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Executive Briefings debriefing, New York edition (#1)

Hello, everyone. I’ve just returned from the New York Executive Briefings. There weren’t any bombshells dropped this year by any of the presenters, who focused on the National Patient Safety Goals (NPSG), problematic standards, the new e-dition of the Comprehensive Accreditation Manual for Hospitals, and lastly gave an overview of the new scoring methodology.

Audience questions this year focused unsurprisingly on medication reconciliation, which continues to be a struggle for hospitals across the country. Universal Protocol was also a focal point during question and answer sessions.

Dr. Peter Angood said that The Joint Commission does not intend at this point to add any new NPSGs in 2009, though revisions are to be expected—and remember, just a few months ago we saw the release of the 2008 NPSGs that, though they did not contain any brand new Goals, did contain significant changes and left much work to do.

An important note on Periodic Performance Review (PPR): If your facility is due to submit a PPR before October, 2008, there are no changes. After October, PPR is optional for this year because of the numbering changes in the manual. If you choose to submit a PPR, though, it will need to be done before December 1 because The Joint Commission’s PPR tool will be offline.

If your PPR is due in January, you will have an extra 90 days to submit it. If due in February or March, you have an extra 60 days to submit it.

Was anyone else in attendance on Friday? What observations did you take away from the New York Executive Briefings?

I’ll be posting additional observations over the next few days, so please check back.

News from Executive Briefings: "D"s Will Not Change

Just wanted to share this posting from Bud Pate, REHS, Vice President of Content and Development for The Greeley Company. Bud is currently attending Executive Briefings in Los Angeles.

Although there may be some errors, the “D”s [indicating that documentation is required] for the new standards will remain as written in the current version of the manual according to Dr. Robert Wise, Vice President for the Division of Standards and Survey Methods for the Joint Commission. Although he acknowledges that there may be errors, Dr. Wise committed that, until they change, documentation is not required unless there is a Circle D logo in the accreditation manual.

Stay tuned for more.

Matt Phillion, Senior Managing Editor of Briefings on The Joint Commission, will be reporting back from the New York Executive Briefings.

An Inside Look at Successful RFI Clarification

Just wanted to share this white paper from Lisa Eddy, RN, CPHQ, CSHA, Senior Consultant for The Greeley Company, a division of HCPro, Inc. Those of you who participated in our working group calls on suicide risk assessment should be familiar with Lisa. Hope you find this white paper useful.

Go to http://www.hcpro.com/content/217282.pdf to download a PDF of the white paper.

Brian Driscoll
AHAP Director

Distinguish Between Medical and Behavioral Restraint

From Bud Pate, REHS, Vice President of Content and Development for The Greeley Company:

Surveyors commonly misapply the behavioral health rules to medical restraint. In fairness, the Joint Commission standards and CMS regulations are a more than a little confusing, even when you study them carefully. But the rules for behavioral health restraint are vastly different than those for medical restraint, so your definition should be crystal clear.

Regardless of the location, behavioral health restraint rules should only be applied to address violently aggressive or self disruptive behavior. We recommend that your policy clearly apply the medical restraint rules to the following situations:

- a patient who is in the critical care unit after a suicide attempt and is being restrained to avoind accidental extubation due to twitching or trying to sit up in bed;

- a patient experiencing involuntary thrashing during acute withdrawal syndrome;

- a confused patient who is interfering with nursing care.

“But wait,” you say, “we should use the behavioral health care rules because we are caring for patients with clear emotional disorders.” Or you may say “The confused patient is trying to hurt the nurse, shouldn’t the behavioral health rules apply?”

But remember, all restraint (medical and behavioral) is implemented to address behavior. And if you truly believed the behavioral health care rules applied you would already be staffing these situations with psychiatric nurses. Ask yourself, “would a debriefing be helpful to see how a future episode would be avoided?” I don’t think so.

There will certainly be those who object to this position. If you are one of them, then I encourage you to fully (and I mean fully) implement all the behavioral health care rules to these situations, including: continuous observation, 15 minutes assessments by a staff member with psychiatric training, post-restraint debriefing with the patient, and all the other very restrictive rules. If you don’t feel these measures are clinically necessary, then you agree with me: these are not behavioral health restraint. So define them as medical restraint in your policy.

Remember: we can debate the fine points of a policy with regulators all day long without reaching an adverse conclusion. However, you will definitely be guilty of an infraction if you violate your own policy. In other words: say what you do and do what you say.

Restraint benchmarking survey

Hello, all. I just wanted to share with you some results from our recent benchmarking survey:

Managing the use of restraints and complying with related requirements continue to be major challenges for accreditation professionals throughout the country. And one of the biggest areas of concern is the use of medication restraints, according to AHAP’s most recent benchmarking survey.

According to the members-only survey, conducted in June and July 2008, 46% of accreditation professionals find medication restraints the most troublesome under CMS’ updated restraint Interpretive Guidelines (24% listed soft limb restraints as most troublesome, while 17% listed “other,” 7% listed zippered comforter restraints, and 6% listed low bed restraints).

The number for medication restraints seems high, says Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, member of the AHAP advisory board, healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor. “Perhaps the organizations need to review their definitions of chemical restraint,” she says. “They may, in fact, not be following the CMS/Joint Commission definition—theinappropriateuse of a sedating psychotropic drug to manage or control behavior. To give a medication may in fact be medical management of the patient’s condition and not inappropriate use.”

When asked how they used medication restraints, 51% of survey respondents said they use them to de-escalate aggressive, destructive behavior. Thirty-seven said they use medication restraints to manage behavior, 25% said they use them for other purposes, and 7% said they use them to restrict freedom of movement.

Hope you found this useful. Go to http://www.accreditationprofessional.com/benchmarking_survey.cfm?topic=WS_AHP_QBS to download the full 11-page report, as well as other benchmarking reports from this year.

Medicare Improvements for Patients and Providers Act

I just wanted to update you on a news brief I posted to the group a few weeks back. Congress overruled yesterday President Bush’s veto of the Medicare Improvements for Patients and Providers Act, based on a bill authored by Senate Finance Committee Chairman Max Baucus (D-Mont.).

While the primary focus of the bill is to improve several key aspects of Medicare, for those of us working in the area of accreditation, under the category of “Enhancements for Rural and Other Hospital Care,” note this short passage:

Revokes unique authority of the Joint Commission on the Accreditation of Healthcare Organizations to deem hospitals in compliance with Medicare Conditions of Participation.

There will be a 24-month transition period for The Joint Commission to complete the application process for deeming authority, and “the amendments made by this section shall not effect the accreditation of a hospital by the Joint Commission, or under accreditation or comparable approval standards found to be essentially equivalent to accreditation or approval standards of the Joint Commission, for the period of time applicable under such accreditation.”

Additional information can be found online here: http://finance.senate.gov/sitepages/medicare2008.htm

What are your thoughts? Does this level the playing field for other accrediting organizations? What effect do you think this will have on hospital accreditation, if any?

We have reached out to The Joint Commission and several other organizations for comment; I will be sure to distribute to the group follow-up information as it arises.

Latest Sentinel Event Alert: Disruptive behavior

I just wanted to make you aware of some breaking news: The Joint Commission has issued its latest Sentinel Event Alert today addressing bad behavior by healthcare professionals.

Disruptive behavior was considered as a possible National Patient Safety Goal for 2008 but was not selected. The Joint Commission has stated in this most recent alert that rude behavior, unpleasant language, hostile attitudes and other bad behaviors does not only create an unpleasant environment but are detrimental to patient safety and quality of care.

This alert ties into new standards going into effect January 1, 2009, which will require healthcare organizations to create a code of conduct defining acceptable and unacceptable behaviors as well as crafting a process for dealing with poor behavior.

The Sentinel Event Alert provides 11 steps to curbing disruptive behavior. These range from providing education and training for healthcare providers about professional behavior and appropriate interactions with coworkers; creating accountability for maintaining appropriate behavior; establishing a zero tolerance policy for disruptive behaviors and a means for enforcing this policy; and crafting non-confrontational methods for reporting and addressing inappropriate behavior.

The Joint Commission’s Sentinel Event Alert can be found online here: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

2009 National Patient Safety Goals released

Just wanted to let you know that The Joint Commission released the 2009 National Patient Safety Goals earlier today on its Web site:

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf

The first link also has a chart identifying which goals have received changes/deletions/additions, and provides a crosswalk to the new numbering system.

Update: Joint Commission to lose "unique" deeming authority?

Hello, everyone. I just wanted to update you on the developing story in last week’s post. Senator Max Baucus’ (D-MT), chair of the Senate Committee on Finance, bill containing language to revoke the unique deeming authority status held by The Joint Commission failed to find support on the Senate floor. Meanwhile, a competing Medicare reform bill, introduced by Senator Charles Grassley (R-IA), has been introduced, containing similar language regarding The Joint Commission’s deeming authority.

Senator Grassley’s proposed Medicare reform package can be found here. A summary of Senator Baucus’ proposed legislation can be found here.

Joint Commission to lose "unique" deeming authority?

Hello, all. Just wanted to update you on a developing story:

Montana Democratic Senator Max Baucus, chairman of the Senate Committee on Finance, announced proposed legislation last week which included language to revoke the unique deeming authority status held by The Joint Commission.

 

This change would require all accrediting bodies, including The Joint Commission, to apply for hospital deeming status for hospitals—a process The Joint Commission and other accreditors undergo for other organizations and facilities (for example, laboratories and ambulatory centers). The Joint Commission currently does not need to undergo this application process for hospitals.

 

The Joint Commission issued a statement on Tuesday, June 10, supporting the legislation, while proposing several amendments. The Joint Commission has requested CMS issue “modernized guidelines and procedures for assessing compliance with existing conditions of participation for hospitals,” according to the official statement. The accreditor also requested a two-year period to undergo the application process following the issue of those guidelines and procedures. Finally The Joint Commission suggests that provisions are made to give the Health and Human Services (HHS) secretary the ability to create up-to-date methodology for assessing the performance of accreditors.

 

A summary of Senator Baucus’ proposed legislation can be found at http://finance.senate.gov/sitepages/legislation.htm.

 

Go to http://baucus.senate.gov/ for Senator Baucus’ Web site.