Month: January 2017

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Additional Policies Required for the Joint Commission “Day-One” Document Binder

As consultants we have noticed that important changes to the survey activity guide often get overlooked because they are not highlighted in TJC Perspectives or E-Alert. For example, last August TJC updated the survey activity guide (SAG) to include three additional documents to the mandatory Day-One document list. These were items 46, 47, and 48 calling for three additional policies. The first of these was the medication management policy (which is required to define the elements of a complete medication order as well as a definition of what constitutes therapeutic duplication). Read more

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SAFER™ MATRIX Explained, Again

The lead article in the January 2017 issue of The Joint Commission Perspectives is on the new SAFER™ Matrix and TJC once more tries to apply some operational definitions to the “likelihood of harm” and the “scope” on the X and Y-axis on the matrix. TJC also discusses educational materials that it has placed on each organization’s secure extranet to help understand the SAFER™ Matrix. We would strongly encourage readers to share these educational materials with department heads and senior leadership to firm up their understanding of the new report format.

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Immediate Post OP Note – Two Thorny Issues Clarified

The “Consistent Interpretation” column in the January 2017 issue of The Joint Commission Perspectives sheds new light on a persistently difficult standard, namely, the immediate post-operative note required by RC.02.01.03. TJC makes two thorny issues crystal clear, the first of which is, what is the next level of care as described in EP 5? During the Fall Executive Briefings 2 years ago TJC staff speaking from the podium got into a debate between themselves about the meaning of this phrase which confused many attendees at that time; one said that the PACU was the same level of care as the OR while the other stated it was not the same.

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NEW CDC GUIDELINE ON VACCINE STORAGE

The CDC has published to its website a new vaccine storage guideline and toolkit that updates information they had published back in 2012. You can obtain the toolkit at: http://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf

This guideline has a huge amount of information about vaccine storage refrigerators, freezers and maintaining proper temperature. This is only a guideline, but as IC.01.05.01, EP 1 states, you are to use evidence-based guidelines when developing infection prevention and control activities. Read more

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CAUTI NPSG CHANGES FOR 2017: More Detail Required

The Joint Commission’s NPSG.07.06.01 has been changed for 2017, and while conceptually it is the same, there are a few new “score-able hooks” or “gotcha’s” that you will want to prepare for. EP 1 establishes a requirement to educate staff and LIP’s involved with indwelling urinary catheters about the importance of infection prevention. They further state that this education should occur at the time or hire, or initial granting of clinical privileges.

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