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Practice, practice, practice

Organizations that have practiced for the live on-site event always do better for the real thing. Everything from notification of the survey to the process of escorting surveyors to the survey room is much smoother and more organized. The advantage of practicing live is that it provides you with an overview of how well your plan is implemented. It allows you to modify your plan. You can never practice enough. Familiarity can only lead to a higher level of consciousness and ease for the staff.

Schedule practice sessions for the interview-type group sessions. Amazingly, it is not unusual for staff members to attend mock survey sessions and seem totally unprepared. As a  group, discuss your vulnerabilities and determine how they will be addressed. There is no excuse for not being able to address your data. Determine who is in the best position to respond to a specific issue, but avoid having a single person answering all the questions. This  gives you the advantage of having your staff well versed in the findings while the surveyors need to probe.

Tip for success: During the practice session, determine which specific issue each leader will address. Also, decide what examples you would like to highlight during this session in your responses. You probably have many good stories to tell regarding PI and patient care quality, and you should plan to highlight them during the interview when the time is right. You want to leave surveyors with a sense of confidence that you have good oversight of the care delivered in your facility.

Editor’s note: This blog post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, Thirteenth Edition, by Jean S. Clark, RHIA, CSHA, and Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA

Communicating patient rights with physcians and staff

You can have the best policies and procedures in the world, but if communication and understanding by those who need to know is not available, the intent of the patient rights chapter will never come to fruition. The chapter captain assigned to patients’ rights, with guidance from the accreditation director, should develop a communication plan to ensure that everyone in the organization understands his or her roles and the impact the chapter holds in relation to job responsibilities and functions.

The first step in a communication plan is to include aspects of this chapter in the job application form and credentials application. Those applying for jobs and physician privileges need not apply if they are not willing to adhere to and respect patients’ rights. For example, you could include the following language in your application:

By signing this application, I agree to treat patients and families with respect, ensure the patient’s privacy and confidentiality of health information, and to review the patient’s rights and responsibility notice.

Communication regarding patients’ rights should always be part of orientation to new board members, physicians, and staff. Some hospitals require all three groups to sign a document attesting that they will abide by and uphold these rights.

Ongoing communication is important for compliance with the patient rights chapter. In particular, the following topics should be considered for educational sessions or communication reminders:

  • Respecting cultural and personal values, beliefs, and preferences
  • Privacy and confidentiality
  • Understanding how patients understand (i.e., health literacy)
  • Advance directives and end-of-life decisions
  • Informed consent
  • Research/clinical trials
  • Dealing with disruptive people (e.g., physicians, staff, patients, family members)
  • Identifying neglect, exploitation, and verbal, mental, physical, and sexual abuse
  • Resolving patient complaints

Note: This blog post is an excerpt from The Chapter Leader’s Guide to Patient Rights: Practical Insight on Joint Commission Standards by Jean Clark, RHIA, CSHA.

Book Excerpt: Tracking required staffing effectiveness standards

The requirements of standard LD.04.04.05 EPs 1, 7, and 13 mandate that governance receives an annual report encompassing not only system and process failures, but also sentinel event information, degree of family involvement, and actions taken to improve safety as well as the adequacy of staffing. Although the former indicators are available to track, such as patient/family complaints and a number of falls, it is not necessary to track them specifically. However, incorporating staffing effectiveness information and analysis data already being collected in the organization makes a lot more sense than the previous requirements. For example, when you are assessing patient flow issues or evaluating a patient fall, you can determine whether staffing issues such as volume, workload, complement of staff members on duty, and  competencies play a role in the analysis.

In conjunction, staffing effectiveness EPs were added to PI.02.02.01. EPs 12 through 14 address patient safety leadership notification of issues related to the analysis of undesirable patterns or trends as well as the inclusion of this information in an annual report.

Tip for success: After the overwhelming experience of complying with this standard in the past, the advice to you is to keep it simple by considering your organization’s needs. You can compile one report incorporating all the features required in the EPs to involve leadership as well as your governing board. The adequacy of staffing notation can be a simple checkbox or column added to your postevent or trends assessments and your root cause analyses as you consider staffing levels and competencies affecting the identified failure. The column or checkbox cam simply state whether staffing effectiveness was an issue. Or you could take the EPs and build these questions into your root cause analysis worksheet and other postevent or trends assessments.  They key is to aggregate this data to determine whether or not any patterns or trends are developing.

Don’t forget to educate your leadership about the importance of understanding the renewed focus on staffing effectiveness as it relates to analysis of data and opportunities for improvement. There could easily be related questions asked by surveyors during the Leadership Interview at the time of an on-site survey.

Editor’s note: This post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th Edition by Jean S. Clark, RHIA, CSHA, and Jodi L. Eisenberg, MHA, CPHQ, CPMSM, CSHA.

AHAP offerings update

I just wanted to give you an update on a few resources that HCPro and AHAP is offering that might be of huge benefit to you. There have been a lot of changes, updates, and new NPSGs coming your way from The Joint Commission and CMS, and we’ve got a lot of good stuff going on in the upcoming months to help you stay on top of it. Here are some things that may be of interest to you:

Speaker Barbara Balik, RN, MS, a senior faculty member at the Institute for Healthcare Improvement (IHI) discusses why just adding another policy isn’t good enough. She will offer candid advice and techniques to give you and your staff a better understanding of the requirements, and share best practices and practical strategies to improve patient- and family-centered care and to communicate the policy to patients and families.

Plus, this webcast provides a great opportunity to get EXACTLY what you want out of it. Barbara has asked that if there is something specific you’re hoping to learn from this show, to please e-mail me (jbeck@hcpro.com) ahead of time and she will make sure to address it in the live program.

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Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.

According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and  studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.

In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.

The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.

Click here to download the Sentinel Event Alert and the full list of recommendations.

Hospitals failing on communication compliance

Two former language-expert hospital administrators in conjunction with Language Line Services have released a new report called “The New Joint Commission Standards for Patient-Centered Care,” that finds hospitals are falling short of The Joint Commission’s language access requirements for patients with limited English.

The requirements were announced in 2009, and  put in place on January 1 of this year, but won’t have an effect on accreditation during the year-long pilot phase.

According to the report and The Joint Commission,  communication breakdowns are the cause for nearly 3,000 deaths every  year, and the majority of these breakdowns involve patients with limited English. Studies show that 50 million people speak a language other than English in the home, and according to the report, some hospitals are not making the connection between language services, patient rights, and patient safety.

The report also says that hospitals may think they are being compliant because they have bilingual staff, contract interpreters, and over-the-phone or video interpreters, but the standards require proof of interpreter training and fluency competence for interpreters in spoken languages as well as American Sign Language  for deaf and hard-of-hearing patients.

The report says hospitals that aren’t in compliance with the new regulations could do damage to their reputations and accrue untold expenses.

Visit The Joint Commission’s Hospital, Language, and Culture website for more information.

Joint Commission releases new website

The Joint Commission has launched extensive upgrades to its website in order to improve access to information about healthcare quality and safety. Based on research with healthcare organizations, healthcare professionals, consumers, and the like, the new website features:

  • Sign-ups for alerts to upcoming events, newsletters, and field reviews
  • A “Daily Update” section with new information from the past 24 hours
  • Enhanced search functionality and multi-media functionality for videos, podcasts, and RSS feeds
  • Interactive features such as blogs, discussion forums, speaker’s bureau request forms, and options to share information with other people
  • Easier navigation and search functionality
  • A Joint Commission events and conferences calendar

Visitors to the site will still be able to access Quality Check, The Joint Commission’s search engine for Joint Commission certified healthcare organizations located within the United States and its territories, and a tutorial of the new site is available here.

Joint Commission’s Targeted Solutions Tool™ makes headway

The Joint Commission’s Target Solutions Tool™ (TST) launched in September has made progress in the area of hand hygiene. Over 700 hand hygiene projects are currently running, over 6,500 hand hygiene observations have been entered into the TST, and more than 2,500 download requests have been received so far for the tools and videos that the TST provides to support these projects.

The TST looks at measurement processes, barriers to success, and methods for implanting solutions, and was designed to smooth the process of solving healthcare’s most stubborn quality and safety issues.

The organization has teamed up with some of the top hospitals in the country to develop these solutions and is still seeking more.

Click here to find out more information.


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 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.