The Circle D Doesn’t Seem to Help

OK, so maybe I’m not the brightest bulb on the tree, but I thought the Joint Commission would be helping us by indicating when documentation of a particular requirement was necessary. The latest posting of the 2009 standards seems to help: they have a Circle D indicating that “documentation is required” next to a subset of requirements. However, that little D does not tell you when clinical documentation is required, only when you must have a policy, plan or other document. So, don’t fool yourself that the medical record need not document a pre-sedation assessment even though the requirement is not closely followed by a Circle D (PC.03.01.07 EP.1). [more]

2009 Standards and NPSGs with Scoring elements

TJC 2009 Manual Scoring is Here!!
TJC 2009 chapters for TJC standards manuals have been posted to the Joint Commission’s website and include the new scoring for the 2009 TJC Standards for both the manuals and the NPSGs. All 2009 Elements of Performance now have corresponding scoring categories of either “A” or “C”. That’s good news!! Those difficult to score category “B” elements have been removed from the standards. Within the new scoring information, the Joint Commission has now added the following symbols to guide healthcare organizations in their understanding of compliance expectations. There are of coure, the afore mentioned Element of Performance categories “A” and “C”, and the symbol “M” with a circle, indicating a measure of success, all of which continue to carry the same scoring requirements and weight as in 2008. However, there are three new symbols that are now applied. There is the triangle with the 2 inside, which stands for “situational decisions rules apply” (Level II finding.) The situational decisions rules have been there all along, although the details may have changed. These include things like working without a license, falsification, two [more]

Patient Identification Issues

What’s the ONE thing you cannot use when identifying your patient? The patient location (room number, bed, etc.) This means whenever you have an opportunity to program electronic equipment with patient identifying information, such as programable pumps, you will want to use the identifiers your hospital requires for patient identification. This issue was brought to our attention from one of our Center clients, the ever-on-top-of-the-latest-issues Maria Gray, from the Caritas Health System. So, we encourage you not to use room numbers or unit locations when programming in patient information – always use the 2 patient identifiers your hosptial has approved for proper identification. [more]

Hand Hygiene Tip #1: Use CDC rather than WHO

In 2002 the Centers for Disease Control and Prevention reported that compliance with hand hygiene guidelines hovered around 45%. Although one would hope (which springs eternal) that compliance is better now, hospitals are severely challenged to reach the 90% minimum compliance level mandated by the Joint Commission. In fact, we find this to be the most frequent reason our clients face “Provisional Accreditation” at the end of their “Measure of Success (MOS)” monitoring period … hospitals just can’t get hand hygiene compliance rates high enough, quick enough to satisfy Oakbrook Terrace. [more]

Fall Reduction Program – Always on Your Mind?

Now that summer has blazed it’s trail and the half-way mark of the year has come and gone, don’t forget to stop and think about taking a moment to evaluate the effectiveness of your fall reduction program. Establishing a risk assessment and even going so far as to monitor compliance with the organizational policy on fall risk assessment, is only a small part of this National Patient Safety Goal. Now would be a great time to really look at your data and see if you have a truly effective reduction program. Ask yourself these questions: [more]

Distinguish Between Medical and Behavioral Restraint

Surveyors commonly misapply the behavioral health rules to medical restraint. In fairness, the Joint Commission standards and CMS regulations are 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: [more]

Take the Pain out of Pain Reassessments in Three Steps

The Problem: Most hospitals have an 80% entrinsic rate of compliance with their pain reassessment policy. This is usually good enough to meet 2008 expectations, but it will not be nearly good enough for 2009 (90% will be the minimum level of performance). The challenge is that the bedside nurse has no reason to go back to the chart when he or she determines a pain medication has been effective. If another dose is needed, no problem … the nurse is in the chart for the follow-up dose of medications anyway. If another dose is not needed, however, the nurse is not inclined to revisit the chart just to document that all is well … it just isn’t natural. [more]

More Things to Correct in 2009

In case you haven’t noticed, you will have about twice as many things to correct after survey in 2009. There will be no “supplemental” findings, only “requirements for improvement.” [Supplemental findings are typically half the number of items on a current survey report form.] So, if the surveyors see two instances when pain was not reassessed per hospital policy, you will have to address the issue (either clarify within 10 days or correct within 45 – 60 days).

… so, how many new positions have you requested for the ‘09 budget????

Shorter Time Frame for Clarification

In our experience between 20% and 80% of survey findings can and should be “clarified” rather than corrected. This clarification (a process to get the finding removed from the report) can be based on an audit of practices from the 30 days prior to survey (category C), based on a surveyor’s misunderstanding of the facts at the time of survey, or based on the surveyor’s misapplication of the standards. We advise our clients to always clarify auditable or erroneous findings. It’s always a bad idea to implement corrective actions for a problem that doesn’t exist. As my grandfather used to say, if it ain’t broke, don’t fix it. [more]

Surveyors Continue to be Broselow Busters!

We continue to see Joint Commission survey reports claiming that “the hospital was using an expired Broselow tape.” This is just silly. First, Broselow tapes don’t expire. Although the most recent version (2007B) is a little more up to date, the most common version in use (2005A) is just fine and reflects the most recent (2005) PALS guidelines.

So … if a surveyor or a consultant tells you that the 2005A tape is out of date or cannot be used for pediatric dosing guidelines, they are simply wrong. True, the versions prior to 2005A may have relied too heavily on different concentrations of some IV medications (creating a problem with National Patient Safety Goal 3B … which is no longer in the manual and the FAQ addressing Broselow has not been picked up in the 2008 version). However: [more]