HCPro.com - Accreditation Monthly

Prepare for the Updated Electronic Application

Tue, 09 Nov 2010 13:30:00 GMT

The Joint Commission announced in its November Perspectives that an updated electronic application, or E-app, will be implemented by the end of 2010. Along with improved functionality such as print capability, there will be additional fields for you to complete before the end of March 2011. Take action prior to December 6 when the E-app will be locked down to verify the accuracy of your organization's information. Consider:

Reviewing your organization's current information. Better yet, print a copy now to have on hand for comparison purposes post upgrade. Review any changes in what is seen for accuracy. Evaluate whether any noted discrepancies make sense for your organization, such as changes due to the addition of new services.
Submitting any changes now. The Joint Commission's plan is for all submitted information currently in the system to be transferred over into the upgraded version. If you are working on updating your services or organizational information but haven't yet submitted them to The Joint Commission, do so before December 6 or the information will be lost and will need to be re-entered at a later date.

As of December 6, the application will be temporarily unavailable. (Note: If you have updates due in November, December, or January, The Joint Commission has stated that there will be a grace period for you until February.) Remember that your information in the E-app drives your survey fee, length, and complement, meaning the number and types of surveyors sent to your organization. By keeping a watchful eye on the integrity of the information on file at The Joint Commission, you won't have any surprises when it comes survey time.

Laure Dudley, RN, MS, CSHA
Consultant

Having Trouble with Ambulatory Summary Lists?

Tue, 12 Oct 2010 13:30:00 GMT

For patients receiving ambulatory care services on a multi-visit or continued basis such as infusion therapy or pain management, The Joint Commission requires that the medical records contain a summary list (RC.02.01.07). In addition, EPs 1–4 of the same standard require that a list:

Be initiated by the third visit
Be readily available for the medical staff to treat and update as indicated
Contain information related to medical diagnoses and conditions, noteworthy procedural history, adverse drug reactions, and current medications including those taken over the counter

The problem is that some hospitals have put in place complex processes for compliance, such as creating a list each visit to make sure that it's not forgotten, trying to capture the information on the second visit, and keeping records of the visit number or requiring full assessments each visit. Realistically, would you need to keep track of the patient's visit number if you didn't affect the treatment? A more streamlined approach would help achieve and sustain compliance, as well as reduce resources needed to comply.

Simplification

Consider developing a single document that includes the patient's medical history and existing conditions. It can be filled out by the patient on the initial visit for services and can be updated as clinically necessary by staff. This document should be placed in a standardized area of the record and be accessible to all staff. The list will then be "active" and can reduce the need for redundancy in obtaining complete information, documentation, and searching the old records each time the patient visits.

Laure Dudley, RN, MS, Consultant
October 2010

CMS & Alcohol-based Skin Prep in the OR - How do you know you’re managing the risks?

Thu, 16 Sep 2010 13:30:00 GMT

With the increased attention on minimizing the risks of surgical fires, it seems like there was something of a movement away from the use of alcohol-based skin preps (ABSPs) in the OR. Lately, that movement appears to be reversing itself, mostly because, when you come right down to it, ABSPs are considered the most effective and fast-acting antiseptic. (You can access a copy of the Conditions of Participation/Interpretive Guidelines at Conditions of Participation Interpretative Guidelines. The information regarding the use of ABSPs can be found on page 327). The downside of using this product is that, as a flammable material, it contributes pretty significantly to the risk of fire.

Clearly, we are in no position to eliminate either risk; infection and surgical fires both must be prevented, so minimization becomes the strategy. Fortunately, CMS provides some thoughts on the matter, which you will also find through the link above, continuing from page 327 onward.

CMS will review policies and procedures to determine whether they address the elements specified in the interpretive guidelines. If you are using ABSPs in your surgical procedure areas (fires can occur anywhere, not just in the OR), you had better have adopted strategies for minimizing the risks of surgical fire, and frontline staff better be able to articulate those strategies.

Steve MacArthur
Senior Consultant

Fire Evacuations in the Procedural Areas

Thu, 05 Aug 2010 13:30:00 GMT

When I ask about fire evacuations in procedural areas such as the cardiac cath lab, PACU, same-day surgery, and operating areas, it is disturbing as a consultant to hear that some of these areas don't take part in fire drills because they are in the "middle of cases" when the practices occur. The next question that I ask is, "Where would you evacuate patients in the event of a fire in this area?" Surprisingly, some staff ponder the question or start a discussion with colleagues about the process, which doesn't give me confidence that patients would be evacuated efficiently and effectively in the event of a fire.

The requirement in the Life Safety Code is that everyone who has a role in the fire response plan will be drilled periodically, with that drilling to include relocation of patients (either through simulation or through the use of empty wheelchairs, stretchers, etc.) to adjacent smoke compartments. Additionally, consider The Joint Commission's position: Although the National Patient Safety Goal on surgical fires applies to ambulatory surgery environments, the original Sentinel Event Alert includes all areas in which surgical fire is a risk.

Although they can be disruptive, schedule practice evacuations on slower days or times to conduct drills in these locations if you are already not doing so. Some facilities practice moving actual patients to the designated area; this takes a lot of coordination, but in the event of a fire, they should have the process down pat. These simulations can affect your response in life-or-death situations. Consider posting an evacuation map in the area that staff can reference. The bottom line is to make sure you can verify that each patient care area knows where to evacuate patients in an emergency, including a fire.

Steve MacArthur
Senior Consultant

Public Comment on Proposed Telemedicine Credentialing Changes

Tue, 06 Jul 2010 19:07:00 GMT

On May 26, CMS posted in the Federal Register proposed changes to the regulations regarding the credentialing and privileging of telemedicine providers for a 60-day comment period. These changes, noted under the "Governing body" and "Medical staff" sections of the Conditions of Participation, allow hospitals to utilize their partnership with the remote Medicare-participating hospitals' telemedicine sites by relying on the credentialing and privileging information furnished by the remote sites for these practitioners. There was a concern raised that when The Joint Commission loses its statutory¹ deeming authority recognition with CMS on July 15, hospitals would be forced to switch to the more cumbersome practice of privileging telemedicine providers in the same way they privilege their on-site staff in order to remain compliant with requirements. This would force hospitals to potentially privilege hundreds of telemedicine practitioners through their own governing body approval process

The Joint Commission responded to this announcement in its June 9 online newsletter stating that CMS has delayed the implementation of changes until March 2011; therefore, it instructed hospitals not to make any changes to the credentialing process at this time. The Joint Commission noted that this directive to hold off making changes was because CMS had released new proposed rules, which are out for public comment, so modifications will likely occur. In the interim, organizations can continue the practice of credentialing and privileging telemedicine providers by proxy.

Consider how these proposed changes will specifically affect your organization based on its use of telemedicine providers. We encourage you to offer your feedback during the public comment period, which closes July 26. The proposed Federal Register regulations and instructions for comment are provided in this link: http://edocket.access.gpo.gov/2010/pdf/2010-12647.pdf

Laure Dudley, RN, MS
Consultant

¹Loss of statutory status required the Joint Commission to apply for deemed authority. In November 2009, deemed authority was granted to the Joint Commission through July 15, 2014.

Can You Put the Kibosh on Frequent Crash Cart Checks?

Thu, 10 Jun 2010 13:30:00 GMT

Are you hoping that those missing crash cart signature checks aren't found on your next internal tracer or accreditation survey? When you think about it, a crash cart does not have to be checked every shift or even every day. There is no specific requirement to check a crash cart. However, there are requirements for making sure emergency medications and supplies (MM.03.01.03) as well as resuscitation equipment (PC.02.01.11) are readily available. There are also requirements in the environment of care standards for maintaining an inventory of medical and life support equipment and following written steps for inspection, maintenance, and testing of this equipment. So how can you evaluate the amount of effort needed to maintain your crash cart equipment and supplies needed for an emergency situation? A good place to start is to ask the defibrillator manufacturer what is recommended for testing to ensure proper function. This may vary depending on the type of equipment you have, and it may be less often than you think. Is your crash cart secured with the same unbroken breakaway lock from the last time it was used? If so, the contents are intact. Is the date of the first expiring medication or supply tagged for a future date so you know when to restock? If so, the contents are current.

As consultants, we see citations all the time as a result of overly strict policies that require staff to perform checks every shift in addition to all of their other responsibilities. What happens if your policy requires checks daily or on every shift but the unit isn't open seven days a week? If your current system of checking crash carts doesn't make sense to you from an operational perspective, rethink your policy. Consider assigning the task of performing the checks to a specific person or title such as the charge nurse. This will provide you with consistency in receiving feedback about the process.

Since your leadership is responsible for the quality and safety of care delivered in your institution, you want to be ready in the event of an emergency. But with a little assessment and planning, you could potentially save a lot of effort and achieve better results.

Laure Dudley, RN, MS
Consultant

New Communications Requirements

Tue, 11 May 2010 13:30:00 GMT

Perhaps you were one of the 1,000 people who attended The Joint Commission's (TJC) recent webinar during which an overview of the approved Patient-Provider Communications standards was provided. The influence of diversity on healthcare equity was emphasized, and since communication is viewed as a shared responsibility in the organization, the new standards require an integrated approach at multiple levels within the hospital. This includes incorporating data collection and assessment into the QAPI plan for monitoring effectiveness. The standards focus on three areas: effective communication, addressing specific patient needs, and data collection and use. TJC feels that these standards go beyond the current expectations, focusing on the safety and quality of care provided and not merely on culture or language services.

Approach
Most noteworthy is TJC's recommendation that organizations need to determine how best to meet their patients' needs by performing a self-assessment of their current practices. Hospitals must then decide how to handle the issue of health literacy for the populations they serve and use the data to make improvements in the process.

There will be a "Roadmap" document available for download on TJC's website at the end of May, which is intended to act as an implementation guide and includes other features such as best practices, references, and tools for hospitals to use.

Implementation
The standards have been approved and were subsequently reviewed with focus groups. Although feedback was positive, there were concerns raised about the resources needed to implement them. As a result, there is no definitive implementation date, although the standards will be printed in the 2011 hospital accreditation manual. Criteria for scoring have also not been determined, but the surveyors will be trained and start reviewing the standards (probably by reviewing hospital data and patient resources available) through 2011. It is not anticipated that the standards will be incorporated into a hospital's scoring decision before January 2012, but you might want to think about completing your assessment soon to establish a baseline. Some hospitals have established a multidisciplinary working group to ensure that all aspects of care are represented as they study and address this issue.

Laure Dudley, May 2010

Guidelines for Intravascular Catheter-Related Infections

Wed, 14 Apr 2010 13:30:00 GMT

The CDC released draft updated guidelines from the Hospital Infection Control Practices Advisory Committee (HICPAC) for the Prevention of Intravascular Catheter-Related Infections for public comment late in 2009. The paper is chock-full of interesting updated information for all types of catheters, and it's important to note that these guidelines will replace the 2002 version.

With an estimated 250,000 cases of CVC-associated bloodstream infections occurring annually, the recommendations provide for guidance related to areas such as site selection, skin preparation, dressing regimes, hand hygiene and aseptic technique for insertion, and avoiding routine replacements to prevent infections, as changing a catheter every seven days has not lowered CRBSI rates.

Although the final guidelines aren't out yet, noteworthy recommendations include when to replace IV tubing based on the current consensus of experts. Based on what is administered through the lines:

Blood—replace every 24 hours
Lipids—replace every 24 hours
Propofol—replace every six to 12 hours (per manufacturer)
Routine peripheral IVs—replace every 96 hours to seven days

However, if an IV is to remain in place more than six days, a midline catheter (PICC line) is still recommended.

By the way, it's no surprise to note that the paper also reports one of the factors of increased infection risk is reduced nursing levels. That's something to think about in consideration of your performance improvement initiatives related to infection prevention.

Laure Dudley, Senior Consultant 04/2010

Grievances, Complaints, and Patients’ Rights

Tue, 09 Mar 2010 13:30:00 GMT

Simply put, CMS defines a grievance as a written or verbal complaint by a patient or patient's representative regarding care or services, abuse or neglect, or potential violations of the Conditions of Participation (CoP). CMS is very specific in the Patient Rights chapter of the CoP (§482.13, A-0118–A-0123) regarding the expectation of prompt resolution to grievances in both the inpatient and outpatient areas.

The Joint Commission has aligned its requirements to CMS in this area by mandating that a complaint resolution process be in place in the Rights and Leaderships chapters.¹ Staff must be able to demonstrate understanding of your organization's policy related to complaint resolution. For example, it's great for staff to know that patients can call The Joint Commission with complaints, but it is not so good if they can't provide the number or know how to direct the complainant to the accrediting body.

In general, we find that outpatient staffs are vulnerable to being less familiar with the hospital's written grievance process. It's a good practice to review the information published in patient handbooks regularly and make it accessible for staff if necessary.

Aside from demonstrating that your policy and your practices are in compliance with the requirements, you must show that they have been approved by your governing body. Items to consider in the review of your process include whether:

You are responding to complaints and grievance in writing within seven days. If not, has the patient or patient's representative been informed that you are still working on the issue and provided with a new timeframe for potential resolution?
The response is composed in a manner that can be understood, including incorporating language or cultural sensitivities into the resolution process.
Complaints and your response to the matter being tracked so you can demonstrate compliance with the regulations and your own policy.
Grievance data are evaluated and considered in your organization performance improvement plans.

It is the expectation that quality and safety issues are being managed by leadership, which includes the involvement of your governing body.

¹The Joint Commission Hospital Accreditation Manual (RI.01.07.01, EPs 1–2, 4, 6–7, 10, 18–20; LD.01.03.01, EP 1–3; LD.04.01.07, EP 1–2).

Laure Dudley, Consultant, March 2010

Proper Tissue Management

Thu, 11 Feb 2010 13:30:00 GMT

You may have noticed in the 2010 Hospital Accreditation Standards manual that The Joint Commission no longer requires temperature monitoring of tissue stored at ambient or indoor room temperature (TS.03.01.01, EPs 8–9). However, this does not change your responsibility in the proper receipt and management of this tissue. Even though temperature logs are not required for room temperature storage, the suppliers' recommendations and hospital policy should be maintained.

Over the past two years, Greeley consultants have continued to identify problems related to tissue storage and management during hospital on-site accreditation assessments. Most notably, hospitals are missing key elements of the tissue management process, including:

Written notation regarding the integrity of the tissue upon receipt
Lack of recording and tracking of the tissue recipient
Documentation of bidirectional tracking missing
Expired tissue in active storage
The failure to have a clear process in place for adverse events such as patient notification of recalled tissue or an infected tissue site

Staff members should be able to articulate the process for notification of the oversight bodies when tissue problems arise, including notification of the Perioperative Care Committee, infection control, and risk management. If you are not already doing so, try performing a tissue tracer from supplier to post-discharge record review to assess for any breakdowns in your process.

Laure Dudley 2/11/2010

Cohesive History and Physical Requirements

Fri, 15 Jan 2010 13:30:00 GMT

When was the last time you checked your organization's written history and physical (H&P) requirements against the federal rules? CMS' Conditions of Participation state that the requirements for completing and documenting patient histories and physical examinations are contained in the medical staff bylaws (CFR §482.22 [c][5][i-ii]). The Joint Commission also addresses these requirements in the Medical Staff (MS.01.01.01, EP 20, and MS.03.01.01) and Provision of Care (PC.01.02.03, EPs 4 and 5) chapters of the hospital standards. This means that H&P completion requirements must reside in the medical staff bylaws, whereas specific content requirements can be addressed in the hospital's rules and regulations. In other words, your bylaws should indicate the time frame in which the H&P must be completed and who can perform them.

Required time frame
The requirements clearly state that the H&P be completed no more than 30 days before or 24 hours after admission and prior to procedures requiring anesthesia services. For outpatient procedures or same-day admissions when the H&P is completed within 30 days prior to the procedure, an update is required after admission and prior to the procedure.

Who can perform an H&P?
The H&P must be performed by a qualified licensed practitioner in accordance with state law and hospital policy.

What is included in the H&P?
The medical staff bylaws or policy and procedures must specify the mandatory components to be included in the H&P. For outpatient procedures, it is permissible to have a focused rather than a complete H&P. The bylaws or policy should specify the required components of this format as well.

Generator Rooms

Thu, 17 Dec 2009 13:30:00 GMT

One of the more inconspicuous areas in a hospital is the room that houses the emergency power generators. In this room the generators sit very still and quiet, waiting for their moment to come to life and provide the emergency power they were designed for. Testing and inspecting requirements for the generators are well defined in the Joint Commission EC standards. However, the requirements for the room that houses the generators are not well understood. In fact, outside of the facilities staff, not many people know where their generators are located, nor do they know whether the room that houses them is properly maintained and prepared.

The NFPA 101 (2000 edition) Life Safety Code® requires hospitals to comply with NFPA 110 (1999 edition), Standard for Emergency and Standby Power Systems. This standard has specific requirements that are often overlooked:

The emergency power generators are required to be installed in a separate room (7.2.1)
If the room is located within the hospital or attached to the hospital, then the walls, floor, and deck above are required to be two-hour fire-resistive rated (7.2.1.1)
No other equipment except that which serves the space is permitted in the room (7.2.1.2)

In summary:

The generators have to be in a separate room dedicated for the purpose of the room
They cannot be in a room that has other nonrelated equipment, such as chillers, water pumps, and compressors
The room must have two-hour fire-rated walls
The door to the room must be at least 1½-hour fire rated, with a closure and positive latching hardware
Any ductwork that penetrates the fire-rated walls must have a fire damper rated for at least 1½ hours
All penetrations through the walls must be properly sealed with fire-rated materials

Any deficiency to the room would probably be scored under the standard EC.02.01.01, "The hospital manages safety and security risks," and EP 3, "The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment." This EP is a Direct Impact element and therefore would contribute toward an adverse decision in the overall scoring decision. Thus, it would be a good idea for you to examine the generator room to ensure that it is compliant.

Brad Keyes, Consultant 12/2009

The Joint Commission Back to Closed Record Review?

Thu, 12 Nov 2009 13:30:00 GMT

Have you heard that the Joint Commission survey will again be doing closed record review? For hospitals with deemed status, CMS is requesting The Joint Commission to review records at a rate of 10% of the average daily census or a minimum of 30 records (20 for small hospitals) during the survey process. If The Joint Commission does not review the required number of records during the open record tracer review, the surveyors will ask to review additional open and closed records. We've already had two clients that have had this happen.

What does this mean for you? You can expect that Joint Commission surveyors will pretty much sit in a room (from what the clients say) and review the records. This gives them more opportunities to find RFIs. Some of the additional vulnerabilities of reviewing the closed record include:

Review of the appropriateness of the discharge summary
Discharge teaching
Unmet goals from the care plan are addressed at discharge
Medication reconciliation at discharge (although not scored this year)
Authentication of verbal/telephone orders within 48 hours (or state statute requirement)
Completeness of the medical record

The Joint Commission is not moving away from the tracer method—it is committed to that survey process—it simply has to meet the required number of records as stipulated by CMS.

We will wait and see how this affects the survey findings in the months to come!

Blanket Warmers, What Is Safe?

Wed, 21 Oct 2009 13:30:00 GMT

When completing readiness assessments, I have noticed much disparity in the temperature of blanket warmers from hospital to hospital and from warmer to warmer in the same hospital. I have also noticed that staff members cannot speak to the "safe" temperature range, and often, the safe range or upper limit is not posted, nor is there a policy readily available.

Safe temperature ranges for blanket and fluid warmers are most commonly published by ECRI Institute, and until recently, it set the "safe" temperature limit for blanket warmers at 110°F (43°C). This temperature was recommended because solutions were often warmed in the same cabinets as blankets, and the lower temperature eliminated the serious burn risk presented by excessively heated solutions.¹ This year, ECRI revised the recommended temperature for blanket warmers to 130°F (54°C).

Manufacturers vary in their temperature recommendations and often do not agree with ECRI.

Recommendation:
Organizations should engage in a thoughtful process that includes research of recommended temperatures. Research can include a Web search, as well as manufacturer recommendations. The organization should then develop a policy for blanket warmer and fluid temperatures that will be used throughout the organization regardless of the manufacturer. Be sure to post the temperature range on all blanket warmers and instruct staff members on the procedure.

¹Health Devices, July 2009 www.ecri.org

Problem Lists - What is Required?

Tue, 15 Sep 2009 13:30:00 GMT

When on-site assessing ambulatory care for standard compliance, I am often asked about what is required for a problem list (now called summary lists).

The intent of the summary list is to provide a quick reference of needed critical information about a patient in order to provide optimal and safe care. Many patients travel from clinic to clinic or provider to provider, and if the critical information is not easily available, it may be missed when making decisions about care and treatment. The list generally includes:

Newly identified and chronic diagnoses
Procedures performed
Allergies and drug interactions
Medications taken (medication reconciliation)

When Required
A summary list must be initiated anywhere in the ambulatory setting by the third visit. Each clinic provider would then update the list as necessary.

When not Required
According to the Joint Commission FAQ dated August 5, 2009, "A summary list is not required in settings where patients present with a known diagnosis and receive one-time predetermined care (e.g., ambulatory surgery, diagnostic imaging services)."

Process
Hospitals with multiple ambulatory care settings should decide who is responsible for initiating the summary list and how the lists will be made available to providers as needed. I have seen both manual and computerized summary lists.

The Joint Commission also cautions, "…should the organization allow each outpatient setting to initiate and maintain its own summary list, the organization increases the risk of not having the most current patient information available to each area."

This is a challenging process for ambulatory care settings where each clinic maintains its own record for patients with multiple visits, such as wound clinic, pain clinic, and physical therapy. In these circumstances, there needs to be a centralized summary list that can be accessed at each visit and updated as needed.

Policies: Say What You Do and Do What You Say

Wed, 26 Aug 2009 13:30:00 GMT

There is sometimes a tendency to want to write everything down in great detail, but more may not be better when it comes to writing policies. Organizations often receive Joint Commission RFIs due to language in their own policies. Consider the following guidelines for writing policies.

Q: Do we need this policy?
A: A policy is needed if:

It is specifically required by an accrediting or regulatory body (e.g., Joint Commission, CARF, CAP, DHR, or CMS).
Specific guidelines are needed to direct decision-making or completion of an activity or function (particularly high-risk, low-volume activities).
There is a widespread and repeated problem and pattern of actions that are inconsistent with the institution's values. Even then, there should be a period of questioning whether the problem is best addressed by a policy or through some other intervention.

Q: What are the characteristics of an ideal policy?
A: The ideal policy will:

Be brief and include only the information needed to convey the key message or steps
Reflect what will be done, not what the organization hopes will happen
Follow the natural flow of the process to enhance compliance
"Say what we do and do what we say"
Avoid requirements that are more extensive than regulatory or accreditation standards
Be developed with input from those who are impacted by the policy (staff members, other departments, physicians, etc.)
Not conflict with system policies

Q: What are some specific policy-writing tips?
A: For starters:

Keep sentences short (average of 10–12 words)
Use clear, concise, easy-to-understand language
Use the active voice (e.g., "assess the following" instead of "the patient will be assessed")
Be consistent with verb tense throughout
Whenever possible, link attachments to online forms on the intranet
Exclude the following documentation in the body of the policy:
- Staff education material (consider alternatives such as CBLs, PowerPoint presentations, or competency checklists)
- Forms and instructions
- Flow charts
- Communication to a specific department regarding an infrequent occurrence

Remember, policies are ineffective if they are over-engineered or too wordy. Policies are not meant to be all-encompassing or a substitute for individual judgment and training.

More from the March 2009 Joint Commission Changes: Anesthesia

Tue, 14 Jul 2009 13:30:00 GMT

Many of the published March 2009 changes were made to align with CMS' Conditions of Participation (CoP). However, when looking at the CMS definition of anesthesia, it does not include sedation. The Joint Commission standard (PC.03.01.01) states, "The standards for sedation and anesthesia care" which then goes on to specify "general, spinal, region, deep, and moderate sedation." Therefore, it is assumed that the following standards will include sedation, but as is often the case, uncertainty remains.

PC.03.01.03 states that a pre-anesthesia evaluation must be completed within 48 hours prior to the procedure requiring anesthesia.

PC.03.01.07 states that a post-anesthesia evaluation must be completed and documented no later than 48 hours following a procedure requiring anesthesia.

Points to remember:

Both evaluations must be performed by an individual with privileges to administer anesthesia
There is no specification in the standard as to how soon after the procedure the post-anesthesia evaluation can be performed

To achieve compliance, we recommend that you:

Build pre- and post-anesthesia evaluations into your documentation process
Design an anesthesia evaluation form that includes the pre- and post-anesthesia evaluations
Educate your anesthesia providers and monitor compliance with the standard

Joint Commission and CMS Alignment: Restraint Management

Tue, 09 Jun 2009 13:30:00 GMT

Before tracers, restraint was one of the most frequently cited requirements for improvement (RFI), formerly known as a "Type 1" recommendation. Since The Joint Commission recently made significant changes to align more closely to CMS' Conditions of Participation, we have a hunch restraint citations may make it back to the top 10 list.

The March update replaces the January update published by The Joint Commission. Be sure you have that information, available on the agency's Web site.

The following is a summary of the direct impact elements of performance (EP). All direct impact requirements for this subject are Category A.

EP.03.05.01 focuses on the indications for each episode of restraint, including discontinuation of restraint at the earliest possible time.
EP.03.05.03, EP.1 requires the use of safe techniques to restrain patients according to hospital policies and procedures.
Suggestion: Implement a well-designed education program that aligns practice across the organization. Provide documentation/competencies of the education. Remember that the medical staff needs restraint education as well. This can be an abbreviated educational document provided to physicians. Don't forget about security guards or other non-licensed personnel that observe patients in restraints or assist with the application of restraints. EP.03.05.05, EP.5 applies only to restraint used for the management of violent or self-destructive behavior. It requires an in-person evaluation by the physician at least every 24 hours. Remember, EP 4 defines the age specific time-limited orders.
EP.03.05.05, EP.6 requires renewal of medical (non violent) restraint according to hospital policy. A single instance of a missing order could generate a direct impact RFI.
Suggestion: Consider the use of protocol orders with specific criteria for discontinuation. There is no longer a requirement that orders be renewed each calendar day, but you must follow your policy.
EP.03.05.11, EP.1 requires a face-to-face evaluation of violent or self-destructive patients by a responsible physician or an appropriately trained RN or physician assistant (PA) within one hour of the application of the restraint/seclusion.
Suggestion: Ensure that all RNs who staff the emergency department or the behavioral healthcare unit have documented training and competencies in evaluating violent or self-destructive patients.
EP.03.05.11, EP.2 requires a nurse or PA who performs the one-hour face-to-face evaluation of violent or self-destructive patients to consult with the responsible physician as soon as possible after initiation of restraint.
EP.03.05.11, EP.3 specifies the content of the one-hour evaluation of violent patients.
Suggestion: Hard code this documentation into forms or computer templates. Include the four required components of the face-to-face evaluation defined in EP3.
EP.03.05.13, EP.1 requires the continuous observation of patients who are simultaneously restrained and secluded.

There are plenty of other requirements to worry about. But we suggest starting here, with the Category A direct impact requirements.

The Joint Commission and Telemedicine: The Final Word?

Wed, 13 May 2009 13:30:00 GMT

In the April issue, we discussed the potential changes to The Joint Commission's position on credentialing telemedicine physicians. At that time, we recommended that you do not change your credentialing practices until The Joint Commission clarifies its position. Below is the information we have to date.

In November, The Joint Commission released a change to MS.13.01.01, which went along with CMS' position on telemedicine, stating that all physicians need to be credentialed and privileged at the originating site¹. However, in the January and March releases, The Joint Commission deleted this change and reverted back to its original position that hospitals may choose to rely on the credentialing and privileging of the distant site² for interpretive services such as radiological interpretation.

It appears that for now, The Joint Commission is holding firm on the option that the hospital may rely on the distant site for credentialing if that site is Joint Commission–accredited, the physician is granted privileges for the services provided, and the originating site has evidence of internal review of the practitioner's performance of the services rendered. The Joint Commission also acknowledges the difference between its standard and the CMS regulation and alerts hospitals that they may be vulnerable to a CMS citation if they choose the JC option.

¹Originating site: where the patient is located
²Distant site: where the LIP providing the service is located

Hold Off on Credentialing Changes

Thu, 16 Apr 2009 13:30:00 GMT

There are two versions of the 2009 CMS changes made by The Joint Commission: the version that was e-mailed on January 6, and the version currently posted on The Joint Commission Web site. (It took us a very long time to find the posted version. It's not under Standards, but under What's New. Go figure!)

The bottom line is that the changes to MS.13.01.01 that were in the January 6 e-mail are not on the Web. Are the changes to MS.13.01.01 in? Are they out? Are they under discussion? We've asked The Joint Commission, but they have not yet responded.

In the meantime, do not make any changes to the way you credential or privilege remote diagnostic-only practitioners! Wait for clarity from Oakbrook Terrace.