Archive for January, 2009
Clarification of TJC S3 Scoring
Have you noticed your TJC S3 score rising? Has it risen markedly over the last two quarters? If so, you may have some questions that you’ve had trouble answering. Hopefully, we can provide some insight that will prove helpful. In discussions with the folks back in Chicago overseeing S3 scoring (who have been most helpful), there was a bump in Quarter 2 ‘08 reported data that most hospitals felt, which was due to data from SCIP measures. TJC had neglected to factor in the SCIP ORYX (core measure) outcomes into the scoring system as they have with all other ORYX measures. So, suddenly, quarter 2 ‘08 reflected this data and caused a sudden (and in many cases, distinct) rise in S3 total. Another issue with rising S3 scores is the fact that only the negative outliersfrom all ORYX measures are counted in the S3 scoring. [more]
Reconsider Dating Open Multidose Vials
Over my 30 year carreer I’ve reviewed medication storage locations in about 500 hospitals. Guess what I’ve learned? It doesn’t work (except that it gives surveyors a “for sure” citation). I can remember only one hospital that succeeded in putting an outdating process in place for open multi-dose vials — it took tons of leverage from leadership and only lasted until the surveyor came back to clear them. So, what are the options? [more]
CMS Pushes for More Joint Commission Changes
The Joint Commission must for the first time meet CMS expectations to maintain its Medicare “deeming authority.” This has triggered significant changes, since the current Joint Commission standards and survey processes do not match CMS standards and survey processes. The first wave of change was the 300 or so new elements of performance that became effective on January 1, 2009. These changes were done “on the fly” (without the typical pause for comments from the field) and bring the Joint Commission standards in better (but not perfect) alignment with the Medicare Conditions of Participation. [more]
Is Staffing Effectiveness on its Way Out?
Apparently the Joint Commission is close to abandoning the requirement for staffing effectiveness measures. Ann Scott Blouin, the Joint Commission’s new Executive Vice President Division of Accreditation and Certification Operations, indicated that removing these standards is one of her high priorities. We have two questions:
1. What has taken JC so long? The staffing effectiveness requirement has been around for more than a decade. It has proven itself to be valueless over and over again. We’ve heard it was on the way out five years ago. We hope that this time it’s for real.
2. What about other standards without value, such as “prohibited entries” and “critical values.”
What’s in a name? NPSG 01.01.01 Patient Identification
Happy New Year! As of January 1st, the 2009 NPSGs are in full force. When we’re talking about NPSG 01.01.01, the patient identification goal, the Joint Commission requires that prior to collecting specimens, giving medications or providing treatments to the patient, staff are to actively involve the patient (or family as appropriate) in the identification process. And, when patient reliability is an issue, and participation from the patient is not possible, the hospital is to designate a responsible caregiver for verification of identity. We suggest designation of the patient’s primary nurse as the “responsible caregiver”. [more]