out this HealthLeaders Media article on the topic as well, it provides some more detail, and is written by AHAP’s own Matt Phillion!

Joint Commission says 2010 NPSGs to be published in October

In its June issue of The Joint Commissions Perspectives, the official newsletter of The Joint Commission, the accrediting body says that it will not publish its National Patient Safety Goals applicable for January 2010 until its October issue of Perspectives. Although the NPSGs applicable for January of the following year are usually published in the July issue of Perspectives of the prior year, the NPSGs are currently undergoing a field review that will result in significant revisions. The review is not expected to be completed until early summer 2009.

The Joint Commission has stated that no new NPSGs will be released for 2010, only modifications to existing NPSGs. It is also asking for comment from the field about the proposed set of NPSGs. You can comment on its Web site through June 23.

Does this timeline affect your survey preparation schedule? Hopefully this time will be used well to create a less cumbersome set of requirements that still focuses on key patient safety issues.

AHAP conference 2009 leadership session

For those of you who did not get a chance to attend the 3rd Annual AHAP Conference that took place in Las Vegas two week ago, and for those of you who did attend and would like a chance to listen to the leadership session, here is your chance. The session touched on how best to engage your hospital’s leaders in both creating a culture of safety and demonstrating involvement in patient safety to comply with Joint Commission standards.

The presentation, given by Ken Rohde, consultant for The Greeley Company, opened the 2009 conference.

To find a copy of the slides that accompanied the presentation titled “The 2009 Leadership Standards: A Toolbox Approach,” click here.

To listen to the audio recorded at the session, click the link below. You will first hear Jodi Eisenberg, Chair of AHAP, introduce Ken.

Get the Flash Player to see the wordTube Media Player.

For those who attended the conference, we hope you enjoyed it and would love any additional feedback you’d like to offer for how we can improve the conference in the coming years.

Many Medicare patients readmitted to hospitals, study says

A study out yesterday from The New England Journal of Medicine shows that 20% of Medicare patients are readmitted to the hospital at which they recently stayed within a month. That percentage jumps to 34 when looking at a three month time period. The data, representing Medicare claims collected between 2003 and 2004, show that more and more discharge is becoming a time at which it is crucial to have a good communication plan in place among caregivers and patients.

Hospitals may soon have a financial incentive to make patient care at discharge a priority. The Wall Street Journal Health Blog reports that part of President Obama’s Medicare budget plan involves not further reimbursing hospitals for patients who are readmitted for the same condition that they had at discharge. Of course, there are many factors to why patients are readmitted: being extremely sick, and perhaps having a primary care doctor who jumps to hospitalization rather than other treatment could lead to repeat visits. A stronger continuum of care that involves better communication on the part of all of a patient’s doctors would also help lower these rates. Also, involving the patient and his or her family (and evaluating if they are health literate) in the discharge process would help lower readmission rates, researchers say.

To read the NEJM article, click here.

Positive Deviance proven to lower MRSA rates

The Robert Wood Johnson Foundation and Plexus Institute today announced the results of a Positive Deviance program, trialed to see the effects it had on MRSA rates. The story caught my eye because I’ve written a couple of stories about Positive Deviance for Briefings on Patient Safety in 2007 and 2008, and the idea always struck me as something so simple, yet so empowering. Positive Deviance solicits ideas for solving a problem from those who deal with that problem often and may think of a solution that might be considered “out of the norm,” but one that works. It’s an approach that attempts to gather behavioral change from those frontline workers who solve problems with the same resources as their peers.

Using Positive Deviance to lower MRSA rates has succeeded, as it was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America this past weekend. The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country. Each hospital was to use Positive Deviance to help carry out the following three actions:

  • screening all patients admitted to a pilot unit for MRSA
  • isolating all patients who tested positive
  • rigorously adhering to hand hygiene and contact precautions

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

This video clip from CBS News shows how one transporter helped his hospital adhere to hygiene and contact precautions (sorry about the commercial before the news).


Could this technique be something your hospital implements? Have you thought of using Positive Deviance for tackling other issues at your facility, not just MRSA?

You can find out more about Positive Deviance by visiting the Positive Deviance Initiative Web site.